by Del Meyer
Marjorie had pleural and parenchymal tuberculosis as an adolescent. Hence she had parenchymal (Lung) nodules in the apex of her lung and thickened pleura in the lung base on one side. She had been appropriately treated with antituberculous drugs. She then followed the prescribed regimen of follow up x-rays every three months for two years, every six months for three years and then yearly. If the new x-ray, when compared to the old x-ray, was essentially identical, one could safely say there was no recurrent activity.
She went to the emergency room for a minor trauma and cut to her hand on Friday evening. This was treated and a chest x-ray was obtained for reasons unclear. No medical indication was recorded on the requisition. The x-ray was very abnormal. Since her previous x-rays were done elsewhere, there were none to compare. Hence, the radiologist appropriately listed all the findings, suggesting multiple etiologies, and suggested studies to rule out tuberculosis, cancer, or multinodular disease. The hospitalist on duty in the evening admitted the patient and ordered a sputum culture for TB, isolated the patient against her wishes and demands, and ordered a CT of her chest. The hospitalist on duty the next day, proceeded with the same direction of testing, and started antituberculous treatment. The family became very anxious when their wife and mother was thought to have reactivated her tuberculosis. The patient subsequently stated that neither hospitalist doctor that admitted her or the one that saw her the next two days on the weekend asked her about her known tuberculosis, the treatment in a sanatorium, drugs for two years and numerous follow up x-rays.
On Monday, she saw a third hospitalist who sat down and spoke with her and obtained the first real medical history. He made a phone call to the pulmonologist who faxed him Marjorie’s medical history and x-ray reports. The decision was made in a matter of minutes that the only problem was a minor laceration that was sutured in the Emergency Room and was clean and healing well. There had been no medical reason for the hospitalization and no reason to suspect tuberculosis reactivation. He promptly discharged her with directions to have her sutures removed in one week.
This is not an isolated case. It is a frequent occurrence in practice because the patient’s personal physician is excluded from taking care of her in the hospital, thus interrupting the efficient continuity of care. Although many studies and reports continue to show the efficiency of having a fulltime hospital physician who is in the hospital continuously, this is frequently not the case. It may be the case in an acute care situation where the treatment changes from hour to hour, but in a large percentage of cases, the patient only needs physician supervision once or possibly twice daily. This has been the usual standard of care for many decades and still is.
There needs to be further study on the new so-called specialty of “hospitalist” – not primarily directed to hospital efficiency, but to cost effective efficiency. This is a very difficult study to do since many of the hospital charts no longer reference the prehospital care. Hence, the study would show cost-effective care when looking at the entire spectrum of care; it may not be cost effective to the patient or improve the quality of care.