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Tuesday, January 6. 2009

Do you want a "Hospitalist"?

General hospitals are increasingly relying on "hospitalists" to care for inpatients, freeing up office practitioner's time for their (steadily less lucrative) outpatient practices.


I have yet to be a hospital inpatient except for childbirth, but I think that, if and when I am, I'd like to see the face of my own Doc daily. 


This is a new model for medical practice. More time-efficient? Probably. Less comforting? Probably. Overall, better or not? I cannot say.


Internists, and what few GPs still exist, are having a tough go of it these days: Medicare, which is the bulk of their work, compensates them now at a rate lower than a plumber or electrician in Boston.

Posted by Dr. Joy Bliss in Medical, Our Essays, Psychology, and Dr. Bliss at 12:58 | Comments (14) | Trackbacks (0)

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From the patient's standpoint it is for the worse, I believe. Husband and I had the same internist we saw every four years or so for physicals for over 18 years then he quit, fed up with malpractice suits and insurance companies trying to limit his care as well as his income. I got another one to have in reserve in case I get sick. In less than a year he quit too, fed up with similar issues. At this point I am not bothering to have a family doctor any more as what's the point of a relationship with someone who knows you and your health history well enough to be able to assess when you are really sick and when you are just demoralized if they won't be around when you actually get sick??? I will take my chances in the hospital if it comes to that.

My kids have had the most atrocious pediatric care over the years, afterr their saintly nORMAN roCKWELL ish baby doc retired. A group practice of five minute visits and insurance protocol driven where they knew little specialized. It's a good thing they are all healthy, as otherwise I would have gone ballistic. I made the mistake of picking a female for the girls' doctor (as a good role model--perhaps it had its effect as one kid plans to apply to medical school) But she did the mommy thing and was only ever in one or two days a week which made her unavailable the few times our girls were actually sick. I respected her for doing right by her own kids by being home, but I felt abandonned the few times my kids were in deep trouble and got awful care from strangers. Go figure. In an ideal world, people like us who live somewhere over 20 years would know their doctors, and the care would be more informed (fewer unneccessary tests because family history and circumstances would help rule stuff out). But more and more we seem to be mo9ving towards the crisis care people from the inner city have had for years. High tech emergency care that knows nothing of context or history. Fine for gunshot wounds, but not much good for more complicated health problems. Pls excuse typos from typing without glasses on tiny netbook!
#1 retriever on 2009-01-06 13:59 (Reply)
I do. I kind of like the thought of a full-time employee of the hospital being responsible for my care, rather than someone who waltzes in and out.

But then at my local practice I prefer to see the NP rather than the Doctor. I'm under the illusion that I get more attention and that I don't really have any unusual condition.
#2 Douglas2 on 2009-01-06 14:06 (Reply)
...full-time employee of the hospital... NOT. They are probably members of a separate practice which contracts with the hospital. This does not make them bad or good, but it releases the hospital of some liability.
#2.1 dorf on 2009-01-07 09:49 (Reply)
What we're seeing here, my friends, is how "universal health care" is going to be when the Obama administration gets going. We all know how well it's worked in Britain and Canada... or not. Canada in particular has been sending its difficult cases down over the border to us. And it keeps emergency cases in the ambulance in the hospital parking lots sometimes as long as six hours, to improve their emergency room waiting times. So the serious cases sometimes die in the ambulances.

On New Year's Eve, my husband had a cat scan at a medical imaging facility. The staff managed to damage him by rough handling to turn him over. He has a chronically weak rib and muscle attachment and the rough handling seems to have either detached his muscles, leaving him in considerable pain. {He's 83 after all, and somewhat fragile.} All this high tech and low interest specializing of medicine is damaging to patients and damaging to America's reputation as one of the greatest medical systems in the world.

Pretty soon we won't have such a a great system any more. And if we're old and unable to protect ourselves, we'll be discarded by the hospitals with the rest of the trash. A bleak prospect.

Jappy was right when he advised us to stay out of hospitals.

Marianne
#3 Marianne Matthews on 2009-01-06 14:36 (Reply)
Hope.and pray he recovers soon, Marianne.
#4 retriever (Link) on 2009-01-06 15:16 (Reply)
Retrevier, many thanks for your well wishes. When I mentioned to Marrianne about staying out of hospitals I was referring to my parents experiences. For the last 4 and a half years I have been caring for my ageing parents, my mom died two years ago, but my dads still alive. They have really had the kitchen sink thrown at them in that time frame. Serious stuff, cancers,leg amputations, stents, vein transplants etc. etc. etc. I have been by their side every single time. Hospitals have become cold, insensitive, institutions which are run by there masters the insurance companies. My parents doctors have been great but it's the hospitals that have the major issues. They want you out the door as soon as you arrive

Had to put my mom in a nursing home for the last two years of her life. Their all the same you can dress them up in a fancy, fancy building but the stench of urine never seems to leave. My mom did get good care at her facility but their a sad place to visit, gut renching

I could write a book about the last 4 and half years of my life I'm looking for a good writer maybe you and Marianne could help me out?
#4.1 jappy on 2009-01-06 17:39 (Reply)
Jappy, you have my admiration caring for your dad. I hope you and the rest of your family are able to enjoy the good parts of having him close, despite the fatigue from caring 24/7 for someone as they fail.

I lost both parents, both parents in law, a brother, and had a sister deathly ill for months, plus two children ill repeatedly within a few years recently. It took a huge toll on the few family members left. My kids have been to funerals and hospitals galore, but one wedding in their entire life. Life out of balance.

I found and find that I can only surmount the inevitable caregiving burnout without being driven to drink by prayer and church, nature, my animals, photography and friends, and writing so much I could put half the known universe to sleep (like Vogon poetry in The Hitchhiker's GUide??).

The internet truly is a godsend when one is housebound worriedly looking after someone ill or weak. One can argue, comfort, fight, trade jokes, get all het up about stupid loathsome political scumbags and make friends and enemies galore without ever leaving home!

One summer in a sweltering non airconditioned British NHS hospital room with 8 frail old ladies doubtless dying faster than they need have been (cost cutting, not to keep them cool, even ones with heart conditions in a heat wave), I kept my spirits up whilst sitting next to my comatose mom rasping with pneumonia by bickering on my blackberry with somebody (probably habu? or maybe it was someone else) about something asinine i had written that they were objecting to.

It totally cheered me up. Until the dragon lady "Sister" Brit nurse advanced on me and bellowed "Give me that THING this instant. It is against hospital policy" and grabbed my Blackberry. One doesn't argue with a British Head Nurse.

Life goes on. May God bless, preserve and keep you,J.
#5 retriever (Link) on 2009-01-06 20:41 (Reply)
Jappy, My head is bowed to you. What a man you are. I've thought that since way back when I realized what you do on weekends. I went through it with my mom and will go through it with my dad, and that's okay with me.

I'm lucky in my town because we have one of the best hospitals in the state. It's hooked up to the University of Virginia hospital, and any doctor can get your entire records with a couple of clicks on a computer, and specialist care is an appointment away. All staff are under orders to be nice or die - kinda like Walmart, and they are almost too attentive and friendly. I've had the same two doctors for the last twenty years and adore them.

As far as letting the (I can't say that 'ist' word) hospital people take care of me, I have no problem with that. Doctors work so hard visiting in-patients in the morning, seeing patients all day and then going back to see in-patients.... Too much. If their jobs were less stressful, maybe many wouldn't opt out and change careers. With everything about you and your care instructions computerized, it's all good.
`
#6 Meta on 2009-01-06 20:50 (Reply)
retriever ... thank you for your kind wishes about my husband's torn muscle/ damaged rib or whatever it is. He's had it before, which is why he had to give up racing sailboats when he turned 60. Oh, yes, he's quite a daredevil. He has osteoporosis, though, now, and that is worrisome. Whodathunk he would get physical damage from health professionals, though.

The health care business is becoming a difficult problem, I think. The system is terribly overloaded and going to be more so when the Obamaplan universal health system is forced upon us.

I think, if one is hospitalized for an operation, one should have one's own personal family ombudsman [or woman] for the post-op period. If they're yours, then you are their first responsibility. If they are 'hospitalists,' they belong to the hospital and protect the hospital, first and foremost. When I had my hysterectomy my mother, who lived in Virginia, was somewhat ill and fairly old, and couldn't come to help. But she sent me a check to pay for a private nurse to stay with me the first three nights. It was a great gift, that really saved me a lot of discomfort and set me firmly on the road to recovery. [This wasn't like many of today's hysterectomies, by the way. It took four hours under anaesthesia and took quite awhile to recover from.] So my mother's gift was quite literally a gift of a normal life.

I guess being in hospital is kind of an adversary proceeding, as lawyers say. That's why you need your own protector.
Marianne
#7 Marianne Matthews on 2009-01-06 22:35 (Reply)
Marianne,

I had that muscle-rip thing once. Hurts worse than pleurisy. Have you asked your doctor about Reclast? It's an I.V., once-a-year infusion of medicine that turns bones to Teflon. The monthly pills for osteoporosis can stabilize the condition, but Reclast is 5 thousand times more potent. It is the only thing used in Europe for osteoporosis - depending on the severity, and Boniva and Fosamax are almost never used. Big Pharma kept it from becoming available here for general use until this past year. (It's also called Zometa.)
`
#7.1 Meta on 2009-01-06 23:15 (Reply)
You are so right, Marianne. You are a blessing to your husband. In our family we have had many troubles,but we are all fiercely loyal to each other when jousting with insurance, hospitals, etc. It's sad that it has to be so. Ironic that it costs one quarter or less as much to go into the Hyatt with full room service than to be ignored and given bad food and woken up all hours in hospitals where dirty people never wash their hands and spread germs to you. In the NHS hospitals, the doctors and residents were the worst for not washing their hands, nurses better. I once royally pissed off a teaching god and his acolytes at the hospital my mom was suffering in by saying loudly "NOSOCOMIAL" when they turned from examining the patient next to her to check her out. Sheepishly they went to wash their hands.

We have generally received good care from all our community practitioners (until my GPs quit to take up basketweaving, or go to rehab, or whatever) but the ones in hospitals had no connection with them or us,and no accountability.

I used to use my languages to sweet talk the various Spanish and Haitian nurses' aides, etc so that they would be nicer (I hoped) to my ill parents,etc. As you see now,being there with them, visiting, is the best assurance you have of getting them better care.

I also used to practice guerrilla visiting tactics: after seeing my relative, I would wash my hands and pick a a random person who had smiled at me and nodded as I passed their room, who was not getting visitors on the floor, to visit visibly. Of course I would ask if I could come in, would say that my mom had fallen asleep but that I had come so far to visit, I was lonely and wanted someone besides a busy nurse to talk to. I used to be a chaplain, so I am used to asking if I can visit...If they told me to go to hell, or were asleep, I would make sure the nurses and staff had seen me there anyway. As I left,I would blather at the nursing station about how "Oh what a surprise, to see my old English teacher/neighbor/cousin's wife! Do make sure she gets the chicken Parmigiana! Her favorite!" It sometimes helps a person get better care. However, obviously, the handwashing, the permission, and never ever let your own relative see you or mine at least would get peevish and jealous.
#7.2 retriever (Link) on 2009-01-07 07:28 (Reply)
I have 11 years of primary care Internal Medicine practice experience, and am a gastroenterologist with 16 years of practice experience.

I think that if a stranger from Mars visited America he would conclude that taking good care of sick people is some sort of crime, judging by the way primary care physicians are treated. He certainly wouldn't conclude that primary care docs are a valued and esteemed resource.

Thank God I don't do primary care anymore. What was once a noble calling and a rewarding career has been turned into a miserable existence. No offence, all you folks, but if you want to know why, take a look in the mirror. No, you didn't invent all the suffocating regulations. You didn't found the rapacious insurance companies. You didn't design the Medicare monstrosity.

But you DID vote for the architects of this mess. And, knowing full well that we have serious problems, America just voted for more of it.

Does anyone really expect a young person to sacrifice his youth and young adulthood to master a profession only to be just getting by economically for the rest of his life, while being harassed all day by 1) insurers who have endless ways to avoid paying him for his work, and 2) angry patients who were promised prompt, personalized care by the same insurers and now find that the doctor doesn't have time to be prompt and personal?

I too would rather my personal physician see me when I am hospitalized. But the hospitalist movement is an entirely predictable result of the actions of.......American voters. Stand by for more of the same, because when we get national health care it's going to be damn hard to find someone who'll get out of bed in the middle of the night to take care of you. Why should anyone go the extra mile day in and day out when he'll get the same reward as someone who doesn't? You all better pray that there are a lot more saints in this country than there appear to be.

I'm self-employed, so I can set my hours and take as much time with my patients as they need, and because I'm a specialist I can usually stay in the black. When that all changes, I'm gone. I'll do something else. And so will many others. Whoever is left will be not your doctor, but an employee of the government.

This may be seen as a whine or a rant. Whatever. But I'm not exaggerating, and the facts don't care.

God bless you all who sacrifice to take care of sick loved ones. There will be stars in your crowns when you stand before the Judge.
#7.2.1 Khornet on 2009-01-07 12:14 (Reply)
It's not a whine or a rant. My ex is a veterinarian and though he does not have the insurance problems, he's seen it all. He used to be on-call varying nights with his partner. People usually call just before they get in bed after Fluffy has been sick all day and suddenly they think he'll die in the night, and the horse calls that last half the night, they finally, after twenty years, turn patients over to a service that works emergencies only. He loves his patients; it's the owners who can often be demanding and unrealistic. I have often said I've never known anyone who works harder than he does.

Good luck in your practice.
`
#7.2.1.1 Meta on 2009-01-07 12:43 (Reply)
Retriever,

For a self-professed devout woman, you would do well to stop braying that you are above anything that walks upright on this planet.
`
#7.2.2 Meta on 2009-01-07 12:50 (Reply)

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