Andrea Sattinger

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.

“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.

Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.

“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.

Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.

How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”

Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”

Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”

“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”

Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?

His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”

Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º

What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”

Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”

Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’

“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.

“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”

David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.

“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?

“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.

“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.

“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”

Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?

“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.

“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.

“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH

Andrea Sattinger writes frequently for The Hospitalist.

References

1. Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
2. Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.

“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”

In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?

Personal Biases

“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”

Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.

In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2

In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.

In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”

What’s Behind Bias?

“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”

Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.

“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.

When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.

Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?

Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”

When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.

Is Reflection the Answer?

Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?

At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.

Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH

Andrea Sattinger also writes about “vintage bugs” in this issue.

References

1. Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
2. Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
3. Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
4. Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.

Jonathan P. Weisul, MD, FACEP, has direct responsibility over both case management and contracted hospitalist services at CHRISTUS St. Frances Cabrini Hospital in Alexandria, La., where he is regional chief medical officer and vice president of medical affairs. To him, the two most important aspects of the relationship between hospitalists and case managers involve communication and respect.

“In our system it’s a very collaborative approach where the case manager presents options to the physician as discharge planning progresses and the physician explains the progression of the patient’s treatment to the case manager,” he says.

In the early days of managed care, Dr. Weisul says, case management received some bad press in that “it was perceived that their interest was [just] getting patients out of the hospital. And I would say that one area where the communication fails is the oftentimes misheld belief on the physician’s part that case managers are trying to practice medicine,” he explains. “Communication usually involves the case manager presenting options to a physician in a way that would be in the best interest of the patient—not trying to usurp any authority from the physician-patient relationship.”

The greatest partnership between hospitalists and case managers occurs when they both share options and needs, and perhaps the best venue for sharing occurs at interdisciplinary meetings. All case managers interviewed for this article stress the importance of daily meetings as a clear advantage for an effective discharge plan.

L. Greg Cunningham, MHA, CEO of the American Case Management Association (ACMA), headquartered in Little Rock, Ark., says the best thing hospitalists and case managers can do to improve their working relationship is “communicate about their patient caseload first thing in the morning.” Both are sharing information. “One is sharing more expectations of what needs to be done for the patient,” he says. “The other is sharing more expectations about what the physician needs to do in terms of decision-making such as getting signatures on forms and communicating with the patient and family.”

Be Proactive

Theresa Brocato, RN, BSN, CPUR, manager of case management and social work at CHRISTUS St. Frances Cabrini Hospital, has been in that position for almost four years. For seven years before that she worked in managed care for Ochsner Health Plan of Louisiana. In her opinion hospitalists can be most helpful to case managers by thinking proactively.

“We have a very proactive discharge planning department,” she says of her department of nine case managers (all nurses) and five social workers who work directly with patients and families, “because as soon as the patient gets to the hospital we start the discharge planning.”

The case managers interview patients and their family and let them know what their estimated time to wellness will be. “We base the estimate on a working DRG [drug-related group],” she says. “We talk to the hospitalist up front, and [we] say, for instance, ‘For this patient, the average time to wellness is about six days, and we need to start preparing for that ultimate discharge. Is there anything you foresee that you might need on discharge, such as equipment or home health?’ And then we start coordinating with the physicians to get the orders in place and get everything set up so that they have a smooth transition at the time of discharge.”

But Dr. Weisul says this kind of communication can be misinterpreted. “Communication seems to fail in the most difficult cases where the physician seems to perceive that the progress of the medical care might not be going on [in] as timely [a manner] as he or she might expect and feels that the case manager, in … looking at when the appropriate discharge time might be, is pressuring the physician,” he says. “But the reverse is true: What they’re doing is just asking for input from the hospitalist [or other] physician as to progress on the path of returning the patient to health and just looking to the future.”

Brocato says the three hospitalists at Cabrini have been easy to work with, sometimes seeking out the case managers and social workers to ask for their help on difficult cases, working with their fellow interdisciplinary-team members to design discharge plans from innovative ideas that solve patient’s challenges, and including the patient in their planning.

Appropriate Levels of Care

At Cabrini Hospital, the case managers and social workers hold daily interdisciplinary discharge planning meetings. Each case is reviewed according to nationally accepted criteria to ensure that the care provided meets standards appropriate for the acute inpatient level of care. Other treatment levels identified during discharge planning include rehabilitation, long-term acute care, and outpatient levels of care.

One recommendation that Brocato would make to hospitalists to better help the work of the case managers, the hospital, and the patients is to recognize earlier which patients will require a longer length of stay (more than three weeks) so that those individuals can be transitioned into a more appropriate level of care.

Some examples of diagnoses in which long-term acute care might be called for, she says, include “osteomyelitis, where a patient will be on a course of antibiotics for six weeks and may require extensive wound therapy. In that case, as soon as we get the results of the bone scan and we see that, we immediately ask the physician to think about moving the patient.”

Other examples include those patients who will need a long time to recover, such as those in the ICU. “Maybe they’ve have been on a ventilator for a long time and they get debilitated,” says Brocato. “Or if they need to be weaned from the ventilator and need some intensive respiratory toilet. The long-term acute care setting is the more appropriate setting to work on trying to rehabilitate the patient.”

Follow-up

Another important element to a good discharge plan is follow-up. Cabrini Hospital has initiated a program whereby a nurse has been hired to call on patients within two days of discharge to check on how things are going. That is, Brocato says, “whether they understood the discharge instructions, to make sure that they got their prescriptions, and [to ensure] they have some kind of follow-up appointment made and are planning to go to that.”

A 2001 study conducted by the section of general internal medicine in the department of medicine at West Virginia University (Morgantown) showed that the effect of employing a nurse discharge planner to work with the hospitalist service had a positive effect on outcomes in an academic teaching hospital.1 When a general medicine service, specialist-staffed service, and a hospitalist service with nurse discharge planner were compared, the hospitalist-discharge planner group was associated with a lower average cost and shorter average length of hospital stay. There was no apparent compromise in clinical outcomes and patient satisfaction with care.

Competent Colleagues

The American Case Management Association (ACMA), begun in 1999, is the first and only nonprofit hospital-based case management organization in the United States. It represents nurses, social workers, physicians, and other professionals who practice hospital case management. The physicians whom ACMA represents are primarily medical directors hired as the catalyst for attendings who are less than cooperative and are impeding discharge (typically not the hospitalists). “The organization is growing at an average annual growth rate of 25%,” says Cunningham. “We’ve just started a new certification process for hospital-based case managers—one for nurses and one for social workers.”

There is a core portion to the exam that tests for knowledge, and a specialty portion of the exam in which “they have to validate those skill sets. The specialty portion of includes a clinical simulation, which is the application of their skills and knowledge,” explains Cunningham. “They have to [show that they can] make not only a decision, but sequential decisions. So we’re testing their ability to take a case and work through it.”

The hospitalist should expect that high level of competency from a case manager, just as the case manager should be able to expect the highest competency of the hospitalist. “The hospitalist should not lessen their expectation of the clinical competency of the case managers,” says Cunningham. “We are advocating that the physicians … increase their expectations of the clinical competency of those individuals.”

Cunningham recommends that hospitalists discuss their case manager’s background if they suspect there is a diminished competency. “Competent case managers “not only make it better for patients,” he says, “but practitioners’ lives are made much easier when competent case managers are hired.”

All the case managers at Cabrini Hospital have a strong clinical background. “It is really important that the case managers are competent in the field they are working in,” says Brocato, “so that the physicians can trust that they understand the clinical side as well as what might be needed at discharge planning. [At Cabrini Hospital] they are placed in the units where they work based on their careers as nurses. The case manager that works in ICU, for instance, was an ICU nurse for many years.”

Brocato believes “hospitalists need to feel confident that the case managers—or discharge planners as they’re called at some hospitals—have a strong clinical background. In that way, when the hospitalists “are discussing their cases, they feel that we know what they’re talking about. For us, it means that we feel we are all on the same page when we’re dealing with the physicians so that we know what the course of treatment will be. Then the case managers are able to make a better discharge plan based on what the expectations of the hospital stay are going to be, so we can plan ahead.”

Dr. Weisul, who oversees three healthcare facilities in the central Louisiana region, knows that the relationship between hospitalists and case managers can be a fruitful one for all concerned. Cabrini has achieved the lowest case mix-adjusted length of stay in its healthcare system. In addition, when physicians were surveyed regarding the discharge planning process provided to their patients, the hospital achieved a combined rate of 97% “satisfied” or “very satisfied.”

“The idea that case management can achieve, with the physician, a low length of stay does not necessarily have to be in an environment of contention,” says Dr. Weisul.

Conclusion

Realize that case managers are there to assist hospitalists meet patients’ care goals. Watch for patients who a need longer length of stay and alert case managers in those cases to ensure moving them to appropriate levels of care, such as long-term acute care setting as soon as possible. Let case managers know how patients and families can reach you post-discharge. Expect the highest standard of competency from case managers and work with hospital administrators and case management to consistently make this a reality. TH

Andrea Sattinger writes regularly for The Hospitalist.

Reference

1. Palmer HC Jr, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627-632.

Resources

• Case Management Society of America (CMSA): www.cmsa.org/
• American Case Management Association (ACMA): www.acmaweb.org/

Jonathan P. Weisul, MD, FACEP, has direct responsibility over both case management and contracted hospitalist services at CHRISTUS St. Frances Cabrini Hospital in Alexandria, La., where he is regional chief medical officer and vice president of medical affairs. To him, the two most important aspects of the relationship between hospitalists and case managers involve communication and respect.

“In our system it’s a very collaborative approach where the case manager presents options to the physician as discharge planning progresses and the physician explains the progression of the patient’s treatment to the case manager,” he says.

In the early days of managed care, Dr. Weisul says, case management received some bad press in that “it was perceived that their interest was [just] getting patients out of the hospital. And I would say that one area where the communication fails is the oftentimes misheld belief on the physician’s part that case managers are trying to practice medicine,” he explains. “Communication usually involves the case manager presenting options to a physician in a way that would be in the best interest of the patient—not trying to usurp any authority from the physician-patient relationship.”

The greatest partnership between hospitalists and case managers occurs when they both share options and needs, and perhaps the best venue for sharing occurs at interdisciplinary meetings. All case managers interviewed for this article stress the importance of daily meetings as a clear advantage for an effective discharge plan.

L. Greg Cunningham, MHA, CEO of the American Case Management Association (ACMA), headquartered in Little Rock, Ark., says the best thing hospitalists and case managers can do to improve their working relationship is “communicate about their patient caseload first thing in the morning.” Both are sharing information. “One is sharing more expectations of what needs to be done for the patient,” he says. “The other is sharing more expectations about what the physician needs to do in terms of decision-making such as getting signatures on forms and communicating with the patient and family.”

Be Proactive

Theresa Brocato, RN, BSN, CPUR, manager of case management and social work at CHRISTUS St. Frances Cabrini Hospital, has been in that position for almost four years. For seven years before that she worked in managed care for Ochsner Health Plan of Louisiana. In her opinion hospitalists can be most helpful to case managers by thinking proactively.

“We have a very proactive discharge planning department,” she says of her department of nine case managers (all nurses) and five social workers who work directly with patients and families, “because as soon as the patient gets to the hospital we start the discharge planning.”

The case managers interview patients and their family and let them know what their estimated time to wellness will be. “We base the estimate on a working DRG [drug-related group],” she says. “We talk to the hospitalist up front, and [we] say, for instance, ‘For this patient, the average time to wellness is about six days, and we need to start preparing for that ultimate discharge. Is there anything you foresee that you might need on discharge, such as equipment or home health?’ And then we start coordinating with the physicians to get the orders in place and get everything set up so that they have a smooth transition at the time of discharge.”

But Dr. Weisul says this kind of communication can be misinterpreted. “Communication seems to fail in the most difficult cases where the physician seems to perceive that the progress of the medical care might not be going on [in] as timely [a manner] as he or she might expect and feels that the case manager, in … looking at when the appropriate discharge time might be, is pressuring the physician,” he says. “But the reverse is true: What they’re doing is just asking for input from the hospitalist [or other] physician as to progress on the path of returning the patient to health and just looking to the future.”

Brocato says the three hospitalists at Cabrini have been easy to work with, sometimes seeking out the case managers and social workers to ask for their help on difficult cases, working with their fellow interdisciplinary-team members to design discharge plans from innovative ideas that solve patient’s challenges, and including the patient in their planning.

Appropriate Levels of Care

At Cabrini Hospital, the case managers and social workers hold daily interdisciplinary discharge planning meetings. Each case is reviewed according to nationally accepted criteria to ensure that the care provided meets standards appropriate for the acute inpatient level of care. Other treatment levels identified during discharge planning include rehabilitation, long-term acute care, and outpatient levels of care.

One recommendation that Brocato would make to hospitalists to better help the work of the case managers, the hospital, and the patients is to recognize earlier which patients will require a longer length of stay (more than three weeks) so that those individuals can be transitioned into a more appropriate level of care.

Some examples of diagnoses in which long-term acute care might be called for, she says, include “osteomyelitis, where a patient will be on a course of antibiotics for six weeks and may require extensive wound therapy. In that case, as soon as we get the results of the bone scan and we see that, we immediately ask the physician to think about moving the patient.”

Other examples include those patients who will need a long time to recover, such as those in the ICU. “Maybe they’ve have been on a ventilator for a long time and they get debilitated,” says Brocato. “Or if they need to be weaned from the ventilator and need some intensive respiratory toilet. The long-term acute care setting is the more appropriate setting to work on trying to rehabilitate the patient.”

Follow-up

Another important element to a good discharge plan is follow-up. Cabrini Hospital has initiated a program whereby a nurse has been hired to call on patients within two days of discharge to check on how things are going. That is, Brocato says, “whether they understood the discharge instructions, to make sure that they got their prescriptions, and [to ensure] they have some kind of follow-up appointment made and are planning to go to that.”

A 2001 study conducted by the section of general internal medicine in the department of medicine at West Virginia University (Morgantown) showed that the effect of employing a nurse discharge planner to work with the hospitalist service had a positive effect on outcomes in an academic teaching hospital.1 When a general medicine service, specialist-staffed service, and a hospitalist service with nurse discharge planner were compared, the hospitalist-discharge planner group was associated with a lower average cost and shorter average length of hospital stay. There was no apparent compromise in clinical outcomes and patient satisfaction with care.

Competent Colleagues

The American Case Management Association (ACMA), begun in 1999, is the first and only nonprofit hospital-based case management organization in the United States. It represents nurses, social workers, physicians, and other professionals who practice hospital case management. The physicians whom ACMA represents are primarily medical directors hired as the catalyst for attendings who are less than cooperative and are impeding discharge (typically not the hospitalists). “The organization is growing at an average annual growth rate of 25%,” says Cunningham. “We’ve just started a new certification process for hospital-based case managers—one for nurses and one for social workers.”

There is a core portion to the exam that tests for knowledge, and a specialty portion of the exam in which “they have to validate those skill sets. The specialty portion of includes a clinical simulation, which is the application of their skills and knowledge,” explains Cunningham. “They have to [show that they can] make not only a decision, but sequential decisions. So we’re testing their ability to take a case and work through it.”

The hospitalist should expect that high level of competency from a case manager, just as the case manager should be able to expect the highest competency of the hospitalist. “The hospitalist should not lessen their expectation of the clinical competency of the case managers,” says Cunningham. “We are advocating that the physicians … increase their expectations of the clinical competency of those individuals.”

Cunningham recommends that hospitalists discuss their case manager’s background if they suspect there is a diminished competency. “Competent case managers “not only make it better for patients,” he says, “but practitioners’ lives are made much easier when competent case managers are hired.”

All the case managers at Cabrini Hospital have a strong clinical background. “It is really important that the case managers are competent in the field they are working in,” says Brocato, “so that the physicians can trust that they understand the clinical side as well as what might be needed at discharge planning. [At Cabrini Hospital] they are placed in the units where they work based on their careers as nurses. The case manager that works in ICU, for instance, was an ICU nurse for many years.”

Brocato believes “hospitalists need to feel confident that the case managers—or discharge planners as they’re called at some hospitals—have a strong clinical background. In that way, when the hospitalists “are discussing their cases, they feel that we know what they’re talking about. For us, it means that we feel we are all on the same page when we’re dealing with the physicians so that we know what the course of treatment will be. Then the case managers are able to make a better discharge plan based on what the expectations of the hospital stay are going to be, so we can plan ahead.”

Dr. Weisul, who oversees three healthcare facilities in the central Louisiana region, knows that the relationship between hospitalists and case managers can be a fruitful one for all concerned. Cabrini has achieved the lowest case mix-adjusted length of stay in its healthcare system. In addition, when physicians were surveyed regarding the discharge planning process provided to their patients, the hospital achieved a combined rate of 97% “satisfied” or “very satisfied.”

“The idea that case management can achieve, with the physician, a low length of stay does not necessarily have to be in an environment of contention,” says Dr. Weisul.

Conclusion

Realize that case managers are there to assist hospitalists meet patients’ care goals. Watch for patients who a need longer length of stay and alert case managers in those cases to ensure moving them to appropriate levels of care, such as long-term acute care setting as soon as possible. Let case managers know how patients and families can reach you post-discharge. Expect the highest standard of competency from case managers and work with hospital administrators and case management to consistently make this a reality. TH

Andrea Sattinger writes regularly for The Hospitalist.

Reference

1. Palmer HC Jr, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627-632.

Resources

• Case Management Society of America (CMSA): www.cmsa.org/
• American Case Management Association (ACMA): www.acmaweb.org/

Jonathan P. Weisul, MD, FACEP, has direct responsibility over both case management and contracted hospitalist services at CHRISTUS St. Frances Cabrini Hospital in Alexandria, La., where he is regional chief medical officer and vice president of medical affairs. To him, the two most important aspects of the relationship between hospitalists and case managers involve communication and respect.

“In our system it’s a very collaborative approach where the case manager presents options to the physician as discharge planning progresses and the physician explains the progression of the patient’s treatment to the case manager,” he says.

In the early days of managed care, Dr. Weisul says, case management received some bad press in that “it was perceived that their interest was [just] getting patients out of the hospital. And I would say that one area where the communication fails is the oftentimes misheld belief on the physician’s part that case managers are trying to practice medicine,” he explains. “Communication usually involves the case manager presenting options to a physician in a way that would be in the best interest of the patient—not trying to usurp any authority from the physician-patient relationship.”

The greatest partnership between hospitalists and case managers occurs when they both share options and needs, and perhaps the best venue for sharing occurs at interdisciplinary meetings. All case managers interviewed for this article stress the importance of daily meetings as a clear advantage for an effective discharge plan.

L. Greg Cunningham, MHA, CEO of the American Case Management Association (ACMA), headquartered in Little Rock, Ark., says the best thing hospitalists and case managers can do to improve their working relationship is “communicate about their patient caseload first thing in the morning.” Both are sharing information. “One is sharing more expectations of what needs to be done for the patient,” he says. “The other is sharing more expectations about what the physician needs to do in terms of decision-making such as getting signatures on forms and communicating with the patient and family.”

Be Proactive

Theresa Brocato, RN, BSN, CPUR, manager of case management and social work at CHRISTUS St. Frances Cabrini Hospital, has been in that position for almost four years. For seven years before that she worked in managed care for Ochsner Health Plan of Louisiana. In her opinion hospitalists can be most helpful to case managers by thinking proactively.

“We have a very proactive discharge planning department,” she says of her department of nine case managers (all nurses) and five social workers who work directly with patients and families, “because as soon as the patient gets to the hospital we start the discharge planning.”

The case managers interview patients and their family and let them know what their estimated time to wellness will be. “We base the estimate on a working DRG [drug-related group],” she says. “We talk to the hospitalist up front, and [we] say, for instance, ‘For this patient, the average time to wellness is about six days, and we need to start preparing for that ultimate discharge. Is there anything you foresee that you might need on discharge, such as equipment or home health?’ And then we start coordinating with the physicians to get the orders in place and get everything set up so that they have a smooth transition at the time of discharge.”

But Dr. Weisul says this kind of communication can be misinterpreted. “Communication seems to fail in the most difficult cases where the physician seems to perceive that the progress of the medical care might not be going on [in] as timely [a manner] as he or she might expect and feels that the case manager, in … looking at when the appropriate discharge time might be, is pressuring the physician,” he says. “But the reverse is true: What they’re doing is just asking for input from the hospitalist [or other] physician as to progress on the path of returning the patient to health and just looking to the future.”

Brocato says the three hospitalists at Cabrini have been easy to work with, sometimes seeking out the case managers and social workers to ask for their help on difficult cases, working with their fellow interdisciplinary-team members to design discharge plans from innovative ideas that solve patient’s challenges, and including the patient in their planning.

Appropriate Levels of Care

At Cabrini Hospital, the case managers and social workers hold daily interdisciplinary discharge planning meetings. Each case is reviewed according to nationally accepted criteria to ensure that the care provided meets standards appropriate for the acute inpatient level of care. Other treatment levels identified during discharge planning include rehabilitation, long-term acute care, and outpatient levels of care.

One recommendation that Brocato would make to hospitalists to better help the work of the case managers, the hospital, and the patients is to recognize earlier which patients will require a longer length of stay (more than three weeks) so that those individuals can be transitioned into a more appropriate level of care.

Some examples of diagnoses in which long-term acute care might be called for, she says, include “osteomyelitis, where a patient will be on a course of antibiotics for six weeks and may require extensive wound therapy. In that case, as soon as we get the results of the bone scan and we see that, we immediately ask the physician to think about moving the patient.”

Other examples include those patients who will need a long time to recover, such as those in the ICU. “Maybe they’ve have been on a ventilator for a long time and they get debilitated,” says Brocato. “Or if they need to be weaned from the ventilator and need some intensive respiratory toilet. The long-term acute care setting is the more appropriate setting to work on trying to rehabilitate the patient.”

Follow-up

Another important element to a good discharge plan is follow-up. Cabrini Hospital has initiated a program whereby a nurse has been hired to call on patients within two days of discharge to check on how things are going. That is, Brocato says, “whether they understood the discharge instructions, to make sure that they got their prescriptions, and [to ensure] they have some kind of follow-up appointment made and are planning to go to that.”

A 2001 study conducted by the section of general internal medicine in the department of medicine at West Virginia University (Morgantown) showed that the effect of employing a nurse discharge planner to work with the hospitalist service had a positive effect on outcomes in an academic teaching hospital.1 When a general medicine service, specialist-staffed service, and a hospitalist service with nurse discharge planner were compared, the hospitalist-discharge planner group was associated with a lower average cost and shorter average length of hospital stay. There was no apparent compromise in clinical outcomes and patient satisfaction with care.

Competent Colleagues

The American Case Management Association (ACMA), begun in 1999, is the first and only nonprofit hospital-based case management organization in the United States. It represents nurses, social workers, physicians, and other professionals who practice hospital case management. The physicians whom ACMA represents are primarily medical directors hired as the catalyst for attendings who are less than cooperative and are impeding discharge (typically not the hospitalists). “The organization is growing at an average annual growth rate of 25%,” says Cunningham. “We’ve just started a new certification process for hospital-based case managers—one for nurses and one for social workers.”

There is a core portion to the exam that tests for knowledge, and a specialty portion of the exam in which “they have to validate those skill sets. The specialty portion of includes a clinical simulation, which is the application of their skills and knowledge,” explains Cunningham. “They have to [show that they can] make not only a decision, but sequential decisions. So we’re testing their ability to take a case and work through it.”

The hospitalist should expect that high level of competency from a case manager, just as the case manager should be able to expect the highest competency of the hospitalist. “The hospitalist should not lessen their expectation of the clinical competency of the case managers,” says Cunningham. “We are advocating that the physicians … increase their expectations of the clinical competency of those individuals.”

Cunningham recommends that hospitalists discuss their case manager’s background if they suspect there is a diminished competency. “Competent case managers “not only make it better for patients,” he says, “but practitioners’ lives are made much easier when competent case managers are hired.”

All the case managers at Cabrini Hospital have a strong clinical background. “It is really important that the case managers are competent in the field they are working in,” says Brocato, “so that the physicians can trust that they understand the clinical side as well as what might be needed at discharge planning. [At Cabrini Hospital] they are placed in the units where they work based on their careers as nurses. The case manager that works in ICU, for instance, was an ICU nurse for many years.”

Brocato believes “hospitalists need to feel confident that the case managers—or discharge planners as they’re called at some hospitals—have a strong clinical background. In that way, when the hospitalists “are discussing their cases, they feel that we know what they’re talking about. For us, it means that we feel we are all on the same page when we’re dealing with the physicians so that we know what the course of treatment will be. Then the case managers are able to make a better discharge plan based on what the expectations of the hospital stay are going to be, so we can plan ahead.”

Dr. Weisul, who oversees three healthcare facilities in the central Louisiana region, knows that the relationship between hospitalists and case managers can be a fruitful one for all concerned. Cabrini has achieved the lowest case mix-adjusted length of stay in its healthcare system. In addition, when physicians were surveyed regarding the discharge planning process provided to their patients, the hospital achieved a combined rate of 97% “satisfied” or “very satisfied.”

“The idea that case management can achieve, with the physician, a low length of stay does not necessarily have to be in an environment of contention,” says Dr. Weisul.

Conclusion

Realize that case managers are there to assist hospitalists meet patients’ care goals. Watch for patients who a need longer length of stay and alert case managers in those cases to ensure moving them to appropriate levels of care, such as long-term acute care setting as soon as possible. Let case managers know how patients and families can reach you post-discharge. Expect the highest standard of competency from case managers and work with hospital administrators and case management to consistently make this a reality. TH

Andrea Sattinger writes regularly for The Hospitalist.

Reference

1. Palmer HC Jr, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627-632.

Resources

• Case Management Society of America (CMSA): www.cmsa.org/
• American Case Management Association (ACMA): www.acmaweb.org/

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003;348:2281-2284.
2. Virshup BB, Oppenberg MPH, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Quality. 1999;14:153-159.
3. Gurwitz JH, Terry S, Field TS, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-1116.
4. Shapiro RS, Simpson DE, Lawrence SL, et al.. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190-2196.
5. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;227:558-559.
6. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
8. Cohen JR. Advising clients to apologize. Southern California Law Review. 1999;72:1009-1069.
9. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
10. Greenwald L. Who's in charge? Perspectives on Clinical Risk Management. Boston, Mass: ProMutual Group Risk Management Services; Fall 2000.
11. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003;348:2281-2284.
2. Virshup BB, Oppenberg MPH, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Quality. 1999;14:153-159.
3. Gurwitz JH, Terry S, Field TS, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-1116.
4. Shapiro RS, Simpson DE, Lawrence SL, et al.. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190-2196.
5. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;227:558-559.
6. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
8. Cohen JR. Advising clients to apologize. Southern California Law Review. 1999;72:1009-1069.
9. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
10. Greenwald L. Who's in charge? Perspectives on Clinical Risk Management. Boston, Mass: ProMutual Group Risk Management Services; Fall 2000.
11. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.

[H]ospitalists are in a very litigation-intensive and volatile environment. … [T]hey are practicing in a niche that has not been fully accepted by the medical community. There’s a lot of tension on various specialty groups as to the role of hospitalists, the value of hospitalists, whether for a variety of reasons they are creating impediments [to] the quality of care, possibly raising competitive concerns. And so the best trained, the best intentioned, and most capable hospitalist is choosing … a dangerous area of practice from a liability perspective.

—Barry Halpern, JD, Snell and Wilmer Law Offices, expert in medical malpractice law

As hospitalists move from patient to patient, consult to consult, and decision to decision, risk management—proactively identifying, assessing, and prioritizing risks with a goal of minimizing their negative consequences—may not stay uppermost in their minds. Yet for hospitalists, by virtue of their constant location and activity in hospitals, risks lurk at every corner, and the potential for being judged at fault is real and potentially costly.

What are the hospitalist’s risks of being sued for malpractice? How can hospitalists best protect themselves against malpractice claims? Does being liable for patient care ever cause hospitalists to handicap themselves, to hold back in some ways?

What Risks Do Hospitalists Face?

“I think the issue that hospitalists are facing from a medical-legal standpoint is there is not a lot of cumulative experience with case law, precedent, in the field of hospital medicine,” says Tom Baudendistel, MD, a hospitalist and associate program director at California Pacific Medical Center in San Francisco.

Besides errors of medical practice, hospitalists are at risk when they:

• Practice beyond the scope of their specialty;
• Fail to communicate or communicate poorly with patients, families, staff, and referring physicians; and
• Fail to exercise independent medical judgment.

Hospitalists work with sicker, more complicated patients in an environment where more things can go wrong. (See The Hospitalist, July/August 2002, “Hospitalists and the Malpractice Insurance Crisis.”) All things considered, hospital-based physicians are at greater risk of being sued than their colleagues who work in offices.

Case #1: The hospitalist failed to detect a vertebral artery dissection in a younger patient. Should they have been able to detect that? It’s a rather unusual stroke presentation. A neurologist would have picked it up—and certainly would have been held liable or negligent if they’d missed that diagnosis. During their training neurologists would have certainly seen this condition as a cause of stroke in someone below age 45. But internists, in general, don’t receive good neurologic training as part of their residencies, and in community hospitals there is no set neurology service.

Neurologists have now become more office-based and allow the hospitalists to do more. By doing more, they’re also exposed to more legal risk. Should the hospitalist be held negligent for missing an unusual stroke? It depends on what you think is a hospitalist’s scope of practice.

—Dr. Baudendistel

Scope of Practice

A hospitalist’s scope of practice is somewhat difficult to define, although the classification “hospitalist” is gaining clarity (including with insurance underwriters), and the hospitalist model is becoming more recognized as a subspecialty. (See “A Malpractice Primer,” The Hospitalist, Dec. 2005, p. 1.)

One challenge in defining the hospitalist’s scope of practice is that hospitalists do a variety of things and work in different departments of the hospital: Some spend more time in acute care, some are more in general care, and some of them are mostly in trauma care.

It is generally acknowledged that healthcare practitioners must employ the same degree of diligence and skill commonly possessed by other members of the healthcare profession who are engaged in the same kind of work in similar locales. Thus, hospitalists need to be acutely aware of how other hospitalists practice in similar settings with similar resources available.

Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.

Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.

SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.

Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.

“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”

“What does neurosurgery want to do?” asked the hospitalist.

The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.

Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”

There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.

The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.

In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel

Communication

Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.

In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1

Some hot-button areas that carry higher risk and call for meticulous communication between providers include:

1. Inpatient postoperative care;
2. Post-discharge communication (hand-offs);
3. Diagnosis and treatment of a patient for whom there is an incomplete history; and
4. Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.

Communication with Patients

Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9

One-on-One with Barry Halpern, JD

My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.

There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .

Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.

And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.

—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix

Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.

A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.

Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.

On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.

The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”

Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”

Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.

The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.

The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”

—Dr. Baudendistel

Communication with Other Clinicians

“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”

At Rex Hospital (one of Rex Healthcare’s six facilities) where Whitaker works, when seminal events (those big bad things that happen) occur and result in severe trauma or death, the appropriate people meet to backtrack through the steps and scenarios that led to the breakdown.

“Fortunately we don’t have seminal events every day, but every day we do have things that go wrong,” she says. “ … And when we look at our Group Cause Analysis meetings, three-quarters of them [involve] communication issues.”

Exercise Independent Medical Judgment

Hospitalists should read their insurance and employer contracts carefully (especially those with a managed care organization) to ensure that the contract includes a statement allowing the physician to exercise independent medical judgment in the treatment of all patients. If that statement is not present, the hospitalist should request a revision in the contract to include such a statement.

In medical residency programs, a distinction is often made between being a consultant and being a co-manager, says Dr. Baudendistel, but “you have to assume there’s no legal difference between [the two].” Case #3 , he says, was a challenge to decide because the responsibilities of the surgeon and hospitalist in postoperative care were not clearly demarcated.

“I think the surgeon was probably saying, ‘I see this all the time and this is within the realm of what happens after one of these surgeries; let’s not be too worried yet,’” he says. “And I think the internist [hospitalist] ultimately pulled the trigger correctly and the [controversy later on pertained to] whether it should have been done a day or two earlier and whether that have mattered.”

This case illustrates that, although hospitalists are members of teams and partner with consultants and primary physicians, in the end they are managers of patient care and may (we hope rarely) have to break ranks to make aggressive care decisions.

“I think that the other thing that was in [the hospitalist’s] favor,” says Dr. Baudendistel of the case, “was that he was writing very thorough notes, [and] really was discussing everything with the family and everyone was on board. He was doing a very compassionate job … trying to manage this care.”

To Dr. Baudendistel, who is the chair of SHM’s ethics committee, this went a long way toward showing good faith.

Reducing Risks: Concern for the Medical Record

If the medical record is found deficient or illuminating in a negative way, it may serve the plaintiff attorney’s strategy well for establishing negligence or wrongdoing. The chart notes documented by nurses, attending staff, consultants, other residents, and therapists could either portray a smoothly managed case or a chronology of errors and omissions. The chart should never be cosigned and never merely assumed to be accurate.

When Things Go Wrong

Whitaker advises hospitalists to keep the lines of communication open. “Especially after something unexpected has happened,” she says. “So many times I think the human tendency is to just withdraw, or you feel terrible and you don’t know what to say, or you’re afraid you’re going to get emotional while you’re talking with the family.”

This is normal human response in these circumstances, but if you act on the impulse to withdraw and avoid the patient and family, or hold back, which may eventually lead to a filed claim from a family that feels abandoned.

“Until now the number of lawsuits has been really steady and the amount that we were paying in lawsuits was increasing,” says Whitaker. “However, we’re trying to work with the families earlier on so if we make a mistake and we realize that we made a mistake then we admit that. And we try to do what we can to make it right for that patient and their family.”

This often means reaching a fair and reasonable settlement, says Whitaker, “and [examining fair and reasonable means reviewing] the communication at the time the event occurred. Did we acknowledge that we made a mistake? Did we let them know we’d be willing to work with them? And did we let them know we [have since] made these changes … so they’ll … be reassured [that] hopefully it won’t happen again?”

Who’s in Charge?

Linda Greenwald, RN, MS, editor of risk management publications at ProMutual Insurance Group in Boston, wrote in the company’s newsletter, Perspectives on Clinical Risk Management, that in prior times, the question, “Who’s in charge?” was rhetorical.10 These days any number of generalists or specialists might claim that role. And therein lies the rub: Greenwald says that in many cases involving hospitalists the lines of responsibility are unclear and one or more systems may fail. If so, Greenwald writes, the result may be a malpractice claim alleging:

• Failure to diagnose when each of two physicians assumes the other has responsibility for follow-up;
• Negligence in treatment when one physician fails to monitor on an outpatient basis the medication first prescribed by another physician when the patient was an inpatient; and/or
• Negligent care when a patient misinterprets the information one physician asks him or her to relay to another physician.10

Halpern concurs that the modern mix of professionals working as a team on hospital care can be a major challenge.

“In olden days, when a primary care physician referred to a surgeon, and the surgeon performed surgery, and the surgeon took responsibility for postoperative care, and occasionally brought in a consultant, the lines were relatively clear,” says Halpern. “When a hospitalist is injected into the mix, unless the hospital has really clear procedures and unless everybody is comfortable with the system and everybody is talking to each other and agreeing on the lines of demarcation, you’re creating a soup that plaintiff lawyers would be happy to stir.”

The more murky the communication, the greater the liability. “And when you have murky lines of communication, murky lines of responsibility, and a medical catastrophe,” says Halpern, “human nature compounds the problem by frequently causing a finger-pointing contest, where each component of the patient care team circles its own wagons [and] points in a different direction. And that is the absolute worst thing that can happen when trying to deal with a patient injury claim.”

Summary

The hospitalist’s primary risk for malpractice claims may be inadequate or absent patient follow-up resulting from a lack of communication. The best means of protection from claims is for hospitalists to incorporate a comprehensive risk management program into their practice.

Several strategies have proved successful to help prevent litigation. In general, hospitalists should make sure that their hospital has clearly delineated policies regarding responsibility for patients; clearly understand—and ensure that your coworkers, colleagues, and referring physicians understand—the hospital’s systems and protocols; exercise good communication skills; conform to the standard of care; know your own scope of care to the best of your ability; and exercise independent medical judgment, even when partnering with others. TH

Andrea Sattinger also writes the “Alliances” department for The Hospitalist.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003;348:2281-2284.
2. Virshup BB, Oppenberg MPH, Coleman MM. Strategic risk management: reducing malpractice claims through more effective patient-doctor communication. Am J Med Quality. 1999;14:153-159.
3. Gurwitz JH, Terry S, Field TS, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1107-1116.
4. Shapiro RS, Simpson DE, Lawrence SL, et al.. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190-2196.
5. Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;227:558-559.
6. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-1370.
7. Cohen JR. Apology and organizations: exploring an example from medical practice. Fordham Urban Law Journal. 2000;27:1447-1482.
8. Cohen JR. Advising clients to apologize. Southern California Law Review. 1999;72:1009-1069.
9. Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care JAMA. 1994;272:1588-1591.
10. Greenwald L. Who's in charge? Perspectives on Clinical Risk Management. Boston, Mass: ProMutual Group Risk Management Services; Fall 2000.
11. Alpers A. Key legal principles for hospitalists. Am J Med. 2001;111:5-9.