Monday, July 21, 2008

Should hospitalists take over the world of inpatient care?

No. A story from the Annals of Family Medicine speaks louder than all the “data” you can marshal about hospitalists and outcomes. The author, Cherie Glazner, M.D., saw the exodus of primary care physicians from her hospital and agonized about whether the old fashioned doctor who makes hospital rounds and sees patients in the office is obsolete. A personal experience provided a compelling answer:

Resolution to my uncertainty came to me most unexpectedly. The next day my mom called; she was taking my 85-year old grandmother, 6 days after receiving a stent in her left main coronary artery, to the hospital. I met them in the strange familiarity of a distant emergency department. The cardiologist, wizened and gray headed, had no explanation for her sodium of 120 mEq/L, her bigeminy, and her low blood pressure. My grandmother, who had raised 4 children on a subsistence dry-land farm with no water or plumbing, explained in her tired and timid voice that the problem was too much medication, but to no avail. The nephrologist would see her in the morning. She wasn’t having a heart attack. Her stent was fine. Dismissed.

The next morning, feeling fatigued, defeated, and fearful of death, my grandmother confided that no one appeared to be in charge. First one cardiologist, then another, had come in without answers. The nephrologist had not yet been in, but she was restricted to 1,000 mL of fluid for the day. She wanted to know why no one had spoken to her family physician. He knew that her sodium bottomed out on hydrochlorothiazide, which the cardiologists, unaware of her history, had started 6 days ago. Her family doctor knew she could not tolerate a blood pressure of less than 120/70 mm Hg, but the cardiologist’s opinion was otherwise. Her family physician knew her passion lay in her rose beds and perennial gardens now that water was freely abundant to her. He understood that for my grandmother to feel too weak to stand up and walk her gardens was a type of death.

We’re not told whether a hospitalist was placed in the middle of this mess, but I suspect so. I also suspect that the hospitalist, steeped in evidence based medicine but pressed for time and functioning as an admitologist in deference to the subspecialists (it's called co-management) was as much in the dark as they concerning the patient’s idiosyncratic reaction to thiazides and blood pressure medications. I think, anyway, that that’s how this all too typical story plays out in many hospitals.

If you attended SHM 2008 you might think the hospitalist movement, like Walmart, is out to take over the world. But I don’t think most hospitalists in the trenches have that agenda. Some traditional practitioners have good reason to quit the hospital. Others can still juggle hospital and office duties and do it well. They should keep doing what they’re doing.

DB over at MedRants has blogged about this story a couple of times and posted a response in the journal. I may comment further after I read his take.

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