Many of them feel like they’re skating on thin ice, but it doesn’t have to be this way.
A hospitalist named in a malpractice lawsuit was speaking to his defense lawyer.
“Is this your first time in a lawsuit?” the lawyer asked.
“Yes,” the physician answered.
“Unfortunately, this is not going to be the last one,” the lawyer said.
As harsh as these words may have sounded at that time, they are accurate. And they bring attention to a sad reality for hospitalist medicine. Because of the way hospitalists’ practices are structured, they are exposed to a disproportionate amount of risk in terms of the liability involved.
There are valid reasons why — which have little to do with higher acuity of the hospitalized patients. It is a complex interplay of situations and scenarios that combine to expose hospitalists to risk. These situations are inherent to the nature of their work, and often, they are beyond their control.
"I am not comfortable prescribing oxycodone at discharge for this patient’s postoperative pain. The surgeon should be doing that,” says an inner-city hospitalist who asked for anonymity.
However, hospitalists often end up having to do things they aren’t comfortable with.
Hospitalists these days increasingly are involved in the care of patients who otherwise would belong to a different line of service, such as general surgery or orthopedics or neurosurgery, or, rarely, obstetrics.
Some experts argue that this trend results in better overall care for the patients by having physicians specialized in hospital medicine take the primary attending role for all hospitalized patients. There also is an argument that this approach results in a better overall length of stay and patient experience — both of which can contribute to higher reimbursements for the hospital. While all of this is still unproved, it certainly exposes hospitalists to unwanted liability by asking them to see patients in which they have little or no expertise.
Then there is also the increasing pressure from most hospital administrators to see more patients each day. Hospitalists are expensive to hire, and reimbursements are going down, putting a lot of strain on the hospitals to keep costs down. Having 15 or fewer encounters a day is a rarity for physicians, unless they are working at a critical-access facility or a small hospital with fewer than than 30 beds. On average, 18 to 20 encounters a day is the norm.
It goes without saying that the more patients they see each day, the less time they can spend on each patient. Whether reviewing the patient’s chart, talking to their families or taking the time for excellent documentation, hospitalists have no choice but to rush.
The magnitude of this problem gets even larger in a relative value-unit structure, where hospitalists attempt to squeeze in 30 to 35 encounters a day with the hope of making more RVUs.
"There is no way in the world you can actually see 35 acutely ill patients each day and still manage to maintain an excellent quality of care. It is just not practically possible” says Shiva Kumar Gosi, MD, the incoming chief of medicine at a large hospital in Glendale, Arizona.
In his practice as a hospitalist, his team has managed to keep the census at 14 to 16 patients a day. This way, he says, they can spend more time on each patient while also maintaining an excellent quality of care.
Another factor that’s underplayed but is equally important toward liability is inadequate supervision of nurse practitioners. Nearly every hospital employs these providers, but the workload assigned to them — and the extent of supervision — is different across the board. Also, each state has its own rules governing the required supervision, so it is impossible to develop standardization. And when hospitalists are busy with their own patients without adequate time to supervise the patients assigned to nurse practitioners, it is easy for quality to fall. Having a well-defined plan for physician involvement in the supervision of midlevel providers can minimize risk.
Other factors might play a smaller role; however, this discussion isn’t intended to create an atmosphere of fear or to incite practice of defensive medicine. It is to emphasize the underlying factors that pose an inherent risk to hospitalists’ practice. Because of this, hospitalists often feel they are skating on thin ice. But they can mitigate their risk by incorporating some safe practices and always adhering to the highest standards of documentation.
Nagendra Gupta, MD, is medical director of the hospitalist program at Texas Health Arlington Memorial Hospital, where he and his team of more than 20 physicians care for approximately 200 patients daily. He also is a full-time practicing hospitalist and is board-certified in internal medicine.