A few weeks ago the New York Times published an interesting piece on hospitalists caring for patients and particularly what hospitalists are doing to improve the discharge planning process to improve care and reduce rehospitalizations. (See "New Breed of Specialist Steps in for Family Doctor.") While the separation between physicians practicing specialty or primary care medicine in outpatient settings from those providing care in hospitals is not new (the Times ran a story on it in 1998: "A New Breed In Medicine: 'Hospitalist'"), it remains somewhat controversial.
Without citing it as such, the story talks about the Foundation-sponsored project BOOST (Better Outcomes for Older Adults through Safe Transitions) at the Society of Hospital Medicine (SHM). Under this $1.4 million award, built upon smaller, earlier grants, SHM has prepared a tool kit, curriculum, and roll-out process to improve the discharge process for older adult patients. BOOST helps hospitalists successfully “hand off” the patient from the hospital to the next step in care, be that home with a primary care physician, home health services, or a rehabilitation site.
The most striking thing about this story is the audience response. On the New York Times blog related to the story, the comments are something like 77 to 1 against hospitalist care. Now, I don’t believe that community-based docs trying to round on their patients early in the morning and interact with the hospital-based medical team between cases in the office--essentially practicing hospital medicine on a part-time basis--actually do better than hospitalists. Yet these patients seem to think so. The blog’s comments express concerns about hospitalists knowing nothing of the patient as a person or of treatment history, and also highlight a profound lack of coordination.
Once again, I think that health care has fundamentally misunderstood the nature of teamwork. While the audience’s comments are probably wrong about the relative benefits of hospitalists--most people are unaware of the harm that fragmentation and inattention cause daily in the traditional system of care--the audience is on to something important.
Perhaps the problem is that unlike real, high-functioning teams, in a hospital the purported team members often don’t know each other, don’t communicate well, and don’t usually have a common playbook (be that electronic record, treatment protocols, or approved pharmacy lists). And a sham team is worse than no team, as it leads to mistakes. (As a micro example, one of Atul Gawande’s checklist items for surgical teams preparing to operate is for everyone to introduce themselves by name and role. It turns out that yelling, “Hey you, in the scrubs,” isn’t the best way to get someone’s attention during a surgical emergency.)
What I think the people commenting on the New York Times’s blog are really reacting to is their shock and surprise that when they or a loved one was in the hospital, a different team member than expected turned up to provide care. Not only does this violate expectations, but it undermines any sense of control that patients and families might have had. You might have put a great deal of effort into communicating your preferences and goals to a primary care physician and shopping for one that meets your expectations for credentials and experience, only to find that it doesn’t matter at all in an emergency.
Think about it--what kind of team is it when a key member (if not the captain), the patient/family, is surprised by a unilateral substitution late in the game? Primary care and other outpatient physicians need to be up front and clear with their patients on how—and if--they will be involved with hospital care. Patients and families, particularly those whose age and chronic illnesses make hospitalization likely, need to know who will be providing care in the hospital. Ideally, patients and families should be able to make decisions about who provides that care. I wonder if we could find a way to make that possible?