Hospitalists in rural and suburban hospitals, which have fewer and less specialized staff readily available for consults, should expect to have a different scope of practice. In time further clarification of the roles, responsibilities, and clinical skills of hospitalists will be established so that the scope of practice is more clearly defined.
Dr. Baudendistel believes that residents tracking to specialize in hospital medicine could benefit from having more education in certain areas: neurology, perioperative medicine, and critical care.
SHM has recognized the need for better risk management strategies to protect hospitalists and will provide this information and continuing education in The Core Competencies in Hospital Medicine to be published the January/February 2006 issue of the Journal of Hospital Medicine.
Case #2: A male patient came into the ED at a rural hospital with an altered mental status. He had a history of falls and the CT scan in the ED showed a large subdural hematoma.
“We need to admit this patient to the hospital,” said the ED doc. “Call the hospitalist.”
“What does neurosurgery want to do?” asked the hospitalist.
The hospitalist tried to reach the neurosurgeon. And the ED doc wasn’t able to obtain neurosurgery consult because the neurosurgeon said that he wasn’t on call for that hospital. So the hospitalist was … left responsible without neurosurgery backup.
Ultimately, the patient worsened. The hospitalist called a different neurosurgeon at a different hospital who clearly wasn’t in charge of the patient. That doctor said, “Get the patient over to us, and we’ll take care of it.”
There was a 12-hour delay, and the patient finally got transferred to the other hospital, had surgery, and did OK. But he was definitely deteriorating.
The neurosurgeon who said he wasn’t on call for that hospital was wrong. He was lying or just didn’t know of his group’s call coverage. It was a clear violation. And it left the hospital in a situation that isn’t all that unfamiliar.
In this case, the hospitalist wasn’t at fault. There was clear chart documentation [provided as evidence] that said, “I called the neurosurgeon three times and they’re not calling back. Finally they called back the fourth time and said that they’re not coming in.” —Dr. Baudendistel
Communication
Communication is crucial in a clinician’s provision of quality care and also provides a safety net to help prevent liability. Communication with patients, families, staff, and other physicians—particularly their inpatients’ primary care physicians—provides the strongest armor against malpractice assaults. Timeliness and the urgency of the issue are key to patient care and are also are examined by those who review malpractice claims.
In recent years medical malpractice claims payouts have increased substantially for both jury verdicts and settlements. For monetary awards involving doctor-patient relations, which are largely predicated upon communication, the median payout is $230,000.1
Some hot-button areas that carry higher risk and call for meticulous communication between providers include:
- Inpatient postoperative care;
- Post-discharge communication (hand-offs);
- Diagnosis and treatment of a patient for whom there is an incomplete history; and
- Acceptance for treatment of patients whose medical conditions may either be unfamiliar to hospitalists or for which they have had limited or no training.
Communication with Patients
Communication—every aspect of it—is essential for the patient’s health, attitude, and satisfaction. Interestingly, legal data show that most patients who have bad outcomes don’t file suit.2 Although patients litigate for a variety of reasons, chief among them is when they perceive they have suffered because of administrative errors, rude practitioners or support staff, or the denial of tests and referrals they had requested and thought were reasonable.3 Data from a number of studies conducted within the past two decades show that although no particular communication skills can be directly associated with reducing malpractice claims, when patients perceive that their providers treat them genuinely and fairly, and update them honestly and regularly, they are less likely to sue.4-9