The loss of PCPs from hospital setting

Nurses Relations

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Specializes in ER.

A retired family doctor was selling her produce and pottery at the farmer's market today. She had privileges at the hospital where I worked. We got to talking about the changes in healthcare.

One big change in the past 10 years is the advent of hospitalists taking over a great deal of the inpatient care. Many, if not most family doctors do not round on their patients in the hospitals anymore.

She said that it really is a loss of continuity of care for both the doctor and patient. I agree. Healthcare has become rather like an assembly line, I told her. It's increasingly centralized, and is not built on personal relationships as in the past. She told me that when the hospital district bought up all the practices, they imposed a computer charting system that further distanced her from her patients, mandating information prompts that cluttered up the charting. It spewed out pages and pages that were difficult to read and extract meaningful data.

I see these trends getting worse and not improving our health care system. And I'm sad that, if I'm ever hospitalized, a stranger, not my family doctor, will be managing my care.

Specializes in Critical Care.

As someone who is very fond of my PCP, I get the complaint; I'd prefer to know he's involved in my care if I was hospitalized. As a nurse however I have absolutely no problem with hospitalists taking over for PCP's in managing patients in the hospital. Hospitalized patient in general are nothing like they were 30 or even 15 years ago (or even 5 years ago for that matter) and I really don't think that most of today's hospitalized patients can be safely managed by a PCP.

Today, most of the patients I care for are managed by hospitalists, but we still have two family practices that manage their own patients. I called a PCP not long ago on a patient who had come in as a CP rule out. Their 2 hour tropinin-I was severely elevated, which usually means a cardiologist is consulted and they are started on a heparin drip. The PCP told me they didn't care about the troponin, it's the CK they were worried about since that is "more specific" and that they weren't going to do anything until the CK turned positive (CK's are actually less specific and take longer to turn positive than troponins). I went around them and called the cardiologist on call who then called the PCP to tell them they were taking over their patient. I also had a PCP a while back tell me they weren't worried about a patient's CXR because it was all white, which is good, because white on a CXR represents air. I called for pain meds for a 88 year old little lady not long ago and got an order for dilaudid IV 2-6mg q 2hrs.

They mean well and there is certainly a profit component involved for the hospital, but all-in-all I don't think the transition to MD's who specialize in managing hospital-sick patients is avoidable.

I shiver everytime I find out that one of my patients is under a PCP. Who has the time to call a PCP's phone in the middle of the night and go through a range of press 1, press 2 etc only to end up with the doctor's on call, who obviously doesn't know the patient, just to get an order for collace or tylenol. Patients get better care with hospitalists. As a nurse, they make my work easier. A PCP has no adequate skills to provide complex acute and critical situations.

Dealing with PCPs is terrible. We have two PCPs with rounding rights and they were doctors before Nixon was in office. Nice guys who have had their patients for years but in the end patient care and my sanity suffers when they take over. Patient's are much better off with the internal med docs who do hospitalist work EVERY day.

Today, most of the patients I care for are managed by hospitalists, but we still have two family practices that manage their own patients. I called a PCP not long ago on a patient who had come in as a CP rule out. Their 2 hour tropinin-I was severely elevated, which usually means a cardiologist is consulted and they are started on a heparin drip. The PCP told me they didn't care about the troponin, it's the CK they were worried about since that is "more specific" and that they weren't going to do anything until the CK turned positive (CK's are actually less specific and take longer to turn positive than troponins). I went around them and called the cardiologist on call who then called the PCP to tell them they were taking over their patient. I also had a PCP a while back tell me they weren't worried about a patient's CXR because it was all white, which is good, because white on a CXR represents air. I called for pain meds for a 88 year old little lady not long ago and got an order for dilaudid IV 2-6mg q 2hrs.

Wow! That is some scary stuff. Thank goodness you were there to step in!

Specializes in nursing education.

I work in a PCP group where I do a lot with care transitions, especially following up on hospitalizations and ED visits. Our patients, when they are admitted, mostly are rounded on and managed by the group, but sometimes are managed by the hospitalists. I can definitely see both sides to this. Yes, hospitalized patients are sicker than they used to be, and the hospitalists (and intensivists) see those complex types of patients all the time and have expertise in this type of care, as well as being available because they don't have a full day of outpatient appointments scheduled.

Yet, many of our patients have longstanding relationships with the PCPs and are complex even when they are not hospitalized, with multiple chronic conditions and social issues. When our patients are admitted to the hospitalist service, we don't even necessarily know that they have been hospitalized. This disrupts follow up and continuity of care. They almost might as well have been at a different hospital that we are not connected with. If he or she is aware of the admission, sometimes the PCP makes more of a social visit.

No easy answers here.

Specializes in LTC, med/surg, hospice.

As a nurse, I prefer the hospitalist but I do get the patient's POV. It sucks because they aren't offered a choice but that's the way things have been for several years now.

Many of the internal medicine docs that I was familiar with were more than capable of managing critical patients and often rotated through being the intensivist.

From a nursing point of view, I don't miss trying to call a doctor who is across town seeing patients in their office practice. I don't miss calls to the answering service after hours.

The hosptialists are always there. The response time is much quicker when you need something for your patients.

Specializes in SICU, trauma, neuro.
I also had a PCP a while back tell me they weren't worried about a patient's CXR because it was all white, which is good, because white on a CXR represents air

Which is why bones show up...black?...on an x-ray...? SERIOUSLY??? :facepalm:

I called a PCP not long ago on a patient who had come in as a CP rule out. Their 2 hour tropinin-I was severely elevated, which usually means a cardiologist is consulted and they are started on a heparin drip. The PCP told me they didn't care about the troponin, it's the CK they were worried about since that is "more specific" and that they weren't going to do anything until the CK turned positive (CK's are actually less specific and take longer to turn positive than troponins). I went around them and called the cardiologist on call who then called the PCP to tell them they were taking over their patient. I also had a PCP a while back tell me they weren't worried about a patient's CXR because it was all white, which is good, because white on a CXR represents air. I called for pain meds for a 88 year old little lady not long ago and got an order for dilaudid IV 2-6mg q 2hrs.They mean well and there is certainly a profit component involved for the hospital, but all-in-all I don't think the transition to MD's who specialize in managing hospital-sick patients is avoidable.

That's some scary stuff right there.

We have a few community docs that still round on their own patients. It is IMPOSSIBLE to get any of them on the phone after 10 pm. We admit them with no orders (except for the admitting order) - which means no diet orders, no pain med orders, and sometimes not even antipyretic orders - its ridiculous. I love getting hospitalist patients.

oh and the one PCP anytime he admits his patients its an automatic week stay in the hospital AND he will order a full workup for EVERYTHING under the sun - even stuff that isn't related to the present admission - they're in the hospital for leg pain, GREAT! Lets do a full thyroid and anemia workup, as well as a UA/CS, lipid panels etc etc etc...

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I called a PCP not long ago on a patient who had come in as a CP rule out. Their 2 hour tropinin-I was severely elevated, which usually means a cardiologist is consulted and they are started on a heparin drip. The PCP told me they didn't care about the troponin, it's the CK they were worried about since that is "more specific" and that they weren't going to do anything until the CK turned positive (CK's are actually less specific and take longer to turn positive than troponins). I went around them and called the cardiologist on call who then called the PCP to tell them they were taking over their patient. I also had a PCP a while back tell me they weren't worried about a patient's CXR because it was all white, which is good, because white on a CXR represents air. I called for pain meds for a 88 year old little lady not long ago and got an order for dilaudid IV 2-6mg q 2hrs.

They mean well and there is certainly a profit component involved for the hospital, but all-in-all I don't think the transition to MD's who specialize in managing hospital-sick patients is avoidable.

You are a nurse after my own heart. I agree.

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