Monday, February 2, 2009

Who's That Doctor?

***FCC Language Warning, Internet Version***

I promise not to dwell excessively on political topics unless they should touch upon medicine and health care, but forgive this one digression. If someone could please explain to me what the fuck President Obama is doing right now, just over one week into his presidency, would you please send me an e-mail to explain it? I am dumbfounded, and deeply worried that we are experiencing the beginnings of Clinton Redux. What I have witnessed over the past seven days is not why I went to the trouble of explaining to virtually all of my friends, who were Hillarites to the nth degree, why she palled in comparison to The Real Deal. This in a state that Clinton crushed Obama 56-41 in the primaries, and my wife and I took heat for being politically-naive daydreamers by supporting The Big O. So, if you've got some understanding of how our President is savvily gaming the system for the greater good, please let me know.

Anyway, today's post is based off a little study done out of the University of Chicago Medical Center and reported in the Annals of Internal Medicine that finds that about 75 percent of patients admitted to their medical center could not name any physician involved in their care.

At some level, this is not altogether surprising, given the structure of an urban, academic, referral medical center: it's the nature of the beast at a place like U of Chicago to have multiple physicians, each from various subspecialites, taking care of a single patient. Plus, each of these physicians are usually in charge of a "team" of apprentice physicians, each with their own rank in a hierarchy well known to those involved in the system but undoubtedly byzantine to patients themselves. (After all, those who play the game know that, say, Fellow trumps Intern, but to a patient ignorant of hospital culture, the only way to find the correct answer would be to guess. I myself can't keep track of ranks within the military, with what little I do know derived from watching far too many reruns of M*A*S*H*.) All in all, not precisely an earthshattering revelation.

Why this study interested me is that I would be willing to guess that if you ran that study at a smaller, 200-bed community hospital where there's a hospitalist program, you'd probably obtain a similar result. That wouldn't have been true 20 years ago, when the vast majority of patients at local community hospitals would have known their doctors by name, because their inpatient doctors would have been their outpatient doctors as well.

At small-to-medium community hospitals there's often no connection between the inpatient docs and the primary care physicians in the community (speaking at least partly based on my experience observing the hospitalist group for which I moonlight), so patients may know their outpatient MDs but have no clue who's the one "in charge" of their care at the hospital. Even the PCPs may not know the hospitalists beyond anything but name, since the turnover rate for hospitalist work is fairly high, so cross-communication between docs behind-the-scenes doesn't take place.

There are some ways to blunt this effect: handing out business cards (the practice I work for encourages this, although I don't know how often the hospitalists follow through on it); taking a few minutes to explain the system and the primary/consultant concept; and the most important of all (though not necessarily easiest), frequent stops by the patient's bedside to communicate with said patient directly. These solutions, which are decidedly low-tech and easy to implement, will only have an impact if hospitalists and hospital administrators prioritize the problem, however, and I'm not sure that those groups are fully aware of how much impact this can have on a patient's sense of safety in the hospital.

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