Leave the outpatient regimen untouched

By  |  August 5, 2013 | 

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.


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About the Author: Brad Flansbaum

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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