Friday, May 28, 2010

New York Times on the hospitalist movement

New Breed of Specialist Steps In for Family Doctor.

DB linked to the article and noted:

Of course, even the Times cannot write a nuanced article about either primary care or hospital medicine. Since I have spent much time working in both fields, I can see the omissions and flaws in their articles.

If they must simplify this issue, then what happens in their other articles.

I’ve never known the Times to nuance much of anything concerning health care. So let’s go through the article. Concerning hospitalists it says:

Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.

As DB pointed out, the piece fails to distinguish between family practice and internal medicine. The next paragraph reads:

Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association.

That paragraph, although literally true, is deceptive. Yes, hospitalists are widely credited with reducing lengths of stay and costs but that claim, as I have pointed out several times before, is not supported by evidence, bolstered by a huge case of publication bias.

In the next paragraph (my italics):

Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.

I have dealt with sloppy language about “medical errors” at length before and will not belabor it here. The next sentence on avoidable readmissions has no evidence to back it up. 30 and 90 day readmission rates have been cited for some diagnoses but we have no research data on how many of those are avoidable. It goes on:

“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun…”

That’s not entirely true. Since 1983 Medicare has not reimbursed hospitals for the care patients received and hospitals lose money on many Medicare admissions. Then a few paragraphs down:

Bad discharges generally result from hurried instructions to patients and families and little thought to where they are headed. One such situation was the centerpiece of a class taught for doctors at Mount Sinai Medical Center in New York. The patient, an elderly woman in the hospital for scoliosis, a spinal condition, was discharged by a hospitalist on a Friday night, with a prescription for a narcotic pain reliever that her pharmacy, as it turned out, did not stock. No one explained how her new medication differed from the old, or gave her a contact number for help. Without medication, by Tuesday, her ankles swollen and her breathing irregular, the woman was back in the hospital.

Since when does withdrawal from narcotics cause ankle swelling and irregular breathing?

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