Case Study: Drs. Traditional and Progressive, on the Virtues of Hospital Medicine

Dr. Traditional

Mrs. Jones has been a patient of Dr. Traditional for the last 10 years. She began feeling unwell last night with symptoms of nausea and weakness. After breakfast today, she developed chest pain and calls Dr. Traditional�s office. He tells her to take an aspirin and call 911 immediately. When Mrs. Jones arrives at the emergency room her chest pain has resolved. The ER physician calls Dr. Traditional for admission to �rule out MI [myocardial infarction].� Admission orders are given over the phone, and Mrs. Jones is moved to a monitored bed. Mrs. Jones� daughter arrives and asks to see her doctor. She is shocked that Dr. Traditional is not there.

It is now 10:30 am, and Dr. Traditional has a booked schedule. He has 7 patients to see before the lunch hour, and another 12 expected this afternoon. He knows he needs to get to the hospital. He tells his secretary Carol to cancel some of his afternoon appointments. Carol looks at the schedule, which includes several patient requested urgent visits. She calls Mrs. Deedy who is coming in for follow-up of her osteoarthritis. Mrs. Deedy is not very happy about rescheduling. �I arranged transportation today, and my son already took off work this afternoon to come with me. I want to talk with Dr. Traditional now.�

Meanwhile, nurse Sarah Steele is taking care of Mrs. Jones, who has lost IV access, is having chest pain again, and has had no urine output in the past 2 hours. Sarah tries to replace the IV, but Mrs. Jones is confused and becoming uncooperative. Sarah calls Dr. Traditional�s office for assistance. After waiting on hold for 5 minutes, she receives a verbal order from Dr. Traditional for a STAT ECG and cardiology consultation, as well as urgent urology and neurology referrals.

It is now 12:45 pm and Dr. Traditional is speeding toward the hospital. He is weaving in traffic as he tries to eat his lunch in the car. He arrives at the same time as Dr. Heart, the cardiology consultant. Mrs. Jones� daughter is relieved to see Dr. Traditional, but very concerned that her mother�s condition has gotten worse. Dr. Traditional receives a page from his office that his afternoon patients are waiting for him.

Dr. Heart recognizes that Mrs. Jones is having acute ischemia with progressive congestive heart failure. He begins anticoagulation, diuresis, and calls Dr. Lung for consultation regarding possible intubation and transfer to the ICU. Dr. Traditional talks with Mrs. Jones� daughter and Dr. Heart, then rushes back to his office. It is now 2 pm, and he is 4 patients behind. Shortly thereafter, Mrs. Jones is placed on the ventilator.

At 4:30 pm, more of Mrs. Jones� family arrives, and have multiple questions that the nurse cannot adequately answer. Dr. Heart is contacted, yet he is unavailable due to an emergency in the catheterization lab, and he advises that Dr. Traditional be paged. Meanwhile, Carol has Mrs. Traditional on the line. �I just want to remind him that my auction dinner is tonight and he needs to be home by 5:30 pm.� Dr. Traditional calls the hospital to talk with the family over the phone, who plead �we need to see you�our mother needs you here.� Dr. Traditional assures the family he will be there first thing in the morning, and ensures that Dr. Heart will be available to personally discuss the treatment plan with them tonight. He arrives home at 6:00 pm to find his wife has already left for dinner.

Comment:

Dr. Traditional cannot be in 2, the net effect is less than optimal care for all. Mrs. Jones had a delay in initiation of therapy, and she progressed to a state that needed urgent intervention. The �shot-gun� consultation approach applied by Dr. Traditional did not replace him being available, supporting the nurses, and responding to family concerns. In addition, Dr. Traditional may have alienated several of his outpatients by canceling appointments, and he certainly upset his wife. Ultimately, Dr. Traditional needed a partner such as Dr. Hospitalist.

Dr. Progressive

Mrs. Smith has been a patient of Dr. Progressive for the last 10 years. She began feeling unwell last night with symptoms of nausea and weakness. After breakfast today, she developed chest pain and calls Dr. Progressive�s office. He tells her to take an aspirin and call 911 immediately. When Mrs. Smith arrives at the emergency room, her chest pain has resolved. The ER physician calls Dr. Progressive for admission to �rule out MI.� Dr. Progressive contacts Dr. Hospitalist for a patient referral. Dr. Progressive updates Dr. Hospitalist on Mrs. Smith�s past medical history and current situation. Dr. Hospitalist evaluates Mrs. Smith in the ED and admits her to a monitored bed. Mrs. Smith�s daughter arrives and asks to see her doctor. Dr. Hospitalist introduces himself and updates the daughter on Mrs. Smith�s condition.

It is now 10:30 am, and Dr. Progressive has a booked schedule. He has 7 patients to see before 12 pm, and another 12 expected this afternoon. Dr. Hospitalist�s admission note arrives to the office via fax. Dr. Progressive asks his secretary Jane to pull Mrs. Smith�s chart, and look-up the family contact numbers so that he can call them over the lunch hour.

Meanwhile, nurse Mary Simmons is taking care of Mrs. Smith. She has developed chest pain again, and she has lost IV access. Mary pages Dr. Hospitalist who immediately comes to the bedside. Dr. Hospitalist re-evaluates Mrs. Smith, and together he and Mary are able to place a small peripheral IV while obtaining a STAT ECG that demonstrates acute inferior ischemia. Dr. Hospitalist initiates anticoagulation therapy and notifies the ICU to prepare a bed for Mrs. Smith. Mary is concerned that the IV won�t hold for long, and therefore Dr. Hospitalist inserts a central venous line after Mrs. Smith�s chest pain subsides. Dr. Hospitalist calls Dr. Heart for an urgent consultation. Dr. Heart requests an echocardiogram and states he will be at the hospital within the hour. Dr. Hospitalist then calls Dr. Progressive�s office regarding the change in Mrs. Smith�s status.

It is now 12:45 pm and Dr. Progressive has finished his morning schedule. He goes to his office to eat lunch. Jane has left Mrs. Smith�s chart and family phone numbers on his desk. With Dr. Hospitalist�s admission note in hand, he calls Mrs. Smith�s daughter to provide reassurance.

Dr. Heart reviews the echocardiogram along with the serial ECGs and concludes �she seems to be doing well. She will need a catheterization in the future. For now just continue your current therapy. She should be able to go to the regular nursing floor tomorrow.� Dr. Hospitalist invites Mrs. Smith�s daughter into the ICU, and together with Mrs. Smith and the ICU nurse Linda Jackson, explains her condition, treatment plan, and prognosis.

At 4:30 pm, more of Mrs. Smith�s family arrives and Mrs. Smith�s daughter gives them an update. Nurse Jackson answers their additional questions. Meanwhile, Dr. Hospitalist is on his way to a Pharmacy and Therapeutics Committee Meeting. He runs into the ICU Director who inquires about Mrs. Smith. �We are scheduled to have an open heart patient tomorrow�should I call the surgeons and delay, or will Mrs. Smith be discharged from the unit by mid-morning?�

Dr. Progressive is wrapping up the day in his office returning phone calls. It is 5:00 pm, and he knows he must be home by 5:30 pm to pick up his wife to attend her auction dinner. As he pulls out of his office parking lot, he calls home to let his wife know he is on his way. Back at the hospital, Dr. Hospitalist�s meeting is finished. He stops at the ICU to check with Linda before he signs out to his night coverage colleague. He is pleased to hear that Mrs. Jones is doing fine.

Comment:

Dr. Progressive has partnered with Dr. Hospitalist. Dr. Progressive is available to his outpatients, and with good communication, he is also available to his patients requiring hospitalization. Dr. Hospitalist can be immediately available if patient conditions change. Furthermore, he can work closely with the nurses, provide families and patients with immediate clinical updates, and facilitate efficient institution-wide care (such as assisting with the decision to postpone the pending open heart surgery in the example above). Finally, Dr. Hospitalist further aides the hospital by providing much needed physician involvement on hospital-based committees.