How often do we hear declarative statements rooted in dogma, propagated over decades? Countless times, physicians providing continuity care for chronically ill patients “assume” that by the very nature of that continuity, they outperform doctors not in that station, especially as it relates to intimate tasks. “Hospitalists are ill equipped to obtain advanced directives; they don’t know the patient like I do,” or something to that effect.
That may be the case, but I suspect community docs are not completing the mission. This is not a spiteful statement, but an observation rooted in experience and evidence.
The system is broke, and while I am sure community docs do know their patients thoroughly, that is not the focus of my post. What is is that same intimacy and whether a physician penetrates it to achieve a consequential end—in this case a “break glass in case of emergency” portfolio. That takes time and emotional energy, and both are in short supply. As doctors, we are all men amongst equals in that domain.
Two recent studies highlight and speak to this theme, and need incorporation into the mindset of those outwardly gazing into the hospital, often harshly. Hospitalists may be not be outperforming, although I don’t suspect this is the case. Its outpatient physicians underperforming—and this is an important distinction. Awareness is lacking and consequently, fingers are waving in the wrong direction.
The first study concerns end of life discussions with terminally ill cancer patients and their timing. The investigators reviewed both charts and conducted interviews with families or patients. The physicians responsible for these conversations were mostly medical oncologists or primary care physicians. From below, you can view the percentage of exchanges that occurred less than 30 days before death:
The study has other nuances but the key takeaway is despite the bonds that many of these doctors have with their patients, they still are delaying essential dialogs. Granted, some information may not be obtainable as the written record or wishes from casual chats are not available; likewise, some diagnoses are sudden and death comes quickly. However, even with this degree of latitude, performance is far from exemplary.
Again, this is a reminder of the current “gold standard” and the model benchmark. They are not the same. Far from ideal, this, a) serves as a humbling bromide for those convinced that the present state of affairs is adequate and a newer model cannot perform superiorly, and b) once again, conveys the difference between provider-patient relationships and how it translates to actual care delivery.
In the next study, an observational investigation of over 8200 patients cared for over 6 years by 347 physicians at 3 hospitals, the authors sought to determine differences in patient satisfaction between hospitalists and primary care physicians. The found that patient satisfaction with inpatient care provided by the two groups was almost identical:
Does discontinuity matter? Is the common refrain, often cited in the lay press as a downside to hospitalist care, “they have no history with the patient,” implying our model must be bad? At least in this trial, the answer is no. We do know HM variability is immense, and groups are in different states of maturation. However, times have changed and so must the paradigm.
We cannot overlook the differences at the doctor or practice versus a population level however. My bet is a primary care physician absolutely committed to his or her patients, practicing in the model of yore, available 24/7 or close to it, will be the choice provider for most people. That is what I would want. However, yearning for this arrangement is illusory, as we know.
It is not all about the money either–as you might be thinking. No, it is the speed and complexity of hospital care, and how difficult it is to “do it all.” Unfortunately, the pace of change in the perceptions of those outside the hospital is not as rapid. Contrary to popular opinion though, perceptions do not follow practice.