Being Cared For By Strangers – Why We Cannot Cut Out the Primary Care Physician from Inpatient Hospital Care

I am not writing this article as a clinician (because I am not one) but as a concerned family member and friend of patients who have been cared for in the inpatient hospital setting. I consulted with physicians, hospital administrators, and various caregivers while writing this blog.

The overall theme of this blog is the lack of involvement by Primary Care Physicians for their patients in the inpatient setting has, in my opinion, resulted in a decrease in the quality of care for these patients.

As I noted in prior publications and webinars , inpatient hospital admissions have been trending down even before COVID, and that trend will continue. While admissions have been decreasing, the acuity and risk factors of inpatient admissions have been dramatically increasing.? In fact, many regard the inpatient hospital setting as a giant Intensive Care Unit (ICU). Many times, especially with the elderly, the patient in the inpatient hospital setting will have multiple chronic diseases.

As I have visited family and friends in the inpatient hospital setting (I am an aging baby boomer), I see firsthand the endless array of hospitalists, ICU intensiveness, critical care physicians, physician specialists focusing on different parts of the body, psychiatrists, residents, etc.? Adding to the confusion, because of nursing shortages and the need for agency nurses, there appears to be no real continuity of nursing care.

As a result of this fragmented care in different forms, there is no caregiver that plays a dual role of viewing the patient from a holistic perspective and being a long-term trusted clinical advisor and advocate.? As a result of this important “care gap,” many times it is family that needs to play that role. In most cases, families also do not have any clinical expertise, but they play this advocate role out of default and necessity.

One would think that the medical record would play a key role in connecting all the providers, and while many times it does, there are also many breakdowns in communication.

When a patient is admitted to the ICU, an intensivist usually takes over for the hospitalist. Also, during critical times in the ICU, when discussions occur with family members concerning enhanced clinical interventions or potential transitions to palliative care or hospice care, family members often have those discussions with caregivers who are strangers to them as well as the patient.

So where is the physician who has the long-term trusted relationship with the patient and, many times, their family members - the primary care physician? The primary care physician has little or no role when their patient is in the hospital inpatient setting.? In fact, they are often not even aware their patient has been admitted to the hospital.?

One would think that this lack of awareness would not be the case in integrated healthcare systems, but it is. Why? The primary care physician’s role in integrated health systems is to see as many patients as possible and to be the gateway, if needed, to the hospital specialists.

Primary care physicians in private practices who historically did inpatient hospital rounds for their patients no longer have the time or resources to conduct in-person hospital rounds.

From my non-clinical perspective, all of this results in poor quality care for the patient and a more stressful hospital experience for both the patient and their family members and friends.

As a non-clinician, while I may not be an expert, I do know that I am made up of more than organs and body parts.?Patients and their family members need a physician advocate who can offer a holistic perspective.?Patients and their families need a long-term “trusted” physician advocate in their corner to guide them through the often-confusing hospital inpatient maze, and that should be the primary care physician.

A Look Back at the Primary Care Physician’s Role in Inpatient Hospital Care

Before the mid-1990s, primary care physicians (PCPs) typically oversaw care for their own patients when they were hospitalized. Since the mid-1990s, the number of hospitalists has significantly increased, and they have replaced the role of the primary care physician.

As noted in the 2021 research article on this subject: “This shift in care delivery model (primary care physician to hospitalist) was motivated by perceptions about increased hospitalist efficiency, availability, specialized expertise, and possible cost and mortality reductions. Despite such advantages, the hospitalist model may increase fragmentation between inpatient and outpatient care, particularly for patients who are frequently hospitalized.”

The Role of Hospitalists

The hospitalists we know today emerged?in response to the need to replace primary care physicians, who treated their patients in all care settings, with physicians who could focus solely on the care of patients while they were in the hospital. Hospitalists also play a key role in hospital profitability, especially because of our fee-for-service reimbursement system.

As noted in an article in Yale Medicine ,

“A hospitalist is a physician who cares for inpatients, meaning they only work inside a hospital. These doctors have often completed residency training in general internal medicine, pediatrics, neurology, obstetrics and gynecology, or?oncology . They may also be board-certified in hospital medicine. The medical training and skills of a hospitalist and a PCP are the same. The difference is the setting in which they practice medicine. Hospitalists work solely in hospitals and are, therefore, more familiar with common hospital tests and procedures, as well as hospital-related conditions like hospital-acquired pneumonia.”

The only real communication that occurs between the hospitalist and possibly other hospital specialists with the primary care physician of the patient occurs in the Discharge Summary. Consequently, it is important that the Discharge Summary covers all critical information.?

The Primary Care Physician’s Holistic Role as an Advocate and Trusted Advisor Could Play a Critical Role When Their Patients Are in the Inpatient Setting

As noted in a research article published in 2021 , “For patients with complex needs, primary care physician involvement during hospitalization could greatly impact patient experience due to their familiarity with their patients’ complex health history and established relationship with patients. For frequently hospitalized patients, active inpatient involvement by a consistent primary care physician with knowledge of the patient’s health and personal preferences could improve patient experience with interdisciplinary coordination and engagement in care during hospitalization.”

As further noted in an article in JAMA , “Concern regarding declining continuity of medical care has been growing during the past 3 decades. Continuity of care has been threatened by an array of forces, including the decrease in primary care physicians, changes in health insurance, the growth of specialization, and the need to ensure easy and timely access to care. Most of the initial focus on continuity of care was in outpatient settings. Another setting that has experienced declines in continuity is the transition from the community to the hospital and back to the community.?By 2006, most hospitalized Medicare patients received no care from a physician who had previously provided care for them.?Several studies have found that such discontinuity is associated with higher post-discharge costs and readmission rates.

Continuity of care received in the hospital has declined as well. Recent studies have suggested that patients admitted for medical illness are likely to be cared for by more than one general internist during their stay.?Such discontinuity seems driven by the growth in care by hospitalists and the fact that many hospitalists have work schedules that do not allow for continuity of care.

More importantly, issues of continuity include more than handoffs, and efforts to standardize better handoffs will not eliminate all the problems engendered by discontinuity. It is unlikely that all relevant information communicated by patients and their families to a physician is included in the electronic medical record or is transmitted orally during handoffs. Information relevant to patient values and preferences and degree of family involvement can be key in medical and discharge decision-making. There is also the important issue of trust. Patients and their families may be less comfortable soliciting and following the advice of a physician they are seeing for the first time, particularly if the topic is value laden, such as end-of-life issues or discharge destination.”

I found an article that was published in March of 2004 Annals of Family Medicine very inciteful, not only for the quality-of-care challenges during that time but also for the quality-of-care challenges that we are discussing in this blog. Per the authors, recognizing the fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing healthcare environment.

This article in the Annals of Family Medicine stated the following, “Family physicians should participate in the care of their hospitalized patients. Depending upon local circumstances, they might not always assume full or primary responsibility for patient care in the inpatient setting. In all cases, though, there will be seamless transitions between different settings of care, and the approach taken to hospital care will support the maintenance of continuing, healing relationships with patients.

All family physicians, however, need to share a common commitment to provide or coordinate all care specified in the family physician’s basket of services, thereby serving as effective personal medical homes for their patients.

Family physicians must continue to be broadly trained and have the competencies required to provide culturally effective and proficient care in a variety of settings. Specifically, family medicine residency programs must include training in community and population health, maternity care, and the care of hospitalized patients.

As the discipline matures, family medicine is challenged by the need to decide what role it should play in academic medicine. This time is also opportune for Academic Health Centers and family medicine to reexamine their respective agendas and to commit to a shared future around a common goal.”

Potential Initiatives That Would Reengage the Primary Care Physician in Inpatient Hospital Care

The simple answer to this problem is increasing the number of primary care physicians in the United States. As I have noted in multiple publications and interviews on primary care , there is no silver bullet answer to the shortage of primary care physicians.? Hopefully, as I have noted in recent publications and interviews , there appears to be a resurgence of both the demand and, more importantly, the supply of primary care physicians.

We still have a major shortage of primary care physicians, but as the demand (as well as pay) for their services continues and their role is expanded in the marketplace, possibly more medical students will choose this specialty. Also hospitalists may also be enticed to go into primary care as greater opportunities and expanded roles come into fruition.

Even though I believe that there will be a resurgence of primary care physicians, we have a current problem relating to the absence of the primary care physicians’ role in inpatient hospital care that needs to be addressed.

The first care gap involves the patient’s admission and discharge. Hospitalists’ unawareness of detailed patient history necessitates a thorough conversation with the primary care physician, both after admission and before discharge of the patient. These measures will certainly improve inpatient experience and health outcomes in the rapidly expanding field of medicine.

In theory, the utilization of technology embedded in the electronic medical record could allow for secure chats and productive communication between the hospitalist and the primary care doctor when their patient is in the hospital, but it is rarely used.?

For frequently hospitalized patients, increasing PCP engagement in the inpatient setting may improve patient experiences, even if the PCP is not providing direct care. PCPs can use their relationship with the patient to help assess preferences and identify needs. This may benefit the patient by encouraging patient engagement in decision-making, strengthening the patient–PCP relationship, and improving interdisciplinary coordination across settings.

To achieve this, the first challenge is ensuring that PCPs receive information when their patient is hospitalized.?Healthcare systems may also consider how to provide PCPs with time and compensation for communicating with their hospitalized patients and their inpatient care teams by phone or in-person visit.

There are some large independent primary care practices who assign nurses to hospitals as well as establishing arrangements with hospitalists who keep the primary care physician in the loop.? Communication is both electronic and by phone if needed. Nurses or Nurse Practitioners could make rounds daily for the PC physician group.

The primary care physician also needs to be kept in the loop on patient progress during the hospital stay. Technology can play a key role in this communication. The physician’s notes, meds, labs, etc., should be sent electronically to the primary care practice daily.

With rapid advances in science, technology, and AI, there can also be additional innovative methods to enhance the communication between inpatient hospital providers of care and the primary care physician.

Finally,?CMS will pay for add-on code G2211 effective date 1-1-2024 which will result in additional income for the provider. “CMS believes it will be used by primary care and other specialties who treat a single, serious condition or a complex condition with consistency and continuity over a long period of time.?CMS emphasizes the longitudinal relationship between the practitioner and the patient.?Primary care physicians are more likely to establish longitudinal care relationships with patients.”?The same rationale to provide this add-on source of revenue for primary care physicians who have established a long-term relationship with the patient should also apply when this patient is in the inpatient hospital setting.

Conclusion

Both my wife and I have inserted in our healthcare power of attorney document that our healthcare designee needs to have a discussion with our primary care physician prior to making any final decisions on end-of-life status, etc.

It is also important that, both in medical school and in residency programs, family medicine physicians develop extensive problem-solving and diagnostic skills that allow them to provide enhanced value to their patients in the inpatient hospital setting.

Finally, in writing this blog, I am not underestimating the valuable role all the providers (especially hospitalists and nurses) play in providing care to patients in the inpatient setting.? I am asserting, however, that the primary care physician, for all the reasons identified in this blog, needs to play a key role for their patients and their families in the inpatient setting.

As always, I welcome feedback from the readers, and I would especially be interested in physicians, patients, and family members sharing their perspectives.

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach.?Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

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