by Dr. Charlie M. Wray DO
After diligently listening to the intern’s presentation and deciding on what our treatment plan would be for our patient, Mrs. Ramirez, my senior resident led our two interns, two medical students, and myself into her room. As we all methodically filed in, slowly gathering around the patient, I could see her anxiously sit up in bed and look around at all the different faces, searching for one to focus on. As the intern reviewed the overnight labs and imaging with her, I stood there and imagined the confusion and overwhelming feelings she probably has every morning when a gaggle of doctors amass around her bed. I contrasted this experience with what would likely occur the following week when I would be back on service as a direct hospitalist, where instead of 6 different white-coated individuals to contend with, my patients would only have to deal with one. From a patient’s perspective, the differences between these two experiences are obvious.
In further thinking, fellow colleagues and I began asking the question, “Do you think patients prefer to be on hospitalist-only teams or on the traditional teaching teams?” We recently published our findings in the Journal of Hospital Medicine and found that patients rated their overall care higher on direct hospitalist services than on teaching services. Even more fascinating, was that this finding held true even when hospitalists were attending on teaching services.
How can this be? Teaching services have 3-4 doctors (in-training) looking over them, medical students with time to come review their care plan and answer any questions, and an attending who is hawkishly watching over all of this to make sure nothing is missed. How could this not be the “gold standard” of patient care? Well, we have some thoughts that might explain why patients seem to prefer direct hospitalists to traditional teaching services.
- 1. More isn’t always better. As I’ve previously alluded, the structural differences between the two services are obvious. We as physicians often forget that most patients probably do not know or understand the differences between medical students, interns, and residents. To patients, they all wear long white coats and use big words they don’t understand. How are they expected to know who is in charge, or whom they should ask questions about their medications or test results? If 4-5 similarly attired people walked up to you when you weren’t feeling well and started using words you didn’t know – wouldn’t you be a bit confused? I know I would!
- 2. The revolving door of residents doesn’t help. To make matters worse, let’s have those same 4-5 people who come to see you every morning change on a daily basis – so that it’s never really the same group of people taking care of you. Resident duty hour regulations, whether you agree with them or not, have certainly not helped with doctor-patient continuity. This revolving door of residents may be the reason why recent work has shown that patients view the attending physician as the most involved in their care. Simply put, they are the most consistent face in the crowd.
- 3. Every good Chef needs a Sous Chef. Where I practice (and where this study was performed), we are fortunate to have Nurse Practitioners and Physician Assistants (NPA) on our direct hospitalist service. These providers help offload some of the work and extend the hospitalist team’s reach so that when I am acting as a direct hospitalist, I can give my patients more time and attention. So now instead of having a revolving door of doctors, the patient has a consistent physician or NPA who is able to take the time to answer any questions, talk to their family, and clarify any uncertainties. Additionally, they know exactly who to look to if they have any questions. So while the use of NPA providers is still growing, our findings may help bolster their role in hospital medicine.
- 4. The proof is in the pudding. Interestingly, the finding that patients rated their overall care better on a hospitalist service, even when hospitalists were the attending on a teaching service, can really liven-up the conversation. One hypothesis is that hospitalists provide a high quality of care that the patients are able to relatively perceive. A study by Chen and colleagues found that hospitals with greater use of hospitalist care were associated with better patient-centered care. These outcomes were primarily driven by patient-centered domains, such as discharge planning, pain control, and medication management – three areas that I think most would agree are often confusing and troublesome for hospitalized patients. In the end, maybe hospitalists are just really good at paying attention to what matters most to patients.
We admit that the patient experience is a highly confounded outcome that could be affected by such small things as the patient not getting their dinner on time, a loud next-door neighbor, or an uncomfortable hospital bed. With regards to our study, while our ED doesn’t preferentially admit certain patient populations to one service or another, there is a scheduling structure that defines which service a patient is admitted to based on resident admission caps. On top of this, our hospitalist service does take care of the vast majority of our transplant patients, which some have argued may be more grateful to the medical establishment, – so that factor could have boosted their satisfaction scores. All are fair and logical critiques.
Needless to say, exploring how we can improve the hospital experience regardless of who is taking care of the patient is both important and necessary. We certainly can’t do away with teaching teams altogether, but we should think about ways to make the complex interactions that are associated with this service more simple for the patient – not just because the data show there’s a difference, but because it’s the right thing to do.
Dr. Charlie M. Wray DO is currently a second year Hospitalist Research Fellow and Clinical Associate in the Section of Hospital Medicine at the University of Chicago. He completed medical school at Western University – College of Osteopathic Medicine and residency at Loma Linda University Medical Center prior to his fellowship. Dr. Wray’s research interests are focused on inpatient care transitions and care fragmentation in the hospital setting. Additionally, he has strong interests in medical education, with specific focus in evidence-based medicine, the implementation of value-based care, and how learners negotiate medical uncertainty. Following his fellowship, Dr. Wray will be joining the staff at the San Francisco VA Medical Center.