I am old enough to remember the excitement about the development of the role of the hospitalist as a novelty in hospital medicine. Like many other things, what could have been a benefit turned into a travesty in many ways, for the same reason.
Originally, the principle was to have a dedicated physician expert in the guidance of patients through the hospital course – always present and available to push through roadblocks to get care quicker, cheaper and more efficiently.
Now, I find that a patient has disappeared through a mystery porthole, only to appear in my office a week later, problem unsolved and even undefined.
“They ran lots of tests, but everything was normal, and they couldn’t find anything wrong.” the patient often says, and brings in a hundred-page stack of discharge notes in mechanical medicalese.
Yesterday, I had one of my diabetic patients with poor control walk in, or hobble in, five days after stepping on a toothpick. My clinic is some distance from the hospital.
The examination really needed only a few minutes. Entry at the MTP pad on one of the toes, anteroposterior. Watery discharge. Foot erythematous, dorsal foot warm and puffy, showing infection deep to the plantar fascia. No fever or tachycardia. Clearly, the foot was dangerously infected. Osteomyelitis, or cellulitis? Surgical exploration and/or drainage? That’s hospital stuff.
Since it’s the New Modern Medicine era, I had the option of sending him to the ER for evaluation for admission. That’s the new gate to the gatekeeper function, the ER. He pleaded to be treated locally in clinic.
His foot was too sick to treat with oral antibiotics, I told him. I’ll chance it, he said. He asked – is it better to get oral antibiotics here now, or after a 24-hour wait in the ER?
Once, in a time long ago, I could have written admitting orders to the hospital, fluids cultures and broad-spectrum antibiotics IV, imaging, labs and a consult. The Time-to-IV-Antibiotics would be at worst eight hours.
He agreed to go to the main hospital and obtain plain films, a sed rate and CBC. I promised I’d try to get him seen at the surgery clinic, so I tried to coordinate the contact. It is far harder now getting in touch with people now than since the pager days. Go figure.
The surgeons are attentive at our facility. I got in touch with them before he dropped by their clinic. By then, he had a CBC, sed rate and films – all consistent with a serious cellulitis without apparent osteo YET. Give it time, by this time tomorrow we’ll have osteomyelitis and surgery, no doubt.
By all measures, does this system work as well as the old one? Does it get the right treatment to the patient as soon as possible? God, no. Had he been less stubborn, I could see this stretching out for a week without IV antibiotics, then eight weeks of IV vancomycin at home. For no reason other than systems inadequacy.
I know what a diabetic foot infection looks like. I know what a forefoot amputation after intractable diabetic foot infection looks like, too. I diagnosed the patient right, and proposed a proper treatment.
In the Brave New World, he would go to the ER McLocum, who would notice the absence of fever and palisading on the films, and could send him home for a trial of cephalexin which would fail. He could then go back and forth to surgery clinic demonstrating a worsening cellulitis.
Or maybe he would call the Surgery Consult at 2AM, AKA the surgery intern, to look at the foot, and propose the same thing. Orals and street’m.
There’s nothing here in the course of events which is BETTER than the care thirty years ago; nor FASTER nor CHEAPER. The ER has now become the portal to the hospital, and the speed of the ER depends on the number of McLocums and staff the hospital chooses to put on duty, to achieve a 12-hour turnaround time. Coupled with “patient empowerment,” which drives people to then seek substandard care at an urgent-care shack, we have a worsening of care, but at an increased price.
I am glad that retirement is not all that far off.