A great commentary out today in JAMA Internal Medicine. The topic? Mucking with established ambulatory medication regimens during hospital stays.
I find the sins the authors allude to–confusing patients, wasting money, and chasing artificial outcomes, have the least traction with younger hospitalists, trainees, and those without much ambulatory experience. The temptation to treat the chart or number holds too much sway.
An unfortunate consequence–whatever we do on the inpatient side gets exported right back to the caregiver and primary doc. They must untangle the chaos we create.
Treating HM docs should minimize responses to ethereal measurements and lab readings. We must also communicate with PCPs to attenuate any potential risks of acting on those findings. The following passage conveys the sentiment aptly:
“The inpatient clinician may not be aware of, or simply ignore, the patient’s long-term success at disease control in the months and years prior to hospitalization. Second, the inpatient physician may treat an elevated parameter in response to (or to prevent) calls from consulting physicians or nurses. Such calls can arise from nurse discomfort with abnormal vital signs, and from the “call house officer if” orders typically seen in teaching hospitals. Third, the practice may be an attempt to “tune up” the patient to assist colleagues, for example, before handoff to another inpatient clinician or discharge to the outpatient clinic. A common thread underlying several of these factors is insufficient coordination between inpatient and outpatient clinicians. This disconnect can arise from inpatient clinicians’ limited experience with ambulatory chronic disease management, poor access to the patient’s outpatient health record or health system, and default to a hospital-centered approach, where treatment is preferred to watchful waiting.”
The lesson? Hold the phone. As our mentors teach us, doing nothing is doing something. In this case, that same “something” treats us or the staff, and not the patient. The unintended harm from our action only emerges after the patient departs the hospital . We then become the problem, not the remedy.