Making nice

Most hospitalists have both good and bad stories about their interactions with outpatient physicians.

Like most hospitalists, Edward Ma, ACP Member, has both good and bad stories about his interactions with outpatient physicians.

On the good side, Dr. Ma was recently preparing to discharge a patient who had been admitted for alcohol intoxication and a possible suicide attempt when he learned that the patient's primary care physician (PCP) had taken care of some of the most difficult legwork for him. “The doctor already knew this patient's family pretty well, so he was able to put out some phone calls and help create a support group,” said Dr. Ma, who practices at The Chester County Hospital in West Chester, Pa., and is also president of The Hospitalist Consulting Group, LLC.

Photo by Getty Images
Photo by Getty Images.

But then there are the bad days. “Some docs we call and call and they never call us back, even when there are issues I need to discuss with them,” Dr. Ma said. Recently, that was the case with a seriously ill patient whose physician didn't get in touch until after discharge when he learned—to his dismay—that Dr. Ma had enrolled the patient in hospice.

Of course, the breakdowns in communication can go both ways. Morgan Moncada, MD, observed this in the years he spent practicing in the community before becoming a full-time hospitalist. “There wasn't a tremendous amount of communication between the hospitalist services and the community physicians,” said Dr. Moncada, who is now medical director for Inpatient Management, Inc. at Reid Hospital in Indiana. “Sometimes I'd get a phone call when my patients were discharged and other times I wouldn't get anything.”

Dr. Ma agreed that the failure to communicate is often the fault of hospitalists. But he also believes that some of these problematic silences can't be fully blamed on any individual physician. “Certain systematic problems exist that create barriers for hospitalists to communicate with PCPs,” Dr. Ma said.

The good news is that he and other hospitalists and outpatient internists have found ways to take down these barriers and communicate effectively for the benefit of their patients and their practices. “We're both trying to do what's best for the patient and the only way that happens is if we're constantly communicating,” said Len Scarpinato, FACP, chief medical officer for Cogent Healthcare's north-central region.

Building a relationship

The push for good communication should start long before a patient enters the hospital, back when an outpatient practice and a hospitalist group first establish a referral relationship, said Dr. Scarpinato.

In Cogent's hospitalist groups, the program manager and medical director typically meet in person with primary care physicians at the start to discuss their relationship and means of communication. “They will meet with the primary care doc and set up parameters,” Dr. Scarpinato said.

That meeting should not be the last of its kind, the experts said: Cogent practice leaders make return visits to the practices. “[The hospitalist leaders] say, ‘We're here. Can you take five minutes to tell us how things are going?’” said Dr. Scarpinato.

Some hospitalist groups spend even more time on these visits. In Dr. Moncada's practice, the nurse director, alone or with a hospitalist, makes quarterly service calls to referring practices. “We bring them lunch and we really kind of pattern ourselves after the pharmaceutical marketing call. We go out to the offices and ask them about how did they like our service, has anything changed for them—basically getting an idea of what works and what doesn't work with these offices,” Dr. Moncada said.

The program makes an effort to assign these visits to hospitalists who already know the community physicians, whether from church, kids in the same school or some other personal connection. “We capitalize on those previously established relationships,” said Dr. Moncada.

The lunch meetings also include office staff. “The office staff [is] really close to the patients. These patients will ask them, ‘Tell me, what do you think about this hospitalist service?’” said Dr. Moncada. “What better way to market a hospitalist program than for them to say, ‘Oh yeah, I met Dr. So-and-so or the nurse director…You'll like them.’ It helps to build that rapport even before the patients come into the hospital.”

Primary care physicians also converse with their patients about hospitalists, and face-to-face meetings can shape these discussions, too. “The patients will tell you about the hospitalist and you can say, ‘Yeah, he's quiet, but it doesn't mean he doesn't care.’ It makes your patients feel better when you talk about the hospitalists as if you do know them and contact them,” said Lisa B. Johnson, ACP Member, a general internist in West Chester, Pa.

To make the meetings even more useful to their outpatient peers, Dr. Moncada's group is embarking on a new program to offer mini didactic sessions during their visits. The sessions will consist of a three- to five-minute talk with five to seven PowerPoint slides covering a clinical issue of interest. “They might learn about sepsis—what are the key indicators or criteria—things that might help them in their office: When should they be calling us if they've got a patient with pneumonia? Is it CAP [community-associated pneumonia]? Is it HCAP [health care-associated pneumonia]? Those kinds of teaching pearls we're going to be bringing out there,” said Dr. Moncada.

Choose a medium

Obviously, not every hospitalist group or outpatient practice will have meetings on that scale, but there is one topic that should always be on the agenda at these gatherings: when and how to communicate. “Most hospitalist practices probably have some form of notification to let [primary care] doctors know that that their patients are coming into the hospital,” said Dr. Ma.

However, those systems vary, and they are more effective when mutually agreed upon beforehand. “Some docs want a lot of communication. Some want none unless it's absolutely necessary,” said Dr. Ma. “We reinforced these issues when we went to meet with them: Do you want to be called on every admission? Every discharge? Or do you want to only be called on the complex matters?”

“A methodology that works for both [the PCP and the hospitalist] has to be worked out,” said Dr. Scarpinato. “In some markets, we've evolved to dropping information on a voicemail. In other markets, it's been ‘Go ahead and page me. I want to hear about my hospital patients.’ In other markets, it's ‘Call my nurse. She'll listen and tell me in between patients and I'll call you back if I think I need to talk to you.’”

In some instances, the best method of communication may not involve a phone at all. “I think email is a wonderful medium for sharing patient information as long as it's done carefully,” said Daniel J. Brotman, FACP, director of the hospitalist program at Johns Hopkins Hospital in Baltimore.

Dr. Brotman recently led the development of a call center that allows community physicians to contact a hospitalist and admit their patients to Johns Hopkins without going through the emergency department, but he's had his share of problems communicating with PCPs on the phone. “Sometimes we end up on hold dealing with the same sort of systems that patients have to contend with when they call to make an appointment,” he said.

Dr. Moncada's group used to routinely call primary care practices when their patients were discharged—a task the hospitalists considered time-consuming but necessary—but then they polled their referring physicians about how they'd like to be contacted. “We were surprised how many of them said, ‘Send me an email.’ When the patient comes in a week later, they don't have to recall the phone call,” he said.

Faxing also remains a popular method of communicating. “There was a group of doctors who said, ‘You don't have to bother calling or anything.’ We still fax them everything,” Dr. Moncada said.

That “everything” should include not only the discharge summary, but also the information that the patient has received, Dr. Johnson said. “I really like getting the exact discharge sheet faxed to us that the patient's been given, because then you know exactly what the patient should know. So when the patient starts describing what was written or how the hospitalist changed a dose, you know exactly what was done.”

Faxing is even more convenient when it can be accomplished automatically. “We're optimizing some of the automated methods, such as autofaxing admission history and physicals and autofaxing not only the discharge summary but also the discharge worksheet to referring providers,” said Dr. Brotman.

But even with automation, there's still going to be a need for doctor-to-doctor communication, the physicians said. “Commonly, we would also get a call saying, ‘This is outstanding, or this is what we did. The patient is going to come and see you in so many days and this is what you should follow up,’ which was very helpful,” said Antonette Brigidi Frasch, ACP Member, assistant professor of medicine in the division of general internal medicine at the University of Pennsylvania in Philadelphia who was previously in outpatient practice affiliated with the Chester County Hospital..

The advent of electronic medical records (EMRs) may reduce the need for some of those direct communications. “We just got electronic medical records and the hospital has them and I think we're weeks to a couple of months away from having a link. Right now, we just have a sign-in number for the Internet,” said Dr. Johnson.

Information goes both ways

Linked EMRs can facilitate information transfer in the opposite direction as well, noted Dr. Scarpinato. “In many markets, we'll get a read-only privilege of that doctor's EMR. In those places where the PCP is still on paper, which is a fair amount of the PCPs and their offices, we'll ask them to fax over pertinent progress notes and/or studies that they've done,” he said.

As his statement implies, although most of the action during an admission is on the hospitalist's end, information also needs to flow from the outpatient practice to the hospital. “It helps if you help them, if you know you're sending a patient who is not a very good historian or if you're sending someone just to a procedure unit for a transfusion. If you have information to give the hospitalists so you can keep it as painless as possible for them, then they tend to do the same thing back,” said Dr. Johnson.

Hospitalists can also take the initiative to get the needed information, Dr. Ma said, describing a hypothetical patient with chest discomfort. “We call the primary care doctor. They pull up all the records from two years ago at another hospital and say, ‘Oh yeah, this patient had a cardiac catheterization and it was completely clean.’ That makes things easier.”

That contact should be made early in the hospitalization to maximize benefit and avoid unneeded testing, according to Dr. Brotman. “The tendency of a lot of inpatient providers is to shoot first and ask questions later,” he said.

“Most hospitalists are very good at deciding what's acute and what's not, but there may have been a lot of diagnostic testing out there that was already done. I'm always open to them just picking up the phone and calling me to find out about that before they end up sending them for another test,” said Dr. Frasch.

She also appreciates it when hospitalists consult her before calling in a consultant. “It's especially helpful for the hospitalist to know what specialist I may have a relationship with because it's just a brief time they'll be in the hospital, but then that specialist is typically who they continue with after discharge,” Dr. Frasch said.

Sometimes Dr. Frasch contacts the hospitalist to offer this information, but she also noted that it's helpful when they ask about her specialist preferences. The issue of whose responsibility it is to establish communication, on this and other topics, is one that even the experts haven't resolved.

Whose job is it?

“I think the onus is on the hospitalist to develop good relationships with the PCPs,” said Dr. Scarpinato.

“It often times does not work when the onus is solely on the hospitalists to improve communication,” countered Dr. Ma. The high turnover rate in many hospitalist programs means that some inpatient physicians are less interested and less able to build relationships than their outpatient peers. “These hospitalists don't ever get the chance to feel they are part of the community, where they would have a sense of duty to each other as physicians,”he said.

Dr. Ma has noted other obstacles to good communication. “Both sides—the PCPs and hospitalists—are busy and neither may really know what the other side would want or what they need.”

Busy hospitalist groups that face little competition may also not see reaching out to the primary care community as an effective use of their time. “Most hospitalist groups don't have competition, so they don't feel they need to cater to the needs of others,” said Dr. Ma.

But the value of open communication between hospitalists and outpatient physicians extends beyond marketing. “If [primary care physicians] can relay confidence in the people taking care of the patient during the hospital stay to that patient, then the patient is going to have a better experience in the hospital,” said David DeSantis, MD, a hospitalist at Reid Hospital.

The benefits of communication also carry over into care provided after discharge, and could reduce the risk of readmissions, according to Dr. Brotman. “We ultimately are going to be sending these patients back to the referring provider and that referring provider needs to know what transpired in the hospital and what our active concerns are, and make sure that the patient doesn't bounce back to the hospital because of a dropped ball.”

Even with the best of intentions, some balls will be dropped, and that's why feedback is a key component in a healthy hospitalist/PCP relationship. Hospitalist programs can conduct surveys and pay visits, but primary care physicians need to speak up, too, the hospitalists agreed.

In instances where the feedback is negative, someone has to be responsible for fixing the problem. “Occasionally there's one that will say, ‘I didn't like what you did with my patient. You used too many new medications. You didn't inform me.’ That's the job of the program manager and the medical director to reach back into the chart, figure out which hospitalist did that and do some quality control so the primary care physician is happy,” said Dr. Scarpinato.

And when in doubt about how to make a primary care physician happy, just ask. “I'm always open to the conversation. It's never a bother when it's my patient in the hospital,” said Dr. Frasch.