Suddenly, it was over. I spent 27 years in private practice of general internal medicine in Sacramento, seeing patients in the office and in the hospital. I admitted them to the hospital directly from my office or met them in the emergency room. If they were having a complex surgery, I’d help monitor them before and after the operation.

Then my local community hospital hired hospitalists. Hospitalists are physicians, whose practice is devoted to treating patients in a hospital setting. There was a brief period of co-existence, but soon the other members of my call-group decided to let the hospitalists assume care of their inpatients. Soon, no one wanted to share call for hospital care. The hospitalists weren’t interested in part-time cross coverage. It was ‘all or none’ if they were to admit and treat patients in the hospital.

My family was unwilling to have me be on-call for my own patients 365 days and nights per year, so I said goodbye to my hospital practice. Although my colleagues smile about how happy they are to be not going in to make rounds or admit patients late at night or fielding phone calls from nurses at all hours, I feel only partially freed, because now I spend a good part of my time trying to piece together the hospital course of my patients.

The problem is that our hospitalists appear reluctant to call primary care physicians when their patients are admitted. Even worse, they don’t notify the patient’s specialists of the admission. Perhaps they assume that the specialist doesn’t want to be bothered or they fear that if they get the specialist involved, more tests and expenses will result.

In addition, after patients are discharged from the hospital with instructions to ‘follow up with your doctor,’ they present to the office without any record or information about what was done during their hospitalization. I don’t know what I’m supposed to follow up on.

There is a cumbersome release-of-information process to find out what happened to the patient. I’ve had patients return to the office with a bag of medications that they were taking before admission and another bag of medications on which they were discharged, asking me to reconcile them.

The patients are frustrated with the added cost of purchasing discharge medications that are versions of what they already have. Often they are discharged home without pain medications or any understanding of their discharge diagnosis.

The transition to a hospitalist system results in a number of potential catastrophes that are likely the result of inexperience as well as a focus on priorities of length-of-stay and associated costs.

Since hospitals are paid per diagnosis, they get more money the less time the patient stays in the hospital (and the fewer tests that are run).

Recently, a 90-year-old patient of mine was discharged on a combination of two medications that never should be mixed together because of the high risk of bleeding (Motrin and Plavix). This serious error was overlooked by the nursing staff, pharmacy and the hospitalists.

On another occasion I had to have one of my patients readmitted to the hospital shortly after discharge for treatment of congestive heart failure. The hospitalists had treated him with a combination of powerful diuretics (water pills), which promptly cleared his fluid-overloaded state. However, they discharged him in the middle of this intensive treatment without adequate monitoring of how fast he was losing fluids.

When he saw me the following week, he had severe kidney failure and weakness from low blood pressure. I had to have him go back to the hospital to receive intravenous fluids.

A 40-year old non-smoking woman with shortness of breath from a rare lung disease was discharged home with instructions to ‘take deeper breaths.’ Review of her hospital records showed minimal interest in uncovering the cause of her respiratory insufficiency.

One of my hemodialysis patients with an artificial heart valve was sent home on a 10-day course of antibiotics for a condition that required prolonged antibiotic therapy and possibly surgery.

Now when I find out that one of my patients has been admitted to the hospital, I let the patient’s other specialists know to check in on the patient. With rare exceptions, the hospitalists don’t return calls or initiate calls to me on mutual patients. Calling the hospitalists directly has been challenging, since their rotations change rapidly and the nursing unit isn’t sure which hospitalist is responsible for the patient’s care.

My letters and calls to the Department of Medicine and Quality Assurance Departments of the hospital have been ignored and in more than one case, ‘lost.’ I fear that as long as this particular hospital’s appellation, ‘center of excellence,’ and the length-of-stay numbers remain good there is little motivation for change.

Certainly the advertisements one sees on TV for its services paint a very rosy picture. Nonetheless, the specialists on staff I’ve spoken with agree that care has declined significantly over the past few years.

Patients are understandably upset to find that neither their specialists nor I were notified about their admission. They are frustrated when their medications are seemingly arbitrarily discontinued or changed, and are placed at grave risk when their medical histories aren’t complete.

Patients and their families are stressed when they are admitted to the hospital. Having rapport with, and trust and confidence in the treating physician is vital. Readmission from a nursing home following a brief hospital stay frequently generates the complaint, “They let him/her go out of the hospital too soon!”

I can appreciate what the hospitalists offer, but without improved collegiality with the office-based physician there is much more to lose. As in all areas of medicine, good communication is the key to ensure that the transitions patients make between office, hospital, emergency department and nursing homes are carefully managed and coordinated.

Medications, diagnoses, drug allergies, dietary instructions and follow-up are areas that often get ‘lost in transition.’ Phone calls, faxes or appropriately secured e-mail should facilitate accurate information and critical data. Systems with electronic health records, shared between their physician and hospital staff accomplish this with ease. Facilities that care for patients that aren’t integrated in this fashion need to make such systems available or make the effort to accommodate these circumstances.

Hospitalists should make it a point to touch bases with the primary care physician about all but the most basic encounters. In training, we considered it part of the job to notify the patient’s regular physician about his/her patient’s admission and condition. Likewise for patients who also see specialists, it is only professional courtesy to let the relevant specialist know that his or her patient is in the hospital. The specialist may have patient information that can simplify their evaluation and treatment-- or avoid duplication of tests that the patient recently had before admission to the hospital. We know the idiosyncrasies of the patient’s reactions to medications or treatment regimens. We care about our patients as people and want to know what’s happening and how they’re doing. Often we’ve been caring for these individuals for years and will continue to care for them after they leave the hospital.

Admitting and discharge summaries should be sent to the attending physician, and an effort made to ensure that any loose threads needing follow up are clearly delineated. In the absence of shared electronic medical records, it should be routine to order a copy of key reports sent to the attending for the subsequent outpatient follow-up. This can be done at the time the test is ordered.

In turn, attending physicians owe something to the overworked hospitalists who try to take care of sick, complex patients in an often chaotic environment. The attending physician can provide a capsule summary of the patient’s history and the key concerns. Relevant data can be faxed over to the staff for helping the treatment team. It behooves the attending to have good relationships with the hospitalist team, and vice-versa, since both want to do the right thing for the patient. To achieve this end, however, much improvement is needed.

With the complexity of patients’ medical problems and treatments, we can’t afford to allow this clinical crevasse to persist. It is too costly in time and money and lives are at stake. I would like to see the hospital medical executive committees set up a task force to look at how this issue impacts their services. Contingencies also should be made for patients seen at ‘out-of-network’ facilities, so that their care by in-network providers remains seamless.

I’m not saying that we should go back to the old style of physicians seeing their patients in the hospital as well as in the office. There are theoretical and real advantages to a hospitalist system. Hospitalists offer 24-7 availability for patients in the hospital and for their nurses, which is an advantage over office-based doctors, who have to make time during the day to visit their patients and write orders. I strongly believe that those doctors who have the motivation and ability to do so not be prevented from doing so.


Sutter Roseville uses hospitalists, and the experience there gives me hope in the system. When the hospitalists admit one of my patients, their dictations are faxed in real-time to my office. The hospitalists there don’t hesitate to call me if they have any questions about the patient’s history or discharge plans. I see the system working much better there, but there’s no motivating force to make the first hospital emulate it. Sooner or later, patients will voice their concerns and all the fancy advertising slogans used by hospitals no longer will sway people’s enrollment.

How would you like your family members treated? Isn’t it time for teamwork? Indeed it is!

Howard Homler MD, FACP
Internal Medicine, Carmichael CA