Continuity of care? Hospitalists? Who calls the family?: Corporate control makes health care worse.

I was recently talking with a friend who was still (justifiably, IMO) furious at her local hospital. Last year her husband, 90, was admitted for an attack of diverticulitis. While hospitalized, he suffered a heart attack on a Sunday morning and was transferred to the Intensive Care Unit. The treatment was fine – indeed now, at 91, he is quite improved – but her complaint was that no one called to tell her! She found out when she went to visit him in the hospital that afternoon. I am sure that virtually any adult presented with this scenario would say “of course, as soon as possible, call the family!” Can you imagine that they didn’t?

Sadly, I can. It reflects a lot of issues in the medical care system. One that my friend identified was the hospitalist system, where the doctor who is responsible for the care of a person in the hospital is not their regular physician, but someone employed by the hospital (usually an internist or sometimes a family doctor). In itself this can be an issue, which I will discuss below, but the bigger problem she identified was the frequent change in who this responsible physician was, different on the weekends, and at night, and almost impossible for her to get to know. Indeed, she was not certain if the doctor she talked to later that day, the one who told her, not apologetically, that they were “trying to figure out what to do with him” (as if this was an excuse for not calling the wife of an 90-year-old patient to tell her that he had a heart attack) was the actual hospitalist or a resident working with them. If you don’t know the attending physician du jour, or even know who they are, it is hard to be sure. I might add that my friend is a highly educated and well-insured person. When they suffer such indignities, and they do, it is certainly far worse and more frequent for people who are not.

Why would doctors not want to call the family of a person in the hospital, especially but not only if they are old and frail and suffer a particular acute life-threatening event, as soon as possible? Is it imaginable that they do not? Why would they not want – insist upon – the family knowing who the responsible physician is? Do they just want to be anonymous, not to be bothered?

Maybe, sometimes, but I do not think that this is the primary reason. Think about it. You are the “hospitalist”, a hospital-based physician tasked with responsibility for the care of lots of people (“patients”) who you didn’t know before they were admitted. On top of that, you are not the weekday hospitalist, but the one covering for them on the weekend, a weekendist if you prefer (I sure don’t!). Maybe you are even the nocturnist, the night-time hospitalist. In any case, you have a list of patients to see, and to get to know, and maybe you come into the hospital in the morning to see them all (which, of course, has to be one at a time, someone first, someone last) when all of a sudden you hear from the nurses that one of them has had a heart attack. Maybe someone you have seen already, maybe not, maybe it is the afternoon, and you have already left the hospital. You tell them, the nurses and the residents working with you, to begin their well-practiced routine of treating an acute myocardial infarction (MI, heart attack) and give other instructions, including to call cardiology, and tell them to call you back. Do you specifically instruct them to call the family? Do you think that would be obvious to them? Does it even occur to you? Is it someone else’s job? Whose?

In the “old days”, when someone’s family doctor took care of them even when they entered the hospital, it was almost certain the family would be called. The doctor knew the person, often had been seeing them for years, and knew the family. They knew, of course, that the family would want to know, and felt it to be their responsibility to inform them. This changed with the creation of hospitalists as a separate specialty, and has accelerated with the corporate takeover of medical care and the dramatic increase in physicians as employees of corporations (most often hospitals, sometimes physician-owned groups, sometimes for-profit, often owned by private equity). Different physician roles have been identified, such as caring for people in the office (and very rarely at home), in the hospital, in nursing homes. While these roles had always existed, often the same doctor filled the different roles for their patients; now different doctors would. The delivery system, which had been patient-focused (“I’m your doctor and take care of you wherever you need care”) became provider-focused (“We, as the providers of care, will develop a system that works efficiently for us; unfortunately for you, that means you will not have the same doctor all the time”).

Actually, there were many good reasons for this change. It is not easy, was never easy, to be a “full-spectrum” family doctor, to see people in the office both with appointments and as walk-ins, to do home visits for those who were ill and found it difficult (from age or disease) to get to the office, to see people in nursing homes and in the emergency room, and make “rounds” on and care for your patients in the hospital. And, often, get up in the middle of the night to deliver a baby. It was tough on the doctor, and tough on their families, as many books and films have depicted. In addition, these family doctors had (and have) much lower incomes than most specialists, including those who do shift work where they know exactly which hours they will work. Plus, as more and more things could be cared for in an outpatient setting (we will leave, for now, whether this was always a good idea), the people admitted to the hospital were sicker and often required more specialized knowledge that a physician who focused only on hospital medicine could better stay up on.

But there were also bad reasons, many of them stemming from the movement of physicians from self-employed to employees, increasingly working for hospitals and even for corporations that had no health professionals in charge. This corporate model, based on the industrial concept called “scientific management” or “Taylorism”, focused on increasing efficiency as the most effective way to generate maximum profit. It is more efficient to have some doctors who stay in the hospital all the time and some doctors who care for people in the outpatient setting (“ambulists”, another term that fortunately hasn’t caught on), and others who care for people in nursing home or even in their own homes. This not only reduces travel time, but allows more people to be scheduled (“speed up”) and provides the basis for further increasing the number of patients seen and concomitantly decreasing the time spent with each (see "Direct primary care" not the answer for our health system. Beware "Project 2025"!, July 9, 2024),

The problem is that this is not always the best for the patient. Yes, it is good to have people who are expert and current on the care of people in the hospital (“inpatients”) to take care of you, just as, when you need one, it is good to have experts in an organ (cardiologists, nephrologists, pulmonologists, etc., and various types of surgeons if you need surgery). But it is also good if the person taking care of you knows something about who you are, or at least your medical history. If they have never seen you before you show up in the hospital, they have nothing to compare your current situation with: are you worse? A lot worse? Better? About the same? And, by the way, if someone actually knows you – your family would almost certainly get a call!

Is it possible to have most of the good with little of the bad? The continuity (sometimes called “primary care”) clinician – family doc, internist, pediatrician, family or adult or pediatric NP – can delegate the key medical decisions to hospital experts but stay as the leader of the team. The leader, not the pain-in-the-neck “local doctor”. The professional who can fill their role as the one who cares for the whole person, not as the subspecialist for only one disease or organ. The one who cared for the patient before admission and will continue to do so afterward, not as the hospitalist for whom the patient was essentially born the day of admission and will disappear the day of discharge. Someone who can provide context and understanding and, believe it or not, continuity!

Of course, we’d need more primary care clinicians, not fewer as is the current direction in which we have been and continue to be heading (Incredible (Terrible) Shrinking Physician Supply, Health Justice Monitor, Sept 7, 2024). This would decrease efficiency, perhaps, but increase effectiveness. And while it might cost more money (thus lower profits for the corporations) it might actually save money for the overall system by having historical memory of the person when they go from home to hospital to home, and not change almost daily each time a new doctor is in charge.

Worth thinking about!

Pro tip: If you have to be admitted to the hospital, or have a heart attack, try to do it on Monday, or at least Tuesday. Do not wait for the weekend!

Specialty Hospitalists: what is best for the patient?

In a “Viewpoint” article in JAMA, April 25, 2012, John Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists: analyzing an emerging phenomenon”.[1] They describe the progression of the hospitalist model – doctors who just care for patients in the hospital, rather than seeing them also in the office from general medical care to specialty care. They note that in recent years hospitals have hired physicians in a variety of specialties, including neurology, orthopedics, obstetrics/gynecology and others, to take care of patients, particularly at night or in emergency situations, so that other doctors to not have to come in to do so.

An argument in favor of this arrangement is that these physicians are present for urgent events (e.g., the neurology stroke specialist who is there right away to care for a person who comes to the emergency room with an acute stroke) and that they may have specialized knowledge that a more “general specialist” doesn’t. In a useful “box”, the authors summarize the criteria that might be applied to deciding if a specialty hospitalist is a good idea. These include the number of inpatients who might require their services, the urgency of the need for those services (is it a matter of minutes that may save a life?), whether the other specialists are so tied up in the operating room or office that they could not respond promptly, and if there so much “sub-specialization” that many doctors in that specialty would not be capable of addressing the needs that arise in the hospital.

I have previously written about “generalist” hospitalists, (Hospitalists, Dec 4, 2008) and expressed my concerns about this movement from the point of view of the patient. The advantage for hospitals and health systems that employ physicians is obvious – they can have some doctors that work in the ambulatory setting, and some that work in the hospital, and each can be most “productive” in that setting and not have to leave to go to the other, decreasing efficiency.  In theory, at least, the hospitalists are very good at managing the problems of people in the hospital, so quality may improve. And, to be sure, doctors often like it also – it makes their lives easier, or more controllable – they are only responsible for outpatient medicine, and don’t have to travel to the hospital to see their patients, or if they are hospitalists, don’t have to go to the office. While not one of those listed by Nelson et al. as a benefit of having hospitalists, this advantage for doctors is real.They can work set shifts, like many of the most popular specialties such as emergency medicine and anesthesiology and intensive care – and then be off.  

This, of course, leaves the patients. While hospitalized patients certainly want to be cared for by a physician or physicians who are skilled in addressing the problems that they have, it is also often a very scary time, and a good time to have the involvement of someone who knows you, who knew what you were like before you got so ill that you had to be hospitalized. Your primary care doctor, if you are lucky enough to have one. The technical skills of the hospitalist may be fine, but they do not know what you were like before, and will not be involved in your care after, your hospitalization. Plus the same attractions that lead to hospitalists in the first place now have led to a sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily even have the same hospitalist making decisions about your care, even during the day, for the duration of your stay.

In addition, the skill sets of hospitalists vary. Dr. Wachter is one of the founders of the hospitalist movement and heads a long-standing hospitalist service at the University of California San Francisco (UCSF). His 1996 article, The emerging role of "hospitalists" in the American health care system,[2] written with Lee Goldman, is one of the seminal articles in the field. But the results that are achieved by teams of experienced career hospitalist groups such as his, in terms of both quality and cost, may well not be replicated by hospitalists who are just out of their residency training and spending a year working in this role prior to subspecialty fellowships in cardiology or gastroenterology. Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction with hospitalist care is equal to that provided by primary care doctors,[3] but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now not seeing them from those who do not.

That said, I do not have a problem with most specialty hospitalists. Specialists are not generalists, unlike primary care providers, we don’t think that every person should have one of each. The person who comes in to the Emergency Department with an acute stroke and benefits from having a stroke neurologist right there is not likely to have a general neurologist. The same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery, among others, or for people who need emergency intervention for an acute heart attack. The case of “laborists” is somewhat different; the women having a baby (arguably the most common reason for people being glad to be in the hospital) who has been followed by an obstetrician or family doctor might well want and expect to be delivered by that doctor (a point acknowledged by Nelson). While many primary care doctors would like to provide this continuity to their patients, they may be unable to in the system they work in. And if it is not their “fault”, it is a pretty guilt-free way to enjoy the benefit.

If the hospitals and health systems make more money and operate more “efficiently” with separate hospitalist and “ambulists” (yes, this term is being used by some!), and if the doctors are happy with the arrangement because it makes their lives more controllable, the boat on generalist hospitalists and “laborists” has probably already sailed, at least in communities large enough for this to be feasible.

Anyone who has flown in and out of the Kansas City International Airport (KCI) knows what a pleasure it is compared to other airports in even relatively big cities. Built on only one level in 3 almost-circular terminals, there are only a few gates for each security checkpoint so the lines are relatively short (compared to, say, the nightmare at Denver International). Once you come in you get off your plane, walk right out into the hall where your baggage carousel is nearby, and then you walk right out to the street (even sooner if you have no checked bag), where you can be picked up or go to your car in the garage right there. It is a true pleasure for the traveler.

But it is not so desirable for the airport and airlines. I have heard that this setup requires more security people than any airport except Heathrow. There are rumblings about redesigning, maybe rebuilding, the airport to make it more “efficient”. Sure, it will be worse for the traveler, but that’s the way it goes.

So maybe you want to ask your doctor if s/he will see you in the hospital. And let the hospital and health system know that you think it is important, too. It is unreasonable to ask your primary care doctor to work a full day in the office and also care for patients in the hospital; that time needs to be built into their schedules by their employers. It could work; you never know. What’s good for people sometimes actually happens.

And if you haven’t flown in and out of KCI, you should do it soon before it becomes Denver. 

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[1] Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700.

[2] Wachter RM, Goldman L., The emerging role of "hospitalists" in the American health care system, N Engl J Med. 1996 Aug 15;335(7):514-7.

[3] Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.

The real face of lack of access to health care

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I have often written about the fact that lack of health insurance is a major source of cost for the health system. People without insurance often cannot afford to pay doctors or buy medications, and so do not seek care for treatable illnesses until they are so far gone that they can no longer be ignored, and then show up in the Emergency Room and require admission and treatment for advanced disease (for example, in Does the nation need a clear policy on a right to basic health care?, April 10, 2009). The cost is not only enormous in human terms -- treatable diseases converted into much more serious conditions because they haven’t been treated -- although this is the most important. It is also much more costly in terms of actual health care dollars, as these advanced conditions are much more difficult and expensive to treat.

However, as in every area, what affects us most are not the data or the statistics, but the individual stories of individual people.  These are the stories that touch our hearts because they we can identify with them – they could be our stories, or those of our friends or neighbors or relatives. These are the stories that make the evening news, the stories that might persuade a legislator to become interested in a problem, the stories that motivate us to send a donation to a worthy cause.

This was brought home to me very starkly when I recently served as the attending physician on our inpatient service in the hospital. We take care of a lot of patients, and they are very sick. Their medical diagnoses varied: kidney failure, diabetic ketoacidosis, malignant hypertension, severe asthma exacerbation, infections in a variety of places, etc. But, really, the most common diagnosis was lack of access to health care, mainly because of lack of health insurance. While not all these people are poor, they, like most people, have limited incomes, and have many other basic needs (rent, food, caring for their children) that compete with health care for the dollars available. Asymptomatic diseases (or conditions with “tolerable” symptoms) often seem to be a lower priority.

I’d like to share some of their stories, although obviously I cannot share their names or present too many actual details about them; I’ll make up initials and change some details that do not affect the essential issues. These are real people, with real names and real problems.

·     AG has diabetes and high blood pressure. (These two conditions, diabetes and high blood pressure, are going to be a recurrent theme; they are the mainstay, most-common, diseases of any general adult medicine practice. They are treatable, but when not well controlled their complications -- strokes or kidney failure or heart attacks or amputations – are also major contributors to the work of many subspecialists: cardiologists and endocrinologists and nephrologists and neurologists and surgeons and orthopedists, just to name a few.) AG had lost his job, and while unemployed and without health insurance he hadn’t been going to the doctor. Luckily, his chronic diseases weren’t bothering him much, except for a small sore on the bottom of his foot. High blood pressure often causes no symptoms, until the stroke or heart attack; foot sores in diabetes are a big threat, because the disease both diminishes the sensation of pain, so it doesn’t hurt much, and the circulation of blood so it doesn’t heal well, but the lack of pain makes it seem not so bad. He finally found a job, a reasonably good job with the promise of health insurance after a while. Unfortunately, it involved walking almost 20 miles per day, not a good thing for his foot. The foot developed a severe infection, requiring expensive hospitalization for intravenous antibiotics, and might still need to be amputated.

·     PS also has diabetes, which, especially when untreated, makes one susceptible to infections, and he has had several of them. Now, in late middle age, he presents with a very serious infection, requiring not only intravenous antibiotics, but surgery to clean out the pus, resulting in an open wound. A machine attached to drain out the residual infection and keep it clean will need to be regularly replaced, for many weeks as he continues the intravenous antibiotics. Fortunately (should you ever be in a similar situation), home health can be arranged to provide these services. Provided you have health insurance coverage. Oh yes, and a home. PS has neither. Makes follow-up care a little more difficult.

·    DR is a good deal younger but also had a severe infection requiring long-term antibiotics for a foot infection, after an unsuccessful attempt at outpatient treatment. And, yes, his diabetes is uncontrolled because he hasn’t had insurance and so hasn’t gone to the doctor or taken his medicine in quite a while. He also had lost over 80% of his kidney function, so he’ll be on dialysis soon. There is a “silver lining” (!); thanks to a law passed early in the 1970s, anyone with end-stage kidney disease requiring dialysis is eligible for Medicare, so he will be insured. Of course, the cost to Medicare will be far, far more than would have been the treatment of his diabetes, had he had coverage before the “end stage”.

·     MT will also become insured through this wonderful program, although her kidney failure is due mainly to untreated high blood pressure rather than diabetes. As I noted above, high blood pressure is often asymptomatic (thus the sobriquet “silent killer”); she didn’t have insurance or money so didn’t go to the doctor to find out how uncontrolled it was, as it slowly destroyed her kidneys.

Not all of our patients’ problems came from diabetes or infections, and not everyone who is uninsured is poor.

·     KF has asthma, pretty severe asthma, for which he was taking an inhaler to be able to breathe. It is a bronchodilator (airway-opener), the right drug for an acute attack, but KF’s attack never went away and he was taking far more of it than was safe. And spending an awful lot of money on it. It is available for a much lower cost at some pharmacies that provide certain generic medications for $4, but he didn’t know that. He does now, after being in the hospital for a week getting expensive breathing treatments. It’s a good thing, too, because the other inhalers that he needs to prevent (or at least decrease the frequency and severity of) these attacks, steroids and sustained-release bronchodilators, cost a lot, well over $100 per inhaler. They have been around for a long time, so one would expect that by now at least some of them would be available generically and cheaper. But there’s a great story here. The propellant in these inhalers used to be fluorocarbons, but these, as we know, destroy the ozone layer and contribute to a lot of bad environmental effects. So they were made illegal, and the pharmaceutical manufacturers had to replace them with environmentally safe propellants. Good for the environment. Unfortunately, bad for KF and millions of other people with asthma; using a different propellant meant that the drug was a “new formulation”, which allowed the drug makers to extend their patents for many years. So low-cost inhaled steroids are still not available. This is a cruel joke, but it is not a joke. The pharmaceutical companies will not suffer; only patients will.

AG, PS, DR, MT, and KF were all people we cared for in one week, and they were not the only ones with a primary diagnosis of lack of health insurance coverage. Of course, we also took care of lots of sick people with health insurance; I don’t work in a “safety net” hospital. People with insurance, even with good insurance (and certainly not all insurance is “good”, not all insurance covers necessary medications and tests) also get serious diseases and need to be hospitalized. But the people whose stories I have told, and others I have not discussed, stand out because they didn’t have to be as sick as they were and require the costly services that they did. That they were, and did, is not only immoral and bad medicine, it is bad economics. It is inexcusable.

Maybe DR and MT would not have had kidney failure and need dialysis if they had Medicare or any other kind of coverage before needing it. Maybe everybody should have Medicare. In a future blog, I’ll discuss the proposals to “save Medicare” that are currently being floated, but now I’d just like to have some thought given to saving these actual people. Got any ideas?

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US Medicine and Medical Education: The Good Part

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I have often, and I think with good justification, been highly critical of the US health (non-) system, particularly in two areas: the fact that we do not have universal financial access to health care (a completely intolerable situation, which cannot be justified or defended morally, although it often is – always by those who have coverage!), and the fact that we have a great deficiency of primary care physicians. I thought it might be time to address two areas in which I think US medical education and practice is superior to that in Europe and much off the rest of the world.

The first is our medical education system. In specific, I am very happy that our medical schools are graduate schools, entered by students after achieving a bachelor’s degree. This is unlike the situation in most countries, such as Britain, where the medical degree is indeed a bachelor’s degree, MBBS, bachelor of medicine/bachelor of surgery. Medicine as a graduate school is the norm only in the US and in Canada; in virtually every other country, students enter medical school out of high school at 18, and graduate 6 years later. While this still can produce excellent physicians, it is in my opinion less desirable. First of all, they do not have the advantage of the broader education that comes with a bachelor’s degree. Secondly, they are very young. In the US, a student entering medical school right from undergraduate studies would usually be 22, but because many take off for a few years (or have another career first) the actual mean entry age in most US medical schools is about 24 (with the median a little lower). This means a more mature student body, with life experiences – at least the experiences of 4 years of college, if not in another profession, in business, in the Peace Corps, etc. This makes a difference. It also means that US medical students are more likely (and, throughout this piece, when I say “more likely”, that is what I mean – greater probability, not 100%) to really want to be doctors, rather than being there because, at 18, their doctor parents told them that they were going to medical school.

I believe that this greater maturity and life experience lead to greater independent community involvement, creation and management of free clinics, etc. As an example, at the University of Kansas Medical School, the Jaydoc student-run Free Clinic is not only completely student-run, it was student developed, maintained and expanded. There are physicians who supervise at each clinic session, but that is their entire role; the students make the schedules, recruit the volunteers, organize the operation, follow up the results, raise the money (including writing grants and doing benefits). When the clinic was created, a call went out from a student, and over 80 students attended the first meeting. They identified what had to be done: find a venue, decide on frequency, raise money, organize scheduling, on and on. Hands went up from volunteers: “I was an accountant!” “I was a community organizer!” “I was a grant writer!” “I was a teacher!” Even those who had not a previous job or career had their college experiences behind them: “I organized the fund raisers for my sorority!” “I volunteered in the free clinic in the community where my college was located!” I don’t think this happens – could happen – in a school whose students all entered at 18.

Moreover, US medical schools use a variety of criteria for choosing the students to admit. They look for such volunteer work, demographic diversity, achievements in a variety of arenas. While many students are “pre-med”, majoring in biology and chemistry, as we have seen in Medicine, science, and humanities: what is their role in medical education?, August 26, 2010, many are history, English, or art majors. (“What is the course for pre-med?”, a Brazilian medical student, in his 4th year at 21 and still confused about the 4 years US students do before medical school, asked me.) In most countries a cognitive examination is the sole criterion for entry into medical school, and social values are not even considered. Thus, say, in São Paulo (which I know a little) to say that the top 200 scores go to the most prestigious medical school, 201-400 to #2, 401-600 to #3, etc., would not be far off! I have been critical of US medical admissions because they are so skewed to upper-middle-class suburbanites (80% of our medical students come from the top 20% of income), but this skew is even more pronounced in other countries where the cognitive exam is the only criterion, and the greatest likelihood predictor of doing well on these exams is going to the “best” (and most expensive) private preparatory schools. The top 2 medical schools in São Paulo are both public and free – something the socialist government is proud of – but the catch is that it would be virtually impossible for a public school student to get a high enough score on the exam to get into one of them. To get into the free, public medical school requires attending the most elite private prep schools!

The second area in which I think American medical practice – here I am talking about the practice of family medicine – is better is that, to a large degree, our family doctors take care of their patients in the hospital. In Hospitalists, December 4, 2008, I bemoaned the fact that this was changing and that primary care doctors are more and more often choosing to (or being required by their employers to) delegate the care of their hospitalized patients to others. I will not reprise all the reasons why I think this is largely a negative trend, since they are detailed in that piece; what is relevant here is that in most other countries primary care physicians (who are, in most other countries, all family doctors or general practitioners), never cared for their own hospitalized patients, turning them over to internists or pediatricians. In this sense, the trend in the US to hospitalists is emulating practice in Europe and elsewhere; unfortunately, in my opinion, it is emulating one of the more less-desirable aspects of that practice.

Indeed, the trend over the last several decades to increase the proportion of medical students with a broad liberal education is being challenged by a counter-trend, which sees education not as important in itself, but as “job training”-- whether this is in trade school, technical college, professional school, or university. In Medical Student Selection, December 14, 2008, I present my concerns that we will narrow the cohort of medical students rather than broaden it.

Thus, as I take this opportunity to laud some of the aspects of US medical education and practice, I also caution us to continue the positive aspects of our system and guard against adopting the negative aspects of the health system in other countries, as we continue to stand rigidly against adopting their proven effective strategies of providing access to health care for all.
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