Medicolegal Issues

Like Mortar and Pestle


Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

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