Dr. Who?

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.

7 Responses to “Dr. Who?”

  1. menoalittle February 1, 2009 at 3:04 am #

    Bob,

    Your patients must be rather healthy if they remember even one sentence of that spiel (correct spelling, btw).

    The following introduction of levity engages the patient: “Hi, I am Dr. Who and I am the head doctor in charge of the team taking care of you. I will be updating your personal physician as your care progresses. If you are dissatisfied with the care in any way, call my office or tell me on my daily evaluation of you. Here is my card.” Of course, tell the patient who you really are. And just as important, reintroduce yourself daily.

    If you get tired of repetition, an HIT device can be rigged to give the spiel, even when you are not there.

    But do not be surprised if patients find it easier to remember Dr. Who than Bob Wachter and that some patient with dementia and in need of attention keeps shouting out “Dr. Whooooo” at the top of her lungs all night long.

    Does UCSF have a policy on aliases?

    Best regards,

    Menoalittle, alias Whonoalittle

  2. DZA February 1, 2009 at 12:04 pm #

    is it any better in a comprehensive/primary care office? many of my inpatients cannot pick their PCP out of a line up because they see an extender most of the time.

    let’s face it. hospital medicine is in many ways primary care for the chronically ill. they decompensate, get hospitalized, get overdiagnosed and overtreated, and are discharged back into the dysfunctional primary care world they came from, rarely the better for it. fact is, after 8 years in a large inner city teaching hospital practice (non-academic side), i know, and am known by, the majority of patients i admit or round on in my practice. i believe this will soon be the same for most mature non-academic hospital practices with any kind of personnel stability. while i did not read the primary source article, i suspect the result largely reflects an academic teaching service effect. nough said about that. that model is dying anyway.

    we all have preloaded macro spiels to address the “hospitalist” introduction. BTW, and no offence, but “hospitalist” is ironically obfuscating…in the early days this moniker could be confused with any number of erroneous positions in the hospital (intern, internist, resident, house doctor, candy striper, whatever). oh bob, if only you could have found a better word…

    bottom line, these days most savvy patients know who we are and what we do, and the rest are rapidly catching up. the tipping point is long past. the bigger problem is continuity for those who need it. for the flaky chest pains that rule out and get sent home within 24hrs the whole issue is somewhat moot. for the difficult patient population, ie, the medically/psychologically/socially/emotionally complex patients, i suggest we invest time and resources into what i would call a “continuity service”. staffed by a small team of hospitalists who are essentially dedicated to continuity and are targeted to this small but highly significant pt population. the design would favor long rounding stretches by single individuals, followed by handover to a predictable follow up partner with a similar clinical style. (no more “mr jones, i am going off service for a few days and i have no idea who will see you tomorrow. they will probably change some of your BP meds, most of your CHF meds and all of your pain and anxiety meds, so good luck and i’ll see you when i get back if you are still here”…and they usually are). by targeting that segment of the inpatient population that does not fit the classic “4 and out” medical archetype, we might actually makes progress in these classic DRG buster patients.

    /0.02 dollars worth
    //and someone check on menoalittle….i suspect he may have a misplaced RFID tracking tag. JK

  3. chris johnson February 1, 2009 at 9:09 pm #

    I’m occasionally struck by the vague “they.” Here’s what I mean. It’s amazing how often in a conversation with a patient’s family (especially if the family has been in an academic center in the past with their child) you hear something along the lines of: “well, they said they are going to check an x-ray later today.” I’m not in academic medicine anymore. I don’t have any students, residents, or fellows. I’m the only doctor this family has seen in days. I was one the one who told them that, sometimes just a little while before. But still it’s “they.” It’s not just a figure of speech, either, and it’s weird, I tell you. I have no explanation.

  4. Bob Wachter February 1, 2009 at 9:30 pm #

    Chris’s comment reminds me of an experience I’ve often had in Radiology-World. I’ll be down there looking at a film (oops, an “image”) and the radiologist will say, “we don’t see any evidence of heart failure or pleural effusion.” I’m a pretty literal guy, so I’m looking around to figure out who this “we” is. I’ve come to believe that this turn of speech is designed to channel the entire Community of Radiologists, from Roentgen on. The inference is that “we” would all agree on the reading, so don’t bother looking for a different opinion.

    I’m guessing that few surgeons speak this way, and that it is relatively unusual for patients to refer to their surgeon as “they”. There is something about having someone’s hands sloshing around your peritoneum that creates more of an individual focus.

  5. chris johnson February 2, 2009 at 5:25 am #

    Maybe it’s the royal we, Bob. Or else the image computer gets an opinion, too

  6. just a patient February 4, 2009 at 2:13 am #

    Why would any of you really care? To Bob’s point, I don’t know the name of my mechanic, pilot, bank teller, or anyone else that I prefer to have only a short term relationship with. I make sure my PCP gets all my test results, reports, labs, … and indeed he and I are on a first name basis. But in a hospital, we patients are all there (ideally) only for an acute care episode. I may choose a bank, or an airline, or a service facility because of its reputation, or maybe through a referral, and similarly I am more likely to seek care at UCSF or Johns Hopkins for the same reasons. But once there, I really don’t care who you are, and in fact, we being your customers, isn’t it more important that you know who we are? But very few of you, if any, will remember that you saw us 1 or 2 months ago (my business wouldn’t survive if that were the case), and even when we’re there, we are often left with the feeling that we are the chart you’re reading, not the person in front of you. So unless its ego, why do you care if we know who you are? Dr. Moy is not far off the mark.

  7. Robert in Portland February 20, 2009 at 10:45 pm #

    There was a poster at the APDIM meeting a few years ago which addressed this issue. Every member of the team has a trifold card they give the patient when they first meet. The first section has thier picture and title. The middle section explains what role that person plays (i.e. defines the role of attending or intern, etc). The third section is a feedback card. It folds and is placed in a plastic display at the foot of the bed where the patietn and family can consuit it anytime. When the patient is discharged, the dischrage nurse helps the patient fill out the feedback section (better be nice to this nurse) and places it in a box to be picked up later. The patient takes home the display with the pictures of “their team.” I don’t recall where this was or what data they had collected, but it seemed a good idea. I hope we plagarize it here!

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