The Foglight - What Happens When the Face of Your Hospital Doctor Keeps Changing?
October 2023
Issue # 4 October 2023
In This Issue: Hospital Physicians (Hospitalists) Part 2
Dear Reader,
During hospitalizations, clients are dismayed when they notice that the doctors keep changing and that the doctor of the day might simply skim the surface. Families try to provide information they think would be helpful, but they are often left feeling frustrated and angry.
Please read on for part two about the current system of hospital-based physician care. If you would like a copy of part one which describes how and why this current system came to be, please email me at gerda@mymdadvisor.com.
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What Happens When the Face of Your Hospital Doctor Keeps Changing?
In my last newsletter, I discussed the rise of the hospitalist. “Today,” I wrote, “if you are admitted to the hospital … you may never see your primary care physician (if you even have one). Instead, the doctors making decisions about you will be a rotating cast of specialists and ‘hospitalists’ who have no idea who you are, have never treated you before, and have no relationship with your family.” I described how the economics of hospitals made it advantageous for hospitals to make it easy and alluring for primary care doctors to stop going to hospitals. And I promised that in a future essay, I would talk about what this change has meant for the average patient.
So, as promised, here’s the bottom line: this shift in hospital care, from being overseen by your own doctor to being overseen by the on-staff hospitalist, is not always a good thing. It has hurt patient care, in several ways.
First, your primary care physician knew you. She (or he) knew your quirks, your history, your context. She knew something about your pain threshold. Maybe you’re the kind of person who is stoic—if you say it hurts a little, that means it’s actually horrible. By contrast, if she knew you were a complainer, someone prone to drama, someone who tended to—how to put this delicately?—overstate the situation. If that was the case, she would not rush and overreact to each new symptom. She might take a breath before ordering risky, costly, invasive tests. Under the hospitalist system, that basic knowledge of the patient has been lost.
What’s more, the way hospitalists are deployed means they have a difficult time building up a store of patient knowledge. They used to be scheduled for 7 days on, then 7 days off. That means that if you got a hospitalist at the beginning of his week-long shift, you could have him for 7 days, by which point maybe you’re ready to go home. That’s the best-case scenario. But if you enter the hospital on day 5 of his shift, you’ll be seen by him for 2 or 3 days, then be handed off. Even if the first doctor might leave behind good notes, the next doctor is really starting from scratch.
And some hospitalists are tethered to a particular ward in the hospital. So if you get transferred to a different ward, on a different floor, you’re handed off to a new doctor. Any relationship you built with the first doctor is lost, and you have to begin anew.
This all matters for judgment. The art of medicine is all about context, and understanding the person who is seeking help. Every time you have to start over with a new doctor, everything that the last doctor knew about you—your stories, your fears, your tricky and unique family dynamics, those crucial pieces of who you are that won’t be on your chart—is lost. And with them, a depth of understanding is also lost.
And some patient history, like tests and treatments that were already tried for a specific set of symptoms, is particularly vulnerable to forgetting. It may be in the chart, but it goes unnoticed. The same goes for possible future courses of action—good ideas might get floated by one doctor, only to be dropped by the next doctor on duty, if the first doctor fails to write down good notes.
For example, I had one client with a tricky lung problem. The doctors had already tried a relatively rare procedure twice, and it still hadn’t worked. Before the second attempt, I had asked what the options would be if this failed. The sub-specialist had said he would try an even more rarely used option.
By the time it was clear that the second attempt hadn’t worked, that sub-specialist had rotated off duty. When the new team came on, they said there was nothing else to be done. This meant that my client would suffer, and potentially die, from this lung problem. I brought up what the previous physician had said. After some debate (and I suspect a behind-the-scenes chat with the original doctor), the team came in and said that the procedure was worth a try.
My client had the procedure, and this time it worked. He had many months of symptom relief and died from something else a year later. And yet he almost didn’t get the procedure that prolonged his life, because there was a breakdown in communication between the doctors on different shifts.
And then, with the pandemic, it got worse. Hospitals got overwhelmed. A lot of doctors retired. And staffing became harder and harder. Now hospitals were doing all they could just to get coverage, often asking doctors to work for a day here, a day there. If you are lucky, you get the same doctor for three or four days. It has evolved into nearly a “doc of the day” system—just get an MD into the building to make sure people are seen by somebody, anybody. And with that, all continuity was lost. There is no context for the human being in the bed.
I have seen, time after time, the wrong information being passed, or steps getting dropped. I saw diagnoses being missed. I have seen one doctor say, “Do it this way,” and a second doctor say, “Do it that way,” and the family had no idea who changed the plan, or why. They didn’t know where to look for answers.
To be clear, these hospitalists are doing the best they can. But put yourself in the shoes of the doctor coming on board: he doesn’t know the patient, he is working off the last doctor’s notes, and he walks into a room with a family that has a million questions. And he doesn’t have answers. Not because he doesn’t know the medicine, but because he has no context.
As the family’s medical advisor, I am also the patient’s historian; I know what’s already been tried, and what’s been tested for. I have often found myself talking to the doc of the day, feeding him or her key pieces of information in a couple sentences. People say, “Don’t you slow the doctor down?” The reality is I speed them up. Because I efficiently feed them key information that they’d have to take 15 minutes to look up or 30 minutes to tease out of a long conversation.
And the family members, who might have the answers, don’t “speak doctor”—they’ve been there all along, but they don’t have the language, the technical expertise, to explain what’s happened. In such situations, the families feel alienated, like they are saying the same things over and over, each time to another new face. And the doctors get burned out and frustrated because they know they’re not doing as good a job as they want to. They may be highly competent, but they don’t have the time to know everything that’s important to make the right decisions.
That’s where I can help.
Dr. Gerda Maissel, MD CPE, BCPA
Dr. Maissel is a Board-Certified Physical Medicine
and Rehabilitation physician
and a Board Certified Patient Advocate
Get out of the fog of a complicated healthcare journey with the help of
My MD Advisor.
For more information visit mymdadvisor.com
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My MeD Advisor
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