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Marginalizing Primary Care in the Hospital: My article in Medical Economics

When I recently spoke to a group of seniors about the dangers and risks of hospitalization in the elderly, one of the audience participants was justifiably confused. She assumed that as her primary care doctor for many years that I would be involved in her hospital care. I had to tell her that was not the case. In fact, in our local hospital, Howard County General Hospital, not only are primary care doctors excluded from caring for their patients, but even more alarming to my patients and to those to whom I have been speaking about this issue, the hospital doctors are under no obligation to communicate at all with a patient’s primary care doctor, and generally they don’t.

Recently Steve Schimpff and I wrote an article in Medical Economics exploring the vexing issue of hospitalist-primary care communication. Currently such communication is largely absent, which creates a substantive deficit of knowledge for the doctors caring for patients in the hospital, and a palpable deficit of trust for patients and their families. Just imagine that an elderly person is sitting in a hospital for a week, subjected to multiple harms that we have described in depth in this blog and in my book, taken care of by a doctor that knows nothing about the patient or his/her history, and not once does the hospital doctor speak to the patient’s primary care doctor, not once. Multiple specialists see the patient, they perform tests and procedures that may have been done in the past and may even have caused harm, they give the patient medicines that may have been tried with poor results, they may even be investigating a “problem” that is not really a problem at all, and not once do they call the doctor who can tell them about all of this.

I can think of so many patients, sometimes many of them in any given week, who are hospitalized unnecessarily for "problems" that, if the hospital doctor spoke to me, could be handled in my office. Instead so many of them are subjected to over-treatment, inappropriate medicines, and prolonged trauma (especially if they have dementia) solely because no one bothered to give me a call or text. In some of these instances the families of these patients demand that the doctors call me, and still I receive no correspondence. So many families and patients feel lost in the hospital environment, do not understand their options, are met by squadrons of faceless doctors who simply tell them what they must do, and there is no one they trust who can help them make sensible decisions. I am on the sidelines, stripped of my role as the patient’s doctor, and the patient is given care that is both uninformed and potentially dangerous.

Why would a hospital allow such a system to persevere? In Howard County Hospital lip service is given to enhanced communication, but there is no mandate from the administration, and so the hospitalists simply do their own thing. Hospitalists must know that they will benefit from better communication by reducing length of stay, improving patient satisfaction, and likely improving outcomes. And most significantly, they must know it is the right thing to do. But, for many stated reasons such as lack of time and not wanting their decisions questions, they don’t talk to us. What are the consequences of this policy? Put simply, it is medical neglect not to involve the patient’s doctor in his/her care at a moment of medical crisis when such advice is most needed. Hospitalists are given the privilege of serving as proxy primary care doctors in our local hospital, displacing community doctors who are no longer allowed in the door. Should they not also have the obligation to take care of patients in the best possible way, which includes involving the doctor who knows the patient best?

I am intending to send a letter to Steve Snelgrove, Howard County Hospital’s President, informing him of my concern about the hospital policy. Many hundreds of my patients have asked what they can do to help, and in that vein, I am organizing a letter writing campaign. I would implore anyone who wants to help with this problem at our local hospital, or at any hospital that has a similar policy, to write a letter and make your anger known. Without a doubt, this short-sighted policy marginalizes primary care doctors at a time they are most needed, puts patients in danger unnecessarily, and is a risk to the hospital. It is time we push for a common-sense fix to a broken system.

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