Hospital doctors... and other examples of care fractionation and commoditization

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Fri May 13 16:58:40 UTC 2016


I think we can all agree that hand-offs lead to fractionation of health care and that they undeniably introduce opportunity for harm and missed opportunities for diagnosis. But I have trouble with the underlying resentment that physicians who do shift work (intensivists, hospitalists, EPs) don’t get to know their patients. Yes, we certainly don’t know our (or your) patients as well as their PCPs and don’t claim to. But to cast out that we don’t have the inclination to get to know them or try to is perhaps a little too far.

Those of us in these roles are responding to forces that, in many respects are beyond our control. EMTALA requires that I at least screen every patient that walks through my door. As a “safety-net” EDs are crushed with high volumes and undifferentiated illness acuity – time is a commodity that is finite. Capitation and declining reimbursements make it nearly impossible for a PCP to round on their admitted patients so the specialty of hospital medicine has sprung up. Advances in life-saving technologies necessitate that the specialty of critical care be facile with each new one that shows up.

I don’t know of anyone in any “shift-work” specialty claims to know a PCP’s patient better than the PCP does. But we all have a chance to improve the situation by picking up the phone to discuss the patients. I can do much better by a PCP’s patient if I get a phone call saying, “Hey, here’s the pertinent history/physiology/sociology of Mrs Z that I’m sending to the ED and what I am hoping for her visit.” The corollary to this is me calling back the PCP who sent the patient after I have completed my initial workup to say, “Here’s what I found. Am I missing something?” If we talk of “ownership of the patient” then don’t we each bear some responsibility to take the burden of checking in with the last provider to figure out where things stand?


Joe Grubenhoff, MD, MSCS| Assistant Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Children's Hospital Colorado
13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
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From: DR WILLIAM CORCORAN [mailto:williamcorcoran at SBCGLOBAL.NET]
Sent: Friday, May 13, 2016 9:11 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization

The more "fractionation", the more hand-offs.

Every hand-off introduces an opportunity for harm.

The larger issue is interfaces in health care.

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
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________________________________
From: "Bruno, Michael" <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>>
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Sent: Friday, May 13, 2016 6:58 AM
Subject: Re: [IMPROVEDX] Hospital doctors... and other examples of care fractionation and commoditization

Hi Bob,

First of all, I'm extremely glad you're still with us and glad you were smart enough - and oppositional enough - to ignore bad advice when you received it!

I think you've put your finger on a very important issue here: the fractionation and commoditization of care due to our provider-centric divisions of labor in medicine to fit in neat little bins of roles and time slots has become a huge risk-factor for error in and of itself.  This is partly because of a shortage of physicians and a recognized premium on moving toward subspecialization, to be sure, and isn’t made better by giving our trainees ‘work-hours restrictions’ that promote the concept that medicine can be practiced conveniently, in comfortable shifts, etc.  But we have been going down a path where medical care is treated entirely as a commodity, where physicians are viewed as interchangeable cogs in a machine, differing only in their specialty/subspecialty.  The patient is not at the center of this model, clearly.  It’s a provider and institution-centric model that favors maximizing practice efficiency, controlling costs, and getting the most out of our manpower.

This problem was summed up nicely in the 19th century by Sr. Wm. Osler, who made a clear distinction between a doctor who treats a disease and one who treats a patient with a disease.  This implies (correctly, I think) that medical expertise includes knowing your patient, which takes time, unfolding as all relationships do, out of multiple encounters spaced out over months and years.  It is NOT enough to simply know the usual disease processes and what treatments are recommended and what the practice guidelines are and apply them to patients who you have known for only 15 minutes.  At least not 100% of the time.  Part of the knowledge base we use to help our patients is our knowledge of diseases and part of it is our knowledge of them.  And this is made impossible with a fractionated model, made up of physicians who work a shift and will never have the opportunity (even if they had the inclination, which they probably don't) to get to know you and the individual aspects of your case and your physiology/history/sociology, etc.  Could this not underlie our widespread epidemic of physician ‘burnout’?

Also, a related problem is that the EHR is a very bad method of doing 'handoffs.'  Just last night I was asked to interpret a STAT portable CXR on a critically ill patient and searched the medical record for information - ANY information - about him that would help me make sense of the mess that I was seeing inside of his lungs.  The patient had been transferred from another hospital six hours earlier.  And you know what I found?  Nothing!  There were no notes, no H&P, no lab results yet, no nursing assessments, nothing.  Only the report of a trans-esophageal echocardiogram that had been done at the time of transfer.  Nothing else.  So I did the best I could with the limited information I had.  How many times had that patient's care been passed between different doctors, and who - if anyone - took "ownership" of his case?

Happy Friday the 13th!

All the best,

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-----Original Message-----
From: Bob Gorman [mailto:bgorman at KNCELL.ORG]
Sent: Thursday, May 12, 2016 11:14 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Hospital doctors...

With so many types of deadly errors, you probably don't want to hear about yet another one. But it kills patients, so here it is.

I'm 74 years young. I've never had a flu shot or the flu. Then I got the flu. I called my PCP who urged me to go to the local ER.
Error point #1, control of my health passed from my PCP, whose known me for 28 years to the ER doctor who doesn't know me at all. He wasn't very optimistic, and gave me a 50%-50% of living till morning. Fortunately, I picked the right 50% so I'm here writing these words.

But a subtle Error #2 occurred, when I was admitted to the hospital - my health decisions will now be made by a 'hospital'
doctor, who also doesn't know a thing about me. After 3-4 days he considered, correctly, that I was too weak to return home, I live by myself, and sent me to e physical rehabilitation facility. Now the fun begins. The re-hab doctor, #3, who also doesn't know me, puts me on a limited fluid diet, even tho the floor nurses say, emphatically, that I'm dehydrated.

Fortunately, I have a strong oppositional defiance strength, so I let them do all their arguing, smiled widely, then when they were all gone, I got up and went to the sink in my room and had a tall cup of cold water. When I left the re-hab facility, I was given a long list of Rx most of which I ignored.

I'm still alive to write these words, many others are not. I'm not sure what to call this thread, 'Hospital doctors', switch of control', 'systemic error' or whatever, I'll let you guys & gals fight over a title...

Bob

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