Go on rounds—in a hospitalist's shoes

Does continuity of care suffer when hospital cases are handed off to an inpatient specialist? Look over this one's shoulder and see what you think.

By Neil Chesanow
Northeast Editor

It's 8 am at Lovelace Medical Center, a 235-bed acute care facility in Albuquerque. Internist Mark L. Wesselman is preparing to round on the hospitalist service. After seven and a half years in an internal medicine practice, Wesselman, 43, became a full-time inpatient specialist in 1999 because, he says, "I'd become disenchanted with my office practice and needed a change."

Lovelace—a 254-doctor staff-model HMO encompassing a hospital, a large internal medicine group, and doctors in private practice—was a pioneer in the hospitalist movement. Its inpatient service dates back to 1993. Hospitalists at Lovelace are intended mainly as a convenience to primary care physicians, Wesselman says. "Most FPs and internists around here are glad to give up hospital work. It lets them keep regular hours, see more patients in the office, and sleep in their own beds at night."

As an internist, Wesselman typically saw two to five inpatients each morning for 45 minutes or so before starting his day at the office. Now he rounds on about 20 patients during his shift. Among the most common problems are pneumonia, chest pain, CHF, altered mental status, pancreatitis, abdominal pain, diabetic ketoacidosis, thromboembolic disease, and infectious diseases.

In the year and a half that Wesselman has been on the team, more than 3,000 patients have been admitted to the hospitalist service. From a managed care perspective, lengths of stay are appropriate, and there have been no major complaints—and no lawsuits. "We do a pretty good job," Wesselman reflects. "Most patients seem happy with it."

8:00. Daily strategy session, hospitalist team room. Hospitalists Mark Wesselman, William Schaeffer, and Payson Ripley convene to discuss the day's schedule. They determine who will care for which patients at what times, and review the patients' needs.

Team members take turns being "rounders" and "admitters." Busy ER doctors are happy to have hospitalists assume responsibility for admitting patients. The service has two hospitalists rounding on seven-day shifts, and three who admit ER patients during rotating 12-hour shifts. Other members of the hospitalist team are off until the following week.

9:20. Preparing for rounds. Wesselman chose a light day for our visit. Most of the 10 patients on the hospitalist floor can be seen that morning. With the census low, Wesselman has time to see his own internist for his annual physical, which he does first. He then heads for the nurses' station to retrieve charts for the day's patients and check their latest lab results at a computer terminal. He also chats briefly with infectious disease specialist Joe Gorvetzian.

"Who has Mrs. Colorado?" Gorvetzian asks.

"I do," Wesselman answers.

"How's her asthma?"

"Much better. I hope to get her out of here today."

Because Wesselman now regularly rubs elbows with subspecialists, getting curbside consults is a snap, although he requires them far less often than when he was office-based. "Before, when I was called to the ER, I'd pore over the patient's chart, trying to figure out what medical issues to address and in what order," he says. "Now, after a year and a half as a hospitalist, I can eyeball records and confidently say, 'This can wait; that can't.' "

9:45. Patient: Thomasa Colorado, 73. Problems: asthma, diabetes, mild organic brain syndrome. One thing Wesselman has learned: The treatments he prescribes as a hospitalist are often no different from those he would have recommended when he was doing primary care. "Sometimes, a hospitalist doesn't add a thing to patient care," he confesses. His first patient, Thomasa Colorado, is a case in point.

"Mrs. Colorado was admitted through the ER with exacerbated asthma. Any internist or pulmonologist would treat her as I did," says Wesselman. "At times, I can get a patient like her discharged faster than an office-based doctor would. A hospitalist learns how to work efficiently within the hospital bureaucracy. But in Mrs. Colorado's case, it made no difference."

10:10. Patient: Jolene Glenn, 40. Problem: aggressive cellulitis. "Jolene was admitted with significant cellulitis that's more complex than average," Wesselman observes. "Despite treatment, she still has fever and a lot of edema. We're concerned about deep-seated infection. When I took over her care four days earlier, she'd already been hospitalized for two days. I was alarmed by her fever, as was her husband.

" 'My wife's leg isn't getting better,' Mike Glenn told me. 'What's going on? Why weren't you here this morning?'

"I explained that Mondays were typically busy, but that I'd known about his wife, shared his concern, and planned to get an imaging study and a consult from a subspecialist. That reassured him. Since we don't have primary doctors' ongoing relationships with patients, diplomacy is essential."

Wesselman had two motives for requesting a consult. "When you're not sure what's going on, two heads are better than one," he says. "But I also knew that it would make the family feel better. When people know you're calling in a specialist, it helps allay their fears."

In the Glenns' presence, Wesselman phoned Mike Deprest, Jolene's primary care physician, and left a message to alert him that Jolene had been admitted. "I purposely did that in front of Jolene and Mike to emphasize that when Jolene is discharged, we aren't simply going to forget about her—that if her leg gets worse, she needs to see Deprest," Wesselman explains. "And Deprest knows I haven't forgotten him, either."

10:25. Patient: John Turietta, 40. Problems: morbid obesity, leg ulcers, renal failure, sleep apnea. "When we admitted John, he hadn't seen a doctor in more than a year and hadn't bathed in two months," says Wesselman. "Some primaries would recoil at treating an obese guy who doesn't take care of himself. For a hospitalist, though, it's routine. I've dealt with enough people like John to shrug and say, 'Oh, he's just another patient.' "

Previously, Wesselman had cleaned Turietta's legs, treated him for sepsis, addressed his acidosis, and requested a nephrology consult. Turietta also needed and received dialysis.

But he requires nursing home care and continued dialysis, too, at a cost of some $30,000 a month. A Medicaid patient, Turietta is broke. Handling such arrangements, however, isn't part of a hospitalist's job.

Wesselman deals only indirectly with cost-benefit issues. "I look at what's appropriate for the patient," he explains. "If I have two similar choices, and one's less expensive, I'll probably recommend that. But the case manager—Nancy Brady, RN—determines a patient's options [10:30]. On the other hand, I'm not going to say, 'Well, I'm sorry, I won't give this guy dialysis.' If that's what he needs, he gets it."

10:37. Patient: Annie Davis, 74. Problems: Abdominal pain, partial bowel obstruction. Davis needs a midline catheter. Wesselman lacks the certification required to insert the device, so he turns to PA Mark Naiman (10:38), who has it. Because Naiman and Wesselman have an ongoing relationship, Naiman dropped what he was doing to perform the procedure. Had a nonhospitalist made the request, it might have taken a day to find someone to insert the catheter.

"I don't mean to suggest that doctors who aren't hospital-based are deficient in getting things done here," says Wesselman. "But I'm now a regular presence, so the staff feels more comfortable with me than they did when I was office-based. And they know how I like things done, which makes them—and me—more efficient."

11:20. Patient: John Iacometti, 75. Problems: partial ileus, abdominal distention, urinary tract infection. Iacometti had just been discharged from the hospital's neurological ward after a laminectomy and a decompression—his third back surgery. But he also had some abdominal distention and a partial ileus when he left the hospital, which staff doctors apparently missed.

After his discharge, when Iacometti went to a nursing home for rehabilitation, his abdominal distention increased. Still weak and deconditioned, he was returned to the hospital ER, where he was admitted to the hospitalist service.

"We're concerned about an ileus," says Wesselman. "John probably has a small one, although the X-ray was too dark to clarify it [11:25]. I'll order another imaging study."

11:40. Patient: John Smith, 82. Problems: Alzheimer's dementia, severe pneumonia. Smith, who's already had a right pneumonectomy, was admitted to the hospitalist service from a nursing home. He had a bad pneumonia with hemoptysis.

"Mr. Smith is very hypoxic and DNR," says Wesselman. "His wife gave the consent. We respect that. We gave him oxygen, IV fluids, and antibiotics. There isn't much more I can do other than sit him up and keep him as active as possible. But he's grown weaker and more lethargic. When I listened to his lungs, he wasn't moving much air. His prognosis is poor."

After several failed attempts, Wesselman succeeded in reaching Smith's wife and son-in-law on the phone at noon. "He's taken a turn for the worse," Wesselman told them. "I'm doing what I can, but there's a good chance he won't make it."

The pros and cons of the hospitalist lifestyle

After lunch, Wesselman will see two more patients. He figures those visits, updating charts for all the patients he's checked earlier, and ordering tests will keep him occupied until 2 pm. He'll then be free for the rest of the day—though he's still on call.

For Wesselman, moving to a hospitalist job has been more of change in position than a career change, since the work he does is similar. The change in lifestyles, though, has been a mixed blessing. "My office practice was getting too busy, cumbersome, and bureaucratic," he says. "I was feeling the pain. I made this move as a way to recapture my enthusiasm for medicine and to get away from all the paperwork and frustration. In that, I've succeeded.

"However, I don't have the connection with patients that I once did. I used to feel like I was a part of their lives. I don't anymore, and I miss that. Still, my patient interactions these days can be quite interesting, rewarding, and profound."

Wesselman's wife and children like his new situation, although there have been tradeoffs for them, too. "When I'm working, they don't see me much," Wesselman concedes. "I come home to sleep and then disappear. But when I'm off, I'm off, so we get to do a lot more things as a family. Overall, the change has been for the best."

 

Neil Chesanow. Go on rounds--in a hospitalist's shoes. Medical Economics 2001;4:52.