question about hospital procedures

<p>My mother is in the hospital with a condition that is not serious, except that anything can be serious for someone in her 80's. I am very thankful that she does not have cancer, heart disease, diabetes, etc., but my anxiety level is still high.</p>

<p>She was admitted about a week ago through the ER for a proposed stay of 5 days. Her regular internist does not, apparently, have privileges at that hospital. Her care seems to have been somewhat fractured, with different kinds of doctors coming in and out and making various decisions. On the last day, she had some concerns about a different organ system. These were dismissed by a PA, who said that it was all in her imagination, everything was fine, she could go home. After 3 days at home getting worse, she was re-admitted today, with the organ system she was concerned about seriously compromised (damage is supposed to be reversible, fortunately). In retrospect, pertinent lab results on the day she was discharged had started to deteriorate, although they were then still in the normal range.</p>

<p>This is my question: her regular internist does not have privileges at this hospital and was not there. I am wondering whether, if she had a doctor with privileges, that doctor would have supervised her hospital care and made the decisions. (Some of my siblings who are there have been unhappy with her current doctor, and would like to see a change, anyway.)</p>

<p>Many internists and family practice docs do not maintain hospital privileges. Patients of these docs are cared for by "hospitalists" based at the hospital or by internists who do have privileges at the hospital. As you have noted, an increasing volume of care is now delivered by mid-level practitioners: PA's, nurse practitioners and the like. (In most states PA's must be supervised by an MD, but the degree of required supervision varies dramatically.)</p>

<p>The</a> Hospitalist Model of Care - a knol by Robert Wachter</p>

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I am wondering whether, if she had a doctor with privileges, that doctor would have supervised her hospital care and made the decisions.

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<p>No, it's very rare now that your primary care doctor would supervise hospitalized patient care. A hospitalist who stays in the hospital all day and is readily available would provide better care than your internist who is busy with patients at his office.</p>

<p>I've had a lot of over-80s friends go into the hospital within the past year with one thing or another. Never saw any internist or primary care doctors of theirs in the hospital. But to the extent that a cardiologist, neurologist or surgeon was involved, that doctor came to see them in the hospital.</p>

<p>You spotlight a real problem--when my father was in the hospital after vascular surgery, the vascular surgeon told me that he wanted my dad to stay in the hospital over the weekend to be observed. The hospitalist cleared my dad for going home that day and the nursing staff was telling my brother that he had better get a rehab hospital set up pronto because dad was being released that morning. </p>

<p>I got the vascular surgeon on the line and he was livid!! Obviously, there can be real confusion about who is in charge of a patient. Not to mention, there is a real push to get people out of the hospital--not only from the hospital viewpoint, but hospital acquired infections can be VERY nasty. </p>

<p>You really have to be aware and pro-active about medical care in a hospital! Glad the damage was reversible.</p>

<p>Yes, my mother's small rural town GP was in his 70's and still seeing pts. in his office but did not make hospital rounds. When she was admitted, for treatment of a leg wound that would not heal (she had a myriad of other health probs also), the "hospital Dr." whom she had never met before took over and began ordering all sorts of tests that were uncalled for, decreasing her Oxygen., stressing her out to no end. Her condition worsened daily. He had her on diff. meds that made herr almost incoherent.</p>

<p>She came into the hospital under her own steam (albeit very slowly) having also just been to the dentist that day, walking in and out of the office with her walker.
We live 5 hours away and I thought she was just going in to get the leg wound treated but she worsened each day. My bro. was there with her.
Finally her GP came over to see her (at my uncle's insistance) and said "we got to get her the H--- out of here, they're killing her". She was scheduled to be transferred to a nursing home the next day. </p>

<p>Bro. called me in the middle of the night to say she wasn't going to make it. I got in the car and zoomed down there. She died four hours after my arrival, exactly one week after checking into the hosp. for treatment of a leg wound.<br>
The cause of death was listed as "multiple organ failure".</p>

<p>I absolutely feel that if her GP who had been her Dr. for 30 years had been seeing her in the hosp. instead of some foreign Dr. who had never seen her before and could not begin to understand the nature of her history with a quick glance at her chart, she would not have died in that hosp.</p>

<p>A few hospital experiences I've had with my family members have always been with one dr in charge. When we select a doctor we look into which hospital he/she is affiliated with. When my father went into hospital for his cancer treatment, his oncologist was in charge. He visited my father daily and was the one who prescribed various tests and specialists to see. The hospital he was at had a very sophisticated computer system, where every test and diagnosis was recorded in the system. When his oncologist pulled up his record online, he had everything in front of him.</p>

<p>My very best wishes for your mom's continued recovery.</p>

<p>First, I agree with the other posters. Second, let me add some other thoughts. Does your mom's current primary care physician have privileges at any other hospital? If so, she should go to that hospital. If not, (and regardless of other considerations about the physician) I suggest you and your siblings help your mom decide whether she is comfortable continuing with her current physician. To go to a physician who doesn't have privileges at the hospital means he can't communicate with the caregivers, can't visit her, etc. Even physicians who have busy practices make rounds at the hospital, check the overall care, and monitor the medical record. He/she can't be there to make daily decisions, but can be a backstop for overall treatment. Also, if he/she were the admitting physician, he/she would have been the discharge physician. </p>

<p>Lastly, for anyone who has a female family member over the age of 40, who is in the hospital: my anecdotal experience is that medical practitioners of both sexes tend to dismiss the "complaints" of females more quickly than they do the complaints of male patients. The "it's all in your head" syndrome is alive and well in hospitals if you're a woman of middle or old age. I've seen it time and time again. My mother presented to the ER with nausea, vomiting, no sweating. They dismissed her - TWICE - without once thinking it might be cardiac related. They never even asked her if she had experienced any pain in her arms. The third time she presented to the ER, finally someone asked if she had experienced any pain, further to the nausea. She said without even a blink, oh yes, my left arm has been aching. She ended up in CCU for 2 weeks. My experience, as I can see is also true for many of the other posters, goes beyond my direct family experience; but I thought I would share my mother's experience because it is so frequently echoed throughout the healthcare system.</p>

<p>Again, best wishes for your mom.</p>

<p>Thank you all for the suggestions and good wishes. PackMom, what an awful story! I am so sorry that this happened. </p>

<p>The hospital was chosen carefully in advance of this situation (anticipating that there would, at some time, be a need). My sisters have good reasons to be dissatisfied with the current internist, and we are hoping that the hospital situation will be a reason for her to change doctors. (The one they met in the hospital seemed much better, and has a subspecialty in gerontology, as well.)</p>

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I am wondering whether, if she had a doctor with privileges, that doctor would have supervised her hospital care and made the decisions.

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It's a mixed bag. I know of practices where the ones who take care of rounding in the hospitals are different from the ones in the office, and I know of many where the same doc is in the hospital, in the office, and even in the skilled nursing facility, if needed. Even if the internist has privileges, it's possible the attending is someone outside his group (eg. patient admitted for surgery), but in these cases, it's not uncommon for the PCP or someone covering him to round.</p>

<p>It's interesting to hear of so many of you with physicians without hospital privileges. We've never experienced that during the years we lived in the U.S. and it's extremely rare for doctors to not have hospital privileges here in Canada. I've never had one who lacked privileges. Anytime any of us has had the misfortune to be hospitalized, our physician has visited us daily. Even if you're admitted through Emerg, your physician is automatically notified the same day.</p>

<p>packmom, what a sad story about your mother. How awful that she, and you, had to go through that. Although I can appreciate the expertise of some of these 'hospitalists', I still think that the family physician is almost always the one who knows the patient best, and who is often quarter-backing the healthcare of seniors in their practice. This has been the case with my parents who live in the U.S.</p>

<p>There are many internists who still make hospital rounds, but the trend is for hospitalists to direct the care of a hospitalized patient. If, however, you become concerned about the care provided in the hospital or the lack of communication among physicians or mid-level providers, most hospitals have patient advocates. Their job is to help you address any issues and they offer a helpful line of communication. Don't hesitate to seek them out and use their services. It's free and typically very helpful.</p>

<p>Best of luck!</p>

<p>The advise offered is very good. The trend is going to the hospitalists now. And during this transition, there is a very wide array of what each hospital, region, area and practices are doing. Was your mom satisfied with the care she received from her primary provider? If she was, I would call him with your concerns. There is nothing wrong with him calling the current hospitalist and speaking with him. Professional courtesy prevails in many places. Also you might inquire if the primary provider is affiliated with a hospital and would he accept her transfer. Just because a hospitalist may cover a pts primary provider while in the hospital, does not mean you cannot communicate your concerns with him as well, if this the case with some of the other posters.</p>

<p>Many internists still have hospital privileges and make hospital rounds. Best to know IF your internist has hospital privileges or not. If so best to know WHICH hospitals. If so, best to know if he/she makes rounds most of the time, some of the time etc. Does he/she have partners that trade off hospital round? Does he/she have a solo practice but has a small group that shares call? If no hospital privileges then is there a hospitalist group? If so, how are things communicated between the hospitalist and the internist at discharge? Is there just a cc of the discharge summary to the internist, or is there a courtesy call so nothing is missed?</p>

<p>VERY IMPORTANT QUESTIONS to ask. </p>

<p>And given that as of June 1st Medicare cut physicians 21 %, and while those claims were held hoping this would be reversed in time and it WAS NOT, get ready for some rough times. The house passed a bill to hold the cuts, the Senate went on vacation without taking up the issue, and came back but did not pass a bill in time. Once they did pass a bill a week later and AFTER THE DEADLINE, it is different than the house bill, and will not be voted on by the house until Tues evening at the earliest. That means physicians have not been paid for ANY service since June 1, and now those claims will be paid late and with a 21% cut. IF the bills pass and get signed by Obama and are retroactive to June 1,, a lot of time and energy will be wasted refiling those claims for the missing 21%. </p>

<p>The bills are temporary, and do not fix the SRG.</p>

<p>Get ready for problems getting a new primary care physician over the next few months if you have Medicare.</p>

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Get ready for problems getting a primary care physician over the next few months.

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<p>Or years.</p>

<p>With further cuts in the already low reimbursement rates for the primary physicians, training hospitals haven't been able to fill the residency slots for primary care physician for years now. With Obama care coming on board, there will be an additional millions of people who never had insurance, seeking primary care in the near future.</p>

<p>Oh darn, millions of people who have lacked primary medical care having access.</p>

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Oh darn, millions of people who have lacked primary medical care having access.

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<p>That was totally uncalled for. I am merely stating the fact. No political implication.</p>

<p>Perhaps just my knee jerk response to the use of "Obamacare" having political overtones. I didn't mean to sidetrack this important and serious thread.</p>

<p>When I made a visit to the ER earlier this year, once I was assigned a specialty, the Doc I saw was essentially a hospitalist; he referred me to 'his practice' for follow up, but he rarely, if ever, was there for appointments, he worked pretty much full time at the hospital.</p>

<p>For a non-medical professional, I am quite well-educated on medical matters, I read medical records as part of my job on a regular basis. It really seems to me that in today's medicine no one doctor can really see the big picture of one's health, it is really up to the patient (who, when seriously ill, is often in no position to be their own advocate) or a family member to share the big picture of health with each individual medical professional they work with.</p>

<p>I am headed to the hospital for surgery this week and, my oh my, this thread does bring up all my concerns, especially since I am the family medical advocate. I will be making a very explicit and clear list for my DH as to what should and should not happen. Looking forward to DD getting through med school, then she can be my advocate :D</p>

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It really seems to me that in today's medicine no one doctor can really see the big picture of one's health

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<p>So, so true, somemom! This can be a real problem especially with all the prescription drugs that a person takes.</p>

<p>somemom, I hope that all goes well this week! </p>

<p>Thank you, everyone, for the responses. My mother is still in the hospital; her latest problem seems to have stabilized, but is not improving yet.</p>