When Hospitalists and Attendings Clash
When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.
Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”
Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.
Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”
These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.
“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”
Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.
Hospitalist-Patient Conflicts
Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”
One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”
Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”
When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”