Defragmentation of Care- PCP and Specialist Combined Visit ( A Medical Students Take)
When was the last time your PCP accompanied you to a specialist visit? Never? Same here. That’s actually not entirely surprising in today’s healthcare environment, given the demands placed on healthcare providers and primary care physicians in particular. But last week, I had the opportunity to be a part of such a visit.
I’m a medical student on my family medicine clerkship with Dr. Gold, and on his schedule this day was a cardiology visit for one of our 78 year-old patients. In the afternoon, we drove to meet her at the cardiologist’s office. She had recently had an episode of atrial fibrillation picked up by her pacemaker, and at this appointment, we would discuss the possibility of starting her on blood thinners. The cardiologist thoroughly explained the algorithms that guide decision-making for the treatment of new a-fib, along with the risks and benefits of blood thinners. He concluded by saying that, while he slightly favored starting the medication, he would leave the decision to our patient. As she took a moment to take in this information, her eyes began to well up. Amidst her tears, she explained that having to add yet another medication to her regimen or the thought of a stroke or going into a-fib again or bleeding from a fall was all too overwhelming to process.
The situation was complicated further by our patient’s chronic pain, which she experiences as a burning sensation across her lower chest. It has been treated with varying success for many years, and she was soon visiting a pain clinic for further assessment. So how was she to decide given these circumstances? The cardiologist offered expertise focused on giving her the best possible care for her cardiovascular health and went on to reassure her that the pain was not cardiac in origin. The presence of her primary care physician in addition, however, proved essential in helping her feel comfortable with her options. Primary care physicians are charged with taking care of the whole patient, a-fib, pain, tears and all. So when it became Dr. Gold’s turn to offer his input, he took a step back and considered her quality of life and her priorities. He helped her to sort through the risk calculators, EKG results and medication side effects to reveal what was really causing her the most distress each day and keeping her up at night. It was not her cardiac issues. It was her pain. Perhaps, he advised, we should address this issue first and then reconsider starting blood thinners in the future.
I would argue that any primary care physician would want this opportunity, the chance to sit down with his or her patient and another member of the healthcare team for one hour and determine what is really best for the patient at a given point in time. The problem is finding that hour amidst the multitude of patient visits, phone calls, notes, prior authorizations and EMR notifications. This time is what Dr. Gold offers his patients, and I believe that this single visit demonstrates how essential that time can be.
Tufts 3rd Year Medical Student
DPC and Hospitalists
How does DPC help patients in the hospital? You can ask my patient quoted below or ask the Hospitalist who took care of him, but I would also like to comment on this.
There are many benefits to Hospital-based doctors (aka Hospitalists)- they are intelligent, well trained doctors and NP/PA’s and they provide 24/7 coverage if something goes wrong when you are admitted. We as primary care doctors used to practice hospital medicine as well as outpatient/office medicine, but for many reasons which is beyond the scope of this blog post, most if not all primary care doctors solely see patients in the office setting now. And there are many negatives to this which most patients who have been admitted to the hospital at some point can attest to:
- As good and caring as these doctors and NP/PAs are, they don’t know the patient like we do.
- Hospitalists often have a minimum of 10-12 patients on their census at a time some of whom may be very ill. That is a lot to manage.
- As a result of #2 and the amount of documentation and computerized order entry that goes along with it, hospitalists have very little time to call and/or email the Primary Care Physician with updates on their patients.
- This contributes to more fragmentation of care and increased costs to the system as a whole.
- Lastly, which is the worst in my opinion, is scared and confused patients.
So what does DPC do to help this? :
- We can actually come visit our patients periodically to check in and see how the hospital stay is going. The patient- like the one quoted below- gets to see their own doctor and be reassured that we are “in the loop.”
- We have more time to communicate with the Hospitalists regarding our patients histories, medication lists, social situations etc. This allows us to work in a collaborative way to ensure the patient gets the best care possible.
- I believe Hospitalists would appreciate this involvement rather than look at as us “stepping on toes.” We can provide information that the patient may not be capable of communicating or that they may not think is vital to their hospitalization.
- The end result is what healthcare should be about- BETTER OVERALL PATIENT CARE.
So here is my patients quote/review: “If U haven’t yet signed up with Gold Direct Medical Services, U R surely walking in the wrong direction! I recently had a several day hospitalization and was actually visited by Dr. Jeff Gold, and was also privy to a conference between him and the hospital doctor, to say nothing of the several daily direct calls to me in my hospital room from him. WHEN WAS THE LAST TIME YOUR DOCTOR VISITED U IN THE HOSPITAL?”
Some date on hospital medicine: