Mr. G went to Howard County General Hospital with a urinary problem.
Ninty-two-years-old and suffering from dementia, but very vibrant with the help of his wife, Mr. G still was an active musician and living a good life. But his hospitalization put a dent in that.
After diagnosing Mr. G with a urinary infection, his hospitalist doctors found many other "problems," consulted five specialists, sent him for a series of tests, put him on insulin and many other medicines, gave him intravenous antibiotics, and kept him in the hospital for over a week. When he left, I, his primary care doctor for many years, found him weak and confused, far worse than when he came in.
We had to stop these new medicines, none of which were indicated based on prior experience, and a review of his hospital stay suggested most of his tests and treatments were unnecessary. Had the hospitalist doctor contacted me, this trauma could have been avoided, his stay could have been shortened, and his decline could have been averted. But that contact wasn't made.
In Howard County General Hospital, primary care doctors no longer can care for their patients in the hospital. That care has been transferred to hospitalists: hospital-based doctors who know nothing about the patients for whom they care.
When I tell my patients about the system that has been implemented, they are shocked to learn that hospitalists have no obligation to contact me, the doctor who knows them best. In fact, despite having typically five elderly patients in the hospital at any given time, I can count on one hand the amount of times I have been contacted, even if families insist on it. I can also recall multiple patients whose hospital course could have been dramatically improved had that contact been made.
To ignore someone who knows a patient's history, wishes, past workups, medicine failures and overall status is truly not optimal medical care. When primary care doctors are marginalized, especially with elderly patients, outcomes are worse, cost is higher, and patients and families are more likely to feel lost and unable to make good medical decisions.
To its credit, Howard County General and its president, Steve Snelgrove, have been exploring this issue and working on solutions. Also, the hospitalists are good doctors who are devoted to care. But by not being compelled to contact a patient's primary care doctor, they are working blindly, typically ordering medical interventions and consults about which their primary care doctor could have provided useful insight. For patients to engage in shared decision making in the hospital, they and their doctors need to have all available information and experience, and currently that is being neglected.
The hospitalist movement is a national phenomenon, certainly not something confined to Howard County. There is some wisdom behind it, as it is prudent to have doctors totally devoted to hospital care.
But if those doctors work independently of the doctors who know the patients best, then there is no possible way they can provide optimal care. Steve Schimpff and I wrote an article in Medical Economics looking at the communication breach nationally. For me as a doctor in the community, I am most concerned about how it affects me and my patients, many of whom are frail and elderly and do not fully understand their options or the dangers of the aggressive care being tossed their way.
Moving forward, we in primary care, and our patients, hope that Howard County General Hospital compels hospitalists to contact primary care doctors on admission and, if desired by the patient, at points of medical decision making. This should not be voluntary.
In my practice, many of my patients plan to write to the hospital to express their wish that such communication become mandatory, to enable more comprehensive and sensible care. I would suggest that others follow the same route.
Andy Lazris is a primary care physician in Columbia. He is co-chairman of the Right Care Alliance Primary Care Council, the author of "Curing Medicare" and the co-author of "Interpreting Health Benefits and Risks."