Three Degrees of Separation

In February 1994, Ms. Sampson's emphysema was causing shortness of breath, which limited her activities. I advised her to call if her respiratory symptoms worsened. Two days later, she did. I saw her in the office, began treatment with oral steroids, advised an increase in her rescue 2-agonist inhaler, and started antibiotic treatment. The next morning she was worse. I advised her to go to the emergency department and asked our practice staff to fax over information. I arrived after the emergency department staff had seen her and reviewed films and blood gas results that revealed an increasing Pco 2. Consulting with the emergency department staff, we concurred that she should be hospitalized. I completed her history and physical, talked with nurses and residents on the floor, added faxed office notes to her record, began intravenous steroids, and let her know I would return in the morning. Before leaving, I listened to her husband's concerns. He felt responsible that his wife smoked until 3 years before. I reminded him that we both did a lot to help her quit. I told him that after her discharge, I would arrange to see Ms. Sampson in our office for her follow-up care. From 1990 to 1998, I served as chief of medicine at a wonderful community hospital. Our mission was to see people, not just patients. We promulgated George Engel's biopsychosocial model and understood the relationship between nurtured, respected practitioners and the patient care they provided. When patients were hospitalized, we covered them with residents and faculty. Because our practice was located in the hospital, we checked on patients throughout the day, often visiting them and their families before leaving at night. These late visits grounded me in patients' experiences of hospital care. I knew when things were going well, and I was there to witness the loss of control that illness and hospitalization often bring. I created postdischarge plans, and later, when seeing patients in the office, knew what had transpired. I left that position in 1998 and took a job 10 minutes away. The casual visits at days' end evolved into stressful attempts to manage patients' needs within my schedule. I began visiting patients once a day and stopped in less and less. Over the past decade, more than a geographic distance interfered with the care I delivered. In reality, hospital-based medicine changed, and I wasn't able to keep up. In the new system, I struggled with the computerized physician order entry system, had difficulty finding digital films, and rarely saw physicians that I recognized. The centrally located doctors' lounge, where generalists and specialists once discussed mutual patients, difficult cases, or just chatted, was moved to an area where few ever ventured. As opportunities to talk decreased, specialists and generalists became less active collaborators. Finally, in 2007, my practice group joined the hospitalist service. I was a hold out because I worried that I would be abandoning patients when they were most vulnerable. However, the hospitalist system did have advantages. They were on top of protocol changes and treatment guidelines for hospital-associated conditions that I was seeing less often. They would be available to visit patients throughout the day, while I could still be involved in my hospitalized patients' care, and, of course, on-call nights would be easier. Frankly, at 60 years of age, I was relieved to no longer drag myself into the hospital emergency department at night to see a patient. In April 2008, Ms. Sampson was again hospitalized for respiratory failure. I found out because her husband called me. He gently inquired, Do you think you can see her? It would make her feel more comfortable. I stopped by that evening. It was quiet on the floor. I entered the room as her nurse adjusted the intravenous line. I introduced myself to the nurse. She was cordial but displayed little interest in my relationship with the patient. Ms. Sampson's first question was, Why do I have to get a head CT? She was 72 years old, hypercapneic, and a bit confused. We talked; I examined her and found no focal deficits. She conversed logically and there didn't seem to be a detectable difference from her baseline, although I expected her to sundown from being in the hospital. I was not sure what to do next. The staff did not ask me to participate in Ms. Sampson's care; I wouldn't have known she was in the hospital if her husband hadn't called me. I contacted the hospitalist on call. He said he had not admitted her and did not order the CT. However, he related that the admitting attending was concerned about Ms. Sampson's use of alprazolam, given her respiratory disease. Did you know this could be harmful? he asked. As a communications researcher and educator, I considered suggesting, Can you tell me why Ms. Sampson is taking alprazolam? that would have been more collaborative. Instead, I answered that she had received a diagnosis of a panic disorder, and for the past 6 years, her condition had remarkably improved while taking the medication; missing doses resulted in increased symptoms. The CT scan question was lost in my sense that I was viewed as the local medical doctor from whom the patient needed to be protected. At that moment, the lack of continuity in the patient's care seemed stark and disappointing. My experience with Ms. Sampson's care has become the norm. After almost 2 decades of admitting to the same hospital, visiting patients there now feels like entering a foreign world. When I agreed to the hospitalist system, I believed that I would be a member of my patients' hospital team. Primary care doctors would collaborate with hospitalists to assure that the art as well as the science of medicine would be maintained. However, that fantasy has yet to be fulfilled. I am notified by fax of a patient's hospitalization. I am seldom informed of a patient's arrival in the emergency department or consulted to discuss their impressions and integrate my knowledge of the patient's ambulatory course into the decision-making process. Most of the time, I find out about patients in the emergency department because they or their families call me. Patients erroneously assume that I have been part of the admission conversations. My belief that hospitalist care would result in abandoning my patients has largely been validated. As a new system replaced the old, we have lost continuity of care and the core element of effective cross-coverage: skilled explicit transitions of responsibility from one clinician to another. What the Sampsons should have heard was, I've talked with Dr. Beckman. We agree that the CT decision can be delayed until your respiratory symptoms improve. Patients and their families are asked to make important decisions for which they often have little knowledge or preparation. Their primary care doctor is often the bridge and the translator. When I support my hospitalized patients by visiting them, their relief when I arrive and their smiles, hugs, tears, and questions confirm the roles that trust and continuity play in caring for those moving from the comfort and predictability of home to the loss of control in the emergency department or hospital. Quality of care includes patient-centeredness. If we ask hospitalized patients and their families what they want, I doubt that they would choose the current model. The new system has evolved on the basis of incentives. What incentives do hospitalists have to understand Ms. Sampson's perspective? Because of rotational coverage systems and infrequency of admissions, it is unlikely that the admitting hospitalist will care for her again. What incentives do primary care physicians have? Systems do not reimburse for sending records, talking by telephone with the hospitalist or family, or visiting the patient. How much value does past knowledge or continuity of care play in diagnostic decisions? How valuable is the family or patient's perspective or their agreement with the care plan? I am not sentimental and don't wish to return to the old days. I believe in identifying and promoting best practices and encouraging the efficient use of available resources. A system that uses hospitalists can adhere to guidelines, provide organized team-based care that reduces medical errors, and improve outcomes. However, if our goal is to continually improve care, hospitalists, primary care physicians, and administrators have to partner more effectively. Are patients receiving the integrated care they need? How should primary care physicians be involved in decision making and care transitions? Are hospitalists satisfied with the care delivered, and if not, how could the process change? Finally, do the incentives in place encourage improvement? When I entered Ms. Sampson's hospital room for her latest admission, she said, Thank God you got here, I can't figure out what is going on. I refrained from sharing that I couldn't figure out what was going on either. We simply must do better.