A study in this week’s Archives of Internal Medicine by Vinny Arora and colleagues found that vanishingly few hospitalized patients could name any of their hospital doctors. Should we care?
I think we should.
Vinny is one of the nation’s up-and-coming researchers in the field of hospital medicine, and a good friend. In this clever study, she and colleagues at the University of Chicago interviewed over 2800 hospitalized patients over 15 months. Three-fourths were unable to name even a single doctor caring for them; of those who “could” name a doctor, the majority of names were wrong. Sobering stuff.
There are multiple issues at play here. At a place like the University of Chicago Hospital, hospitalized patients on the teaching service are cared for by gaggles of residents, students, and others who are increasingly working in shifts and running for the exits because of duty hours limits. Although the limits have made the housestaff better rested (and less ornery – my interns this month on the wards at UCSF were 10 times more pleasant than I was in late January of my internship), patients are now being covered by all sorts of “floats,” anonymous problem-solvers who are mostly putting fingers in clinical dikes.
On top of that, at the U of C (and UCSF, for that matter), all the ward attendings are full-time faculty members who lack continuity relationships with their inpatients. Many people will say “Oh, it’s those damn hospitalists,” but I’m reasonably certain that a fair percentage of the U of C attendings aren’t hospitalists, but rather are generalists or subspecialists doing their one-month-per-year stint on the wards. Unfortunately, the paper doesn’t break the “Could you name?” data from the teaching service down by hospitalist vs. non-hospitalist attending – that would have been interesting. I hope the hospitalists did a particularly good job in making an initial connection, but I wouldn’t be surprised if they were no better than everybody else. This is a skill that we all need to work on.
A few other fascinating findings:
- The predictors of not being able to name any of the hospital doctors included some patient-related factors (being male, African-American, older, and less well educated) and some system-related ones (being admitted through the ED or by a night float resident). None of that is too surprising.
- Most patients claimed to understand our Byzantine hierarchy (residents, interns, students, attendings…). Those who said they did were a bit more likely to correctly identify one of their docs than those who didn’t.
- Patients were called a month after discharge to check on their satisfaction with their hospital stay. Guess what? Patients who could name one of their doctors were significantly less likely to be satisfied. Perhaps they scribbled down the physician’s name in order to lodge a complaint or to call their favorite malpractice attorney.
In their discussion, Vinny and friends describe interventions that have been tried to increase the likelihood that patients will be able to identify their doctors. One study showed that placing the docs’ pictures in the room (no darts, please) helped. And – in response to a campaign by a family who blamed their 15-year-old son’s death on a dearth of attending supervision and an inability to tell who was a trainee – the state of South Carolina recently passed a law that requires all doctors and trainees to wear large badges with their names and their roles (“attending”, “resident” “intern”) prominently displayed. I get it, but the slippery slope problem is real. As Gawande wrote in Complications,
By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training the next generation. We want perfection without practice. Yet everyone is harmed if no one is trained for the future.
But let’s return to the matter at hand, the strange case of Dr. Who? Does any of this matter? When I get on a plane tomorrow, I’m not going to be paying much attention to the pilot’s name (unless it is “Sully” and we’re flying over a river), since I know that flying is so safe that, from a risk perspective, which pilot is at the helm doesn’t really matter. (This, by the way, is the scary side for providers of “systems thinking” – if the system succeeds in guaranteeing safety, the workers inevitably become commoditized, accompanied by the downdraft on wages and prestige that commercial pilots have experienced.)
But it seems to me that patients need to have a personal connection to their physicians, particularly at times of great need and uncertainty. Lest you think this is non-controversial, it turns out that not everyone agrees. In a series of comments he may now be regretting, a federal spokesperson told Karen Barrow of the New York Times that he didn’t think this was such a big deal:
“Do you really need to know who your doctor is, or is it more important to know some processes that will help you get at the information you need?” said Dr. Ernest Moy, medical officer at the federal Agency for Healthcare Research and Quality.”
Responding to the finding that dissatisfied patients were more likely to be able to name their doc, he continued,
“In some ways ignorance is bliss,” said Dr. Moy. “We assume when you walk into a hospital you are going to be taken care of, but maybe we put a little too much faith in hospitals.”
Hmmmm. I don’t buy it, particularly in the case of hospitalists. After all, when we first meet our patients, we are encountering an anxious and ill person who is often wondering who the hell we are and why their primary care doctor isn’t here instead.
To navigate that tricky initial encounter, I’ve developed a sort-of standard intro, which seems to work well. If you’re a hospitalist who struggles with how to handle this awkward moment, you might try something like it:
“Hi, I’m Bob Wachter [Note: You should probably insert your own name], and I’m going to be your attending physician during your hospital stay. I work with a whole team of young doctors and trainees – you’ve already met some of them – and we’ve spoken about your case. I’ll be in touch with them throughout your hospitalization, and I’ll be seeing you at least once a day myself, sometimes more. I’ll also be in touch with your regular doctor, Dr. XXX, to be sure that she remains in the loop and that I know all the key things about your medical history.
Big hospitals are really confusing, and you’ll be seen by many different doctors and trainees. A few weeks after you leave here, the hospital is going to send you a survey asking ‘Did you know who the doctor in charge of your care was?’ I need you to answer that question, ‘Yes’, because that’s me!”
And then I hand the patient my card, and try to write my name on their room’s whiteboard. I think most of them do remember my name, and I haven’t been sued yet.
Interestingly, 3-4 times in the past few years a funny thing has happened after I’ve recited my schpiel, which is designed to describe what a hospitalist is without invoking the confusing and clunky name.
“Oh, so you must be a hospitalist,” patients have said on these occasions, bringing joy to my soul.
Anyway, folks, let’s work on this one. It’s not that hard to do, and it seems pretty crucial, notwithstanding Dr. Moy’s comments. I’d love to hear from any of you hospitalists (or residents) who have developed even better ways to make that vital initial connection with your patients.