Are hospitalists becoming de facto PCPs for patients with complex illness?

Key takeaways:

• Hospitalists are becoming primary physicians for patients in decline.
• Hospitals are the new “clinic” for patients with complex illness.
• Hospitalists are increasingly initiating discussions about patients’ values and goals.

HOSPITALISTS REALIZE the joy of never having to work in clinic again. Hospital problems call for physicians to treat high-acuity complex illnesses—and as a result, hospitalists typically have short-term relationships with patients and families.

But increasingly, patients with complex illnesses return to the hospital unable to recover long enough to even attend clinic visits. This poses a problem: The hospital, not the clinic, is becoming the place where we may need to manage chronic illness and advanced disease in addition to complex illnesses. While some patients do recover, others are in a revolving door of decline that we label a series of medical problems.

A patient with heart failure, COPD and chronic kidney disease comes in for pneumonia followed by a COPD exacerbation followed by heart failure. Next, they come back with acute kidney injury with known chronic kidney disease.

We order several rounds of rehabilitation either at home or in a facility. But when do we stop calling these individual medical problems and start calling them decline?

Conversations with patients about values and goals are about to be the new culture of hospital medicine.

That raises another tough issue: Specialists and PCPs are not consistently bringing up prognosis in the clinic visits that these patients do have. (If they do, that doesn’t appear in the notes as a detailed discussion.) In some cases, patients coming to the hospital understand that they have been in decline. But others haven’t had that conversation with any physician, and they are floored by the suggestion.

Disease progression

As patients become more complex, they are like a car that keeps hurtling toward a brick wall.

Every time a patient requires a specialist for a complex illness, the car picks up speed. But as more medical providers become involved, fewer reveal to patients the brick wall that lies ahead.

Instead, that discussion has become the “hot potato” in medicine. Every provider who could discuss disease progression and prognosis seems to think that someone else should initiate the discussion.

Part of the problem is that even when patients have a follow-up visit after a hospital stay, it’s probably not to discuss goals of care. Nor will a 15-minute visit come close to a meaningful goals of care conversation that could actually help a patient or family.

At the same time, hospital administrators are busy trying to understand why readmissions occur. But that’s something we really can’t understand without correctly analyzing some readmissions within the context of patients’ progressive illness, home life and family support. If hospitalizations are viewed only as an acute stay, we will have missed the real reason why many of our patients are being hospitalized in the first place.

Our thinking about acute hospital stays may need to change and include a bigger view of a patient’s situation. Otherwise, we won’t be able to assess the relationship between an acute stay in the context of a patient’s chronic medical issues and any declines.

Our changing role

As hospitalists, we may also need to change our understanding of our role with some of our patients. For those with chronic and progressing disease, we have become their primary physician and the hospital has become the “clinic” for patients with complex illnesses.

That leaves us increasingly in the position of needing to ask about a patient’s values and goals in addition to our conversations about advanced disease. As the population ages, hospitalists are increasingly facilitating these conversations to help patients and families understand and navigate disease complexity. Those conversations can guide future hospital stays even if they don’t change the current plan of care.

But having these discussions is no easy task when the patient comes in unprepared due to the paucity of previous conversations. A hospitalist who has no prior relationship to the patient has to lay out the reasoning behind that discussion and carefully explain what led up to it. Typically, one of two things then happens: Patients gratefully appreciate addressing their values and declining quality of life. Or they are offended and dismissive because this new doctor doesn’t know them.

And if we choose to use palliative care for complex illnesses, that becomes a very heavy lift, particularly when little has previously been said about advanced disease in the context of medical complexity. When patients have chest pain, they don’t question why a cardiologist comes into their room. But when we consult palliative care, that’s another big discussion on why those specialists are being called in.

Our changing patient population

In “Being Mortal,” Atul Gawande, MD, MPH, writes this: “We have been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. … [T]he vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs that you are willing to make? And what is the course of action that best serves this understanding?” (“Being Mortal,” page 259)

Dr. Gawande contends that all clinicians should apply this thinking to every patient they touch. Our patients with chronic and progressing disease deserve to be pulled out of the revolving door for just a few minutes to speak on their own behalf and express their thoughts and values.

Our patient population in the hospital has changed, and these conversations are about to be the new culture of hospital medicine. Patients and families need to prepare themselves for the tough journey of coping with complex illness, which is only harder when they can’t use a patient’s own goals for guidance.

As hospitalists, we have successfully avoided the clinic, but the clinic has now come to our front door. It’s up to us to take that opportunity and meet patients where they really are.

Colleen Poggenburg MD, MS, is a lifelong Wisconsin resident who received her medical degree from the Medical College of Wisconsin and is board certified in family medicine. A physician advisor, Dr. Poggenburg has been a hospitalist for 18 years, has worked in hospice for the last five years—and has volunteered in the anatomy lab for 25 years. She enjoys being close to family and friends, and her hobbies include swing dancing and caring for a 100-year-old home.