I've become somewhat disgusted with a new "vision" for hospitalists at our institution, and I wanted to get some feedback.
Just prior to the Society of Hospitalist Medicine meeting in Chicago, I read a post from another hospitalist blogger lamenting the push to degrade hospitalist medicine from a specialized clinical field of internal medicine into a "jack-of-all-trades" utility that provides a "convenience factor" for proceduralists. He called for strong leadership from SHM to voice disapproval of this dangerous trend. I didn't hear anything as definitive as I would have liked.
It seems that some hospital administrators have the misguided goal of having hospitalists admit 100% of the patients in order to allow all of the specialists (read: obscenely well-compensated proceduralists) to perform as "technicians".
At first, I thought the push to get a very small hospitalist program to start doing pre-operative medical evaluations was noble... until I realized we were only doing them for highly-lucrative elective procedures for surgeons already making 7 figures.
But that wasn't enough. Now the proceduralist/technicians want to maximize the number of procedures (which are supposed to include a global 90-day period of post-op care) without having to deal with all that pesky time-consuming post-op management. Hospitals that make money off the backs of these guys salivate at the notion of boosting their procedure output. What's the new en vogue way to achieve this? By turning over all of that post-op care to the hospitalist. We are being shamelessly used to construct the assembly line that plucks the money off the Medicare (and occasionally privately-insured) tree.
Now, at our institution, it's a total crapshoot whether or not the hip fractures wind up on medicine with an ortho consult, or ortho with a medicine consult. In either case, our surgeons do typically leave daily notes on their patients (but I use the word "note" quite loosely). I have rarely seen a shred of "management" being provided ("plan: per hospitalist"). But one doesn't have to look far to see where this is going -- the hospitalists are being used as bargaining chips to pacify the proceduralist/technicians... especially those that can uproot and take trauma-center status with them.
And so the slow march to shove inappropriate patients down the hospitalists' throat ensues. Epidural abscesses are admitted to medicine because an infection is a medical problem. Prisoners with jaw fractures are admitted to medicine because they're on psych drugs. Otherwise healthy 30-somethings with appendicitis are admitted to medicine because... well... does it really matter?
Make no mistake, I plan to exit stage left the moment it's in the cards, but is this a pervasive problem in the field of hospitalist medicine? Am I going to have to ask every potential future hospital to what degree they try to manipulate the Medicare National Bank at the expense of the hospitalists? Do you know how much money is wasted for me to do an H&P at 3am on a patient that I will literally be making absolutely no medical decisions for? With all the other bullshit hoops we have to jump through to get paid for our work, why is this not Medicare fraud?
For the moment, our proceduralist/technicians are having a field day with the administrative support for dumping on the hospitalists. I, for one, am ready to cease using the prefix "Doctor" for someone who wants to be treated like a glorified mechanic (even though I've long thought of interventional cardiologists as slightly-better-educated plumbers). You want to be a technician? Then maybe it's about time you were paid like one.
Thursday, June 11, 2009
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8 comments:
I was recently called by an oncologist to admit a patient from his clinic for nausea and vomiting and he wanted to complete their cancer work-up. The patient had no other medical problems. He then told me that he would consult (This was a Thursday by the way). I asked why I needed to admit. He could admit and I could easily consult. He then told me that I wasn't needed as a consultant and I asked then why do I need to be involved with his patient and their cancer work-up. He stated "fine" and hung up.
I am not an admitologist but that is what we are being relegated to. The proceduralists need someone to baby-sit their patients and answer the pages. I have only been a hospitalist for three years, straight out of residency, but this is my second hospital and I am getting pretty sick of the BS associated with the job.
The nice thing is our medical director and his boss are supportive of us "pushing back." But, not everyone in my group is willing to put up a fight and for the sake of calm, will allow themselves to be walked over, therefore their is no consistency. We will see how long that lasts when the specialists start to complain to the Lords above us.
when a nurse asks we a question related to something a subspecialists is on the case for, even though I know the answer, I tell them to call them. It's not my job to field their pages just because it's convenient.
I have no problem admitting anyone for which I will have something of value to add to the care. But, as Doc said, I am not an admitologist. I simply will not admit a patient for which I have nothing to offer on daily rounds.
I think we are all suffering from an identity crisis. When I was a PCP seeing my patient wherever they went--a true, patient centered medical home-- I saw the patient in the hospital, in the office, in the nursing home, and for house calls when on hospice. This was 2008, by the way, not 1978. I was truely that patient's advocate and interpreter, and the glue that held the treatment plan together for all the various special interests (surgeons, oncologists, etc) who saw the patient. Admitting the patient did not make me an "admitologist" during intern scut, because I had a much longer view, and could do my job best if I stayed as intimately involved with the patient's care as possible. We are now reaping the rewards of our fragmented views--everyone feels their part of the elephant, no one knows what an elephnt is.
Doc:
Was the N/V secondary to chemo? If not then it is not unreasonable for a hospitalist to admit.
Wow. This is causing me to have flashbacks to residency, admitting to medicine all of the patients the surgeons didn't want to deal with. Hospitalist medicine was supposed to be a field with its own unique perspectives, not a glorified (albeit higher-paying) internship.
I'm not exactly sure what you object to. You're in a field who's existence arose to meet the need of inpatient hospital management which is what you're being asked to do. Much like an intensivist, there's literature supporting improved outcomes on a number of parameters in some groups of surgical patients when they're inpatient care is managed by hospitalists.
It seems imminently logical to improve efficiency of a system like ortho, neuro, or CTVS using delegates for inpatient postop care. Much of the convalescence of these patients is from their medical co-morbidities rather then post surgical care.
Dr. Rob, you have a point, but although some patients are complicated, most do not require a Medical Village.
If the hospitalist simply does the post-op care work for the procedure performed and which is included in the surgeon's RBRVS payment, the surgeon is defrauding the MNB and misusing the hospitalist.
Refugee, if you're not careful you'll be replaced by a nurse practitioner or physician assistant. I need my paycheck. Hospitalists have something worthwhile to contribute to most every patient's care.
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