When you comment that you sometimes have no idea who you’re dealing with from their outer appearance - I hear you! Believe me, it’s even more confusing from the perspective of a patient. Triple that if you’re a patient in a teaching hospital. That’s a real nightmare!

Your father had a tough job, Dr. Hebert … you’re right, all the hospitals wanted to hear was the good stuff. People who have a complaint or a criticism usually don’t make out too well. I can’t imagine what it must be like for someone who was actually hired to do “quality research!” He would have to either be very self assured, or very self sacrificing!

About your “liberal views” … I’ve noticed that you do have a few more liberal ideas, but on the whole, I consider what I’ve seen in your blogs moderately conservative. The only really liberal idea I’ve run across so far is the fact that you would like to see socialized medicine. I still wish you’d do a few “discussion” posts with me regarding that … it would be interesting, informative, and a great topic for the Concordia Discors blog. :)

But what he found consistently was that patients complained because they never knew who they were talking to. The door would open and someone in a white coat came in and started asking questions. Sometimes the invader was a doctor, sometimes a nurse, sometimes a physical therapist. But today a lot of doctors wear scrubs in the hospital and nurses and techs do also, so who knows who is who? Sometimes even I don’t.

That is why I never wear scrubs, and I usually wear a tie when I round. Neckties are on their way out these days, but at least when I wear one I know i will not be mistaken for anything other than a doctor. I always tell a patient why I am there and who I am. If I am covering for another doctor, I say, “Hi, I am Dr. Hebert. I am seeing you for Dr. Jones today.” That is common courtesy, and the reason for the confusion in the hospital is simply that doctors are not courteous.

I could go on and on about courtesy, and though I have many liberal views, on this subject Miss Manners and I are 100% in concordance. Etiquette tells us how to behave and lets others know what to expect. It is a form of communication. People who refuse to adhere to standards of etiquette are refusing to communicate with others. It is like talking to someone with sunglasses on. You cannot judge their expression, so you cannot really tell how they are responding to what you say. This is not fair.

I learned a related lesson from a professor in medical school. He was a psychiatrist, and he complained that sometimes he would walk into a hospital room to see a patient, and the patient would look at him and say, “My doctor doesn’t think I am crazy. He didn’t say he was calling a psychiatrist.” He asked us if in our future practice we would be courteous physicians and tell a patient that we intended to consult a psychiatrist before actually doing so.

I have expanded his advice by always telling patients which other doctors or specialists I intend to get to see them.

“It may seem like I am being greedy. Obviously I could admit a patient to a hospital and see the patient every day for free.”

I don’t expect (and I don’t think anyone does) to see a physician in a hospital or his office for free. I agree that all calls should be reimbursed.

About the touch factor and talking in medicine … until the “powers that be” understand that, and medicine “works it into” the regular repertoire (practically and financially,) real medicine will continue to lose patients to alternative medicine - which is not only sad, it’s scary.

“When people are very ill they are afraid and may not respect boundaries the way one would like them to.”

Are you sure they understand the boundaries? The first time I was ever admitted by someone other than my own physician, it took me several days to figure out what was going on. He dropped in on me on day one, and I never saw him again. I had no idea why … or why I was being seen by someone I didn’t know. Would have been nice if someone had explained the new policy.

He didn’t stay away due to becoming embroiled in a morass of silliness either … the only question I ever ask when in that position is when they’re going to let me out. ;-)

But seriously, I think that if patients are made to understand by yourself ahead of time that you’re not going to be the one taking care of them in the hospital if ever they’re admitted, they’ll just be glad to see you … especially if the hospitalist also reminds the patient that the call you make will be a courtesy call, and that they should save their questions for him.

I would think that if there were a problem beyond that point, although the patient knows that you won’t be dealing with their care until their discharge, that there might be something that the hospitalist isn’t communicating to the patient, or that the patient feels the hospitalist isn’t understanding … your input might actually solve a problem that could be potentially more serious - be it with the hospitalist or the patient.

I think these things can work, but there needs to be a fair standard, and the patients need to understand what’s going to happen before they find themselves in the situation, whenever possible. It has to be worth the physician’s while, too … that’s simply common sense.

It may seem like I am being greedy. Obviously I could admit a patient to a hosptialist and see the patient every day for free. But hospital care is like a tar baby. Once you get involved, you are in it all the way. I have made the mistake of making gratis courtesy calls on people in the hospital and been bombarded with questions and concerns about the plan of care. I hate to say it, but I have learned long ago that if you are not getting paid on the case, stay away! A simple hello can blossom into a full-scale, no-holds-barred battle over which doctor said what and when and who is responsible for this or for that. When people are very ill they are afraid and may not respect boundaries the way one would like them to.

For this reason, I think courtesy calls by the primary doc should be reimbursed, even if just nominally to say, “We understand that talking to patients is practicing medicine too.”

These creases in medicine can be worked out, but it requires a recognition that the human touch is important in therapeutics. So far, I have gotten little indication from the business side of medicine that this is so.

You know, I believe you’ve probably expressed it best of all … and from that perspective, it makes a great deal of sense. I could almost hear myself saying the same things, under the circumstances you’ve just described. I can also “hear” your own regret as you assess the situation …

I believe that hospitalists are an inevitability, especially as more and more physicians are specializing, and generalists are becoming more and more overworked - not to mention underpaid by comparison.

I see the common sense in the fact that a physician trained in emergency medicine might do better in the ER … or that a hospitalist might be better at dealing with in-house crises and so on. I can also see that the dual juggling would also be very disruptive of the regular care of your out-patients.

Isn’t there a way to compromise?

Perhaps … let the ER deal with the emergencies, as long as they know to contact you when faced with something unnusual - which you, being familiar with the case, may be able to clarify.

Perhaps, while letting a hospitalist do the bulk of the inpatient care, involve yourself in the following ways whenever possible: seeing your inpatients when you can; remaining aware of what’s happening with them, and having a hand in the decisions surrounding their care … but most importantly, allowing them to know that you are aware of their situation, and are actually taking an active part in their care …

This wouldn’t be perfect for anyone, I know. Not for the patient, who would more than likely prefer to have you do all of it … not for the hospitalist, who would find himself working as more of a team member with each generalist, while still doing the bulk of the work … and not for you, since you’d still have to make time for more than just the clinic.

But - it would also be a better balanced approach than the impersonal “take it or leave it” it’s becoming now - or the all or nothing, “go it alone” … headed for burn-out … which seems to be the other side of the coin.

You know what really bothers me? The idea that medicine seems to be becoming a job instead of a calling.

When the pastor of a church takes on the “job” of “feeding his flock,” he knows that he’s going to be called out at all hours to deal with emergencies, and that he’s never going to have a week end off! He enters the ministry with the idea of “serving” as a “minister.”

When I went to nursing school, it was with altruistic motivations. I had no notions of easy hours, large paychecks … and since I’d already been working in a hospital for years before that, I had no rosy dreams about what I was facing. The fellows that I knew who went off to medical school went with the same ideas - to serve. To help alleviate pain. To try to make living better for those around them.

No, none of us were climbing up onto a sacrificial altar, but we knew what we were getting into - we each chose our own aspect of medicine, knowing what kind of job it would be.

Don’t those who go into medicine today do it for the same reasons? I can’t believe people have changed that much over the years.

Hang in there, Dr. Hebert … and do what you have to do to keep going. If you care for your patients, they’ll always know it. Even those of us who are really opposed to “one size fits all” medicine understand that there’s only so much you can do. Just don’t stop caring.

Also consider that hospital work is a 365 day proposition. I can close my office Christmas day. Can’t sent all my patients home Christmas eve. Hospital work means getting called at 4 am by the ER. It means getting phone calls all day in the office, which disrupts my office schedule.

Worst of all, there is nothing more frustrating than having to leave patients in the waiting room because you have to run to the hospital to take care of a hospital emergency. A few really sick hospital patients can wreak havoc on the best-planned day at the office.

I continue to hang with it but sometimes it can be overwhelming to handle both. Medicine has succeeded in keeping sick people alive longer and the result is that the acuity of illness among inpatients has greatly increased in the last few decades. If people keep getting sicker it may simply be impossible to keep doing both.

You certainly have it very cut and dry … some physicians would rather save 14 minutes in driving rather than let the patients who’ve learned to trust them have the reassurance that at least in some way, someone they’re familiar with knows what’s going on.

And any physician who tells me that he’d rather wake up a bit earlier, refreshed, than see a patient who’s trusted him, and is dying in the ER … wow! I’m sure plenty of docs feel like you do, Bruce … I guess that’s perhaps one of the reasons why I’m no longer seeing any of you.

You know Bruce, medical emergencies almost never happen at a patient’s most “convenient time,” either. We don’t necessarily want to see an “expert” at a “low cost at a time that is convenient to us” … we want to be able to see a physician when an emergency arises. We know it will probably not be our PCP … under the circumstances - but being completely abandoned by a trusted PCP to the hands of strangers over a hospital stay is another thing altogether.

I don’t know what frame of mind some people go into medicine with … but I’ve met a lot of different kinds of doctors in the last few years. Those who are practicing medicine for the love of medicine, and yes, even for the love of those they take care of … can’t hide it. You can feel it when you’re with them, and it engenders an amazing trust. Those who see it as a business - resenting the time they’re giving to people - doing a job … also can’t hide it.

Most of us aren’t looking for Dr. Welby, dear heart … most of us are just looking for someone we can actually count on when we need them the most … even if they are not the ones administering the care at that time.

Additionally, if you don’t take hospital call, you don’t get out of bed at 2Am when someone is dying in the ER. You can awake refreshed, get to work a little earlier, and see an extra clinic patient.

The other side to this is that patients are rational consumers. They want to see an “expert” for their problem at a low cost at a time that is convenient to them. Internists and family practioners are not experts. Hospitalists know more about acute illness than doctors who practice solely in clinics. Patients have asked for and recieved more specialized care, but in the process have to accept externalities. Dr. Welby will not be there in the morning to pat your hand. Welcome to reality.
b

Good luck in your research Moof. I too would like to know how docs lose money on hospitalized patients.

best,

Flea