Let primary care doctors practice more outpatient medicine

Let primary care doctors practice more outpatient medicine

Long ago, before our hospital changed over to a nearly complete hospitalist model, the faculty at our internal medicine practice served as the attending of record for all of our own patients, as well as the patients of the residents we supervised, when those patients were admitted to the inpatient services across the street.

When we would arrive in the morning, we would look at the admission list, note that one or two of our patients had been admitted, and maybe one or two of some of our residents’ patients, and knew that our day would have the addition of rounding on those patients as well as our full schedule of outpatient responsibilities.

As the hospital transitioned over to a near-complete hospitalist model, they requested that we relinquish this responsibility, give up the care of our inpatients to hospitalists. It was less of a request and more of an FYI. One of the main issues was that on any given housestaff inpatient team, the residents would often have up to a dozen attendings they had to discuss their different patients with during morning rounds and through the day. A pure hospitalist model certainly improves this.

Feeling a bit rusty

As those of us in the outpatient world gave up on the majority of our inpatient responsibilities (except the occasional social visit to our patients who are admitted), the perishable skills of inpatient care drifted away from most of the faculty who focus their lives in the outpatient setting. We are outpatientists, not hospitalists.

The one thing that has persisted has been our coverage of weekends on the service. A few of our colleagues continue to staff the medicine service inpatient service, and we as a practice have done service to the hospital by covering the weekends. We’ve divided them up, so that most attendings cover just 2 weekends a year.

Not very much of a burden, 2 weekends out of the year is not much at all, made more manageable because we have such a large practice.

But over the past few years, as we’ve moved farther and farther away from being inpatient doctors, more and more of our faculty have expressed dissatisfaction with this part of their responsibilities.

When you only do it 2 weekends out of the year, that means there are often many months between the times you actually even log onto the inpatient electronic health record (different from our outpatient EHR) — let alone take care of septic patients with metastatic cancer awaiting brain biopsies on Monday morning.

We are highly skilled at managing outpatients, but when we are asked to cover the quite ill patients who are lying on the inpatient service, many of my faculty have been open and honest in expressing their lack of confidence in their skills and ability to really safely take the best care of these patients.

As the voices requesting to be removed from this task grew more numerous and louder, we finally realized we had reached a breaking point, and more and more of our faculty told me they were just not comfortable taking care of this population of patients anymore.

Arriving at a solution

So we have a proposal in place, to relinquish this responsibility, and take up a new one, something that I’m sure were good at, and now the challenge is trying to figure out how to build this new model to provide the best service to our patients, to our practice, and to our hospital.

Weekends!

We’ve developed a business plan to offer up our services to make available access for patients on the weekends, a time when access to primary care has historically been quite limited.

Right now, our practice closes at 5 pm on Fridays, our phones roll over to the answering service, and an on-call resident and attending handle phone calls and requests from patients calling up over the weekend.

Many of these are routine, simple clinical situations, easily handled with some medical advice or a prescription sent to the pharmacy. But often times these are things that require a visit to the doctor, the laying on of hands, the palpating and auscultating and probing that we do. And even more intensive interventions.

 Right now, the options for patients from the on-call providers are to go to the emergency room, or to a local urgent care center.

Long waits. Providers that do not know them. Different EHR’s. Overtesting. Overtreating.

Doing what works — and what we love

Wouldn’t it be better if we could send these patients, these types of clinical cases, to an outpatient setting that is more appropriate, the continuity-of-care location that our patients know and love, and where we are comfortable practicing?

The emergency room is inundated with what we call “primary care-responsive encounters.” Upper respiratory tract infections, minor injuries, UTI’s, rashes, the bread-and-butter spectrum of conditions that present to our office Mondays through Fridays.

Many patients who arrive in the emergency department with nonurgent/nonemergent conditions are currently being routed to their telehealth program, where a provider goes over their issue via a video link. How much better would it be if they were able to just turn those patients around and send them across the street to our office, where a primary care provider would be sitting waiting for them, ready to handle these needs?

Also, we may now be able offer rapid discharge visits the next day to patients ready to be discharged from the hospital on Friday. Right now, patients are often held in the hospital over the weekend when no one can get them into an appointment with their doctor for close follow-up in the next 24 to 48 hours.

Wouldn’t it be nice if instead of holding those patients lying there in a hospital bed all weekend, preventing another patient from coming up from the overcrowded emergency room, that we could send them home from the hospital on Friday afternoon, and have our provider see them in the office the next day if necessary?

My faculty is excited by this new concept, this new model of care, and we hope our patients will be as well. Rather than being sent into the emergency room to figure out if they’ve got strep throat, I can see them in the office the same or next day over the weekend.

And some patients may even like to schedule an annual physical or a routine follow-up visit on a day when they don’t have to take off work to see their doctor.

I’m not suggesting that we all begin to work 6- and 7-day work weeks, but we are certainly happy to exchange the inpatient weekend service coverage that we do now (and mostly dislike), with something that we are good at, with something that our patients really need.

True, there will be hiccups, problems with setting this up and getting it figured out right. Days with no patients, days with way too many. Trauma and drama, wrong patients in the right place, right patients in the wrong place. Finding the right coverage system, the right resources to take care of these patients, the right mix of patients, and even just spreading the word that this is available, will all be challenges.

I know of several specialist and subspecialist colleagues who do some weekend hours, and getting buy-in from them that we can send an urgent ophthalmologic patient across to ophthalmology clinic instead of to the emergency room might continue to enhance care and get our patients what they need without the long, long wait in the emergency department to be seen by a specialist.

We are working with the hospital to ensure that we have access to radiology services and laboratory services, and even reaching out to our insurers to make sure we can get authorization for same-day CT scans over the weekends.

I’m confident this is going to be a great new model of care, and my faculty is certainly excited about offering this service to our patients and to our hospital, and they are all more than pleased at the opportunity to give up covering a job they don’t like doing, trading it in for something they love.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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Published at Sun, 19 Mar 2017 17:00:55 +0000