Q: My mom, who is 86, has been in relatively good health until recently. In December, she was admitted to a hospital with chest pain and it turned out she had had a small heart attack. She did OK, and is home now, but the hospital stay and subsequent doctors' visits have not been easy at all. Normally, my mom went to her doctor alone and my sister and I were never involved. When she got sick, we wanted to be available more. In the hospital she was tired often and got slightly confused at the very end. We thought our being there and talking to her doctors would help her. We were very surprised that the doctors did not want to talk with us. First of all, there was a different physician there every day. One time when my sister got to talk to a specialist, he refused afterwards to call me, saying she should have done that. My mom's primary doctor does not go to the hospital anymore, so he was of little help. When she got home and we scheduled a follow up with the specialist group, another physician -- who we had never met before -- appeared. Overall, we were often confused and are still not sure who her main heart specialist is. My mom is feeling fine, but the whole experience gave my sister and I a very bad taste. Is there a way to avoid this situation in the future? Can her regular doctor deal with her heart problem? Any advice is appreciated.
A: We doctors want to hear when our patients are not fully satisfied with our services. It takes courage and trust to discuss these issues and, way too often, families and patients choose to stay silent. In this situation, the relationship between the doctor and the patient suffers. Nobody wants that.
The situation described by Sara is very common. Nowadays, primary doctors very often have their patients admitted to a hospitalist -- a physician specially trained to work in the hospital and follow patients there. This is a reflection of the art of medicine becoming very complex, with new updates and therapies appearing every single week. It is also dictated by our system of insurance reimbursement, which makes it virtually impossible for a given physician to have enough time to be in the office and see enough patients there and then go to the hospital and see patients who are admitted. Very few doctors still do it. There is also the reality of a larger physician specialist groups sharing patients between the partners. Let me use my group as an example. At any given time in our hospital there, is at least one attending geriatric physician available to serve as an expert and see patients but it is not the same doctor every day. This way, a family may see two, even three doctors from the same group during a hospital stay, especially a longer one. This does not mean doctors do not communicate with one another. Just the opposite -- we try to be very clear in our plan of care and communication more now than before is essential.
When it comes to hospital-based doctors, they may work in two to four-week shifts. What this means is that some patients' hospital stays will overlap with the shifts of two different attending physician. Because of this, the main doctor responsible for their care could change at some point during their stay. Doctors try to explain this in advance and give a "heads up" when it happens, but it may not always be clear to the patient and the family that the change of the doctor is coming.
With doctors' appointments after the hospital stay, the rule is that if the specialist physician who took care of the person in the hospital is available, he or she will see this patient in the office. In certain circumstances, say with a heart attack, time may be of the utmost importance. There may be a procedure or test planned and waiting may not be an option. It is also considered a "good standard of care" to see a patient within one to two weeks after a discharge. When time is important, the first available appointment will be given to the patient even if it is with a different physician then the one in the hospital.
There was also a problem discussed here with more than one family member requesting a call with an update. I cannot tell you all how difficult this can be for a physician. We assume, maybe incorrectly, that the person seeking to discuss the patient with us is indeed a family "spokesperson" designated by everyone else to be responsible for sharing the information with the rest. We do not take into account that two siblings may not be talking with one another or that the person asking the most questions and demanding our time may not be prepared to disseminate the information with everyone else involved.
This is when patients and families can help enormously by identifying a spokesperson early and having that individual be the main contact with the medical professionals. Not to be difficult about it, but imagine that there are 15 active patients in the hospital to be checked on in any given day. Even if each patient takes 15 to 20 minutes of a physician's time, we are talking four to five hours just with patients. Now add to these 15 conversations with family members -- another two hours of your day. Obviously, if we have to speak with two family members for each patient, it would take too much of our day -- which can also checking tests, talking with other specialists, primary doctors, nurses and so on. Don't get me wrong -- talking with patients and their families is the most important thing we do, but our time for it is limited.
Can a primary doctor do a follow-up instead? Often yes but the best practice would be to directly ask him or her about it early enough, even before the discharge from the hospital.
How else can a family help streamline communication? Having one family member do the spokesperson job is the first step. Identifying who is the doctor in charge in the hospital. When talking to a specialist, asking when the doctor (or their partner) is available to talk to again will be very helpful. Do not be shy about it -- we doctors do want to partner with you for the sake of better communication.
Dr. Beata Skudlarska is a Bridgeport geriatrician. Send questions to Bridgeport Hospital Center for Geriatrics, 95 Armory Road, Stratford CT 06614 or email@example.com.