Long ago, before our clinic changed over to a virtually complete hospitalist version, the faculty at our internal drug clinic functioned as the attending of record for every one of our own patients, in addition to the patients of the inhabitants we supervised, when those patients were admitted to the inpatient services throughout the road.
When we would arrive in the morning, we would examine the entry list, note that one or 2 of our patients had been admitted, and possibly a couple of a number of our taxpayers’ patients, and knew that our day could have the accession of rounding on those patients in addition to our entire schedule of inpatient responsibilities.
As the hospital transitioned over to a hospitalist version, they requested that we relinquish this duty, give up the care of our inpatients. It had been less of a request and much more of the FYI. Among the primary problems was that on any given housestaff inpatient group, the inhabitants would frequently have around a dozen attendings they needed to explore their patients with through morning rounds and through the day. This enhances.
As those of us in the outpatient world gave upon the vast majority of our inpatient responsibilities (except the occasional social visit to our patients that are admitted), the perishable skills of inpatient care jumped away from most of the faculty who focus their lifetimes in the inpatient setting. We are outpatientists, not hospitalists.
The 1 thing that has persisted has been our coverage of weekends about the service. Some of our coworkers continue to staff the medication service inpatient company, covering the weekends, and service has been completed by us as a practice to the hospital. In order that many attendings cover just 2 weekends a year we’ve divided them up.
Since we have a huge practice not much 2 weekends from the year isn’t much in any respect, created more manageable.
But with this portion of their responsibilities, as we’ve moved further and farther away from being doctors, more and more of our faculty have expressed dissatisfaction over the last few decades.
When you only do it 2 weekends from the year, so there are usually many months involving the times you really even log onto the inpatient electronic health record (different from our inpatient EHR) — let alone take care of septic patients having metastatic cancer anticipating brain biopsies about Monday morning.
We’re highly proficient at handling outpatients, but when we are asked to cover the very ill patients that are lying about the inpatient provider, a number of my faculty are open and honest in expressing their lack of confidence in their skills and ability to safely choose the very best care of those patients.
We finally realized we had reached a breaking point, as the voices requesting to be eliminated from this task grew more rapid and more varied, and also increasingly more and more of our faculty told me that they were not comfortable caring for the population of individuals anymore.
So we have a proposal set up to relinquish this duty, and occupy a new one, something that I am sure were great at, and now the challenge is trying to determine how to build this new version to offer the very best service to our patients, to our practice, and also to our clinic.
We’ve developed a business plan to offer our services up to make access for individuals on the weekends, even a time when access to care has historically been quite limited.
At the moment, our practice closes at 5 pm on Fridays, our telephones roll over to the answering service, along with attending and an on-call resident manage requests and telephone calls from individuals phoning up the weekend.
Many of them are regular clinical conditions, easily handled with a prescription or a few medical advice. But often times these are items that call for a visit to the physician, the auscultating and probing along with laying on of hands that we do. And much more intensive interventions.
At this time, the alternatives for patients out of the providers would be to go to a local care centre, or to the emergency area.
Long waits. That do not know them. Separate EHR’s. Overtesting. Overtreating.
Doing exactly what works — and also what we adore
Could not it be much better if we can send these kinds of scenarios, those patients, to an inpatient setting that is appropriate, the continuity-of-care location our patients love and know, and also where we are comfortable practicing?
The emergency area is inundated with that which we call “primary care-responsive experiences” Minor injuries, Upper respiratory tract infections, UTI’s, migraines, and the range of conditions that pose to our office Mondays through Fridays.
Patients that arrive with conditions in the emergency department are currently being routed to their telehealth program, where a provider goes over their issue by means of a video connection. If they had the ability to simply turn those patients and ship them to our workplace across the road, how much better would it be?
We may now be able offer rapid discharge visits the next day. If no one could get them into a consultation with their physician for close follow-up in the next 24 to 48 hours patients are often held in the clinic over the weekend.
Would not it be nice if rather than holding those individuals lying there in a hospital bed all weekend, preventing another individual from coming up from the overcrowded emergency area, that we could send them home from the hospital on Friday afternoon, and possess our provider see them in the office the next day if necessary?
My college is excited by this new concept, this new version of care, and we expect our patients will likely be. Instead of being routed to the emergency area if they have got strep throat, to figure out, I could see them.
And a few patients may even want to schedule an annual physical or a visit on a day when they do not need to take off work to visit their physician.
I am 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 largely despise), using something that we are great at, using something our patients actually need.
There will be hiccups, issues with putting up this and getting it figured out. Days with no patients, days with way. Trauma and play, incorrect patients in the perfect place, right patients in the incorrect place. Finding the coverage system that is perfect, the resources to look after these patients, the mixture of individuals, and simply spreading the word that this can be obtained, all will be challenges.
I am aware of many specialist and subspecialist coworkers that do a few weekend hours, and receiving buy from them that we could send an urgent ophthalmologic individual across to ophthalmology clinic rather than to the emergency room might continue to boost care and get our patients what they need with no long, long wait in the emergency section to be observed by a specialist.
We are currently working to ensure that we have access to laboratory services and radiology services, and even reaching out to our insurers to make certain we could get consent for CT scans over the weekends.
I am convinced this will be a wonderful new version of care, along with my faculty is definitely enthusiastic about offering this service to our patients and to our clinic, and they are all more than happy at the chance to end up covering a project they do not like performing, trading it in for something that they love.
Fred N. Pelzman is an associate professor of Medicine, New York Presbyterian Hospital and associate manager, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs in MedPage Today’s Building the Patient-Centered Medical Home.