Truly be the “PCP in the hospital”

When patients are most in need of a familiar face, they often must trust the stranger who was assigned to walk in their door. But it doesn't have to be that way.

It's been 20 years since Robert M. Wachter, MD, FACP, and Lee Goldman, MD, FACP, coined the term hospitalist (11. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-7. [PMID: 8672160]), yet often patients are still unfamiliar with the title. This can be a good thing (maybe they haven't been hospitalized in 20 years), but it does mean that we need to explain to them (and their families) who we are and what we do. I often find myself saying, “I'm here to act as your PCP while you're in the hospital. I'm in charge of your care, and I help coordinate the other members of the team. In addition, I keep your PCP informed of everything that happens while you're here.”

Unfortunately, this is somewhat disingenuous. While I may be “acting” like their PCP, there is one way that I'm really nothing like their PCP: I don't know them. This is probably the first time we are meeting, at a time when they are at their sickest and most vulnerable. So when patients are most in need of a familiar face, they often must trust the stranger who was assigned to walk in their door.

Photo courtesy of Dr Secan
Photo courtesy of Dr. Secan

But it doesn't have to be this way. We could be more like their PCP by establishing and maintaining a long-term relationship. In general, I believe we hospitalists do a reasonable job of maintaining continuity from day to day. I take care of Mrs. Jones today, and, presuming I'm still working tomorrow, I continue to care for her. Even if I'm off for the weekend, when I return on Monday, if she's still in the hospital, I'll likely resume her care. But this is not how PCPs see patients. PCPs see their patients again and again across time—and I propose that we should try to do the same.

The numbers indicate (and my experience confirms) that our patients come back to the hospital over and over again. According to the Healthcare Cost and Utilization Project (22. Weiss AJ, Elixhauser A. Overview of Hospital Stays in the United States, 2012. Healthcare Cost and Utilization Project. Statistical Brief #180. October 2014. Available online. ), in 2012, patients ages 65 to 84 had 261 hospital stays per 1,000 patient population. This rises to 502 hospitalizations per 1,000 in patients over age 84. This works out to 1 hospitalization every 2 years on average. Especially considering many of these hospitalizations are going to be concentrated in a small number of chronically ill patients, there's simply no reason why we shouldn't strive to provide them with greater continuity of inpatient care.

When these patients return to the hospital, it's becoming increasingly common that they'll encounter the same hospitalists. According to the most recent survey from the Society of Hospital Medicine (33. 2014 State of Hospital Medicine Report. Society of Hospital Medicine.), the median turnover rate at adult hospitalist programs is down to only 8%, and in 38% of groups, there was no turnover at all. This means that just as our patients visit the same hospital for many years, many hospitalists remain in their positions for many years, too.

In addition to showing that it's possible to maintain greater continuity, the evidence indicates potential benefits. While there aren't any current data about this specific situation, there is significant literature to support gains in patient satisfaction associated with continuity of care. For example, in 1992, a study (44. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ. 1992;304:1287-90. [PMID: 1606434]) found that when evaluating satisfaction with a consultation provided by their primary care physician, “an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed.” In 2004, a review of the literature (55. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2:445-51. [PMID: 15506579]) noted that “a consistent and significant positive relationship exists between interpersonal continuity of care and patient satisfaction.” While the inpatient and outpatient worlds are different, patients are still patients, and we shouldn't be surprised that patients prefer to see a physician they know rather than a stranger.

When patients are first admitted to a hospital, they should become attached to the hospitalist who sees them. On further admissions over time (months or years), as often as possible, they should continue to be managed by that same hospitalist. The benefits of this are enormous. For patients, they now have a clinician they know and trust. Even though they're ill, they can feel confident that they are in the hands of someone who knows them. They don't feel like they have to recount their lifetime history. Their families also know and trust the clinician. This makes the ongoing process of communication smoother, especially at difficult times like discharge or end-of-life planning.

In the outpatient setting, it's typical to choose a PCP to maintain a relationship over time. We are unhappy and frustrated when we have to find a new primary physician, such as when our insurance changes. Patients feel the same way in the hospital, and it's time that we give them what they really need—continuity.