Leon Reinstein, MD, was a hospitalist long before he even realized he was one. When he came to Sinai Hospital in Baltimore in 1985 to establish an inpatient rehabilitation unit, he became a staff physician. He enjoyed the opportunity to pay more attention to patient care and educational activities than to administration and business concerns, but he didn’t have a name for what he did. “I actually stumbled across the concept. I read an article about hospitalists,” he says. “And I realized that I was one.”
Following Dr. Reinstein through a day in his life as a hospitalist offers insight into what makes him so effective in his work and why—after 20 years—he continues to enjoy his role and to inspire other physicians to follow in his footsteps.
Round and Round
Dr. Reinstein, one of four hospitalists on the 46-bed unit, begins his day at 7:30 with rounds at the hospital. Unlike his colleagues in private practice, however, his hospital patients are just steps from his office. His rounds, involving mostly total joint replacement and fracture patients, take approximately 45 minutes, after which he returns to his office to write up notes. He also prepares for the daily 9:45 a.m. “morning report.” This meeting with Dr. Reinstein’s resident, Melita Moore, MD, along with representatives from nursing, social work, and physical therapy, is an opportunity to review any changes or developments from the previous evening.
One of the meeting’s goals is to prepare patients for discharge. With an average 10-day length of stay, the team has to address problems such as constipation or infections that could hinder patients’ progress and delay their release. Pain issues are also a common topic. Getting and keeping pain under control is a top priority for Dr. Reinstein and his team. When patients are comfortable, he notes, they are better able to participate in physical therapy and rehab, and they eat and sleep better.
Plugging into Patient Care
After the morning report, Dr. Reinstein gets on the computer to input some notes and check lab results. He can do this thanks to the hospital’s computerized physician order entry (CPOE) system. He loves having access to information “in a second at my fingertips.” For example, he looks up lab values for one patient and records them on a warfarin flow sheet. He then orders medication using a “quick orders” tab that gives him a choice of dosages. At the same time, he is able to view a chest X-ray for another patient.
“I’m not a computer geek, but I love this system. It’s very interactive and easy to use,” says Dr. Reinstein, adding, “It includes information on everything from allergies and patient alerts to diet, activities, and diagnostic tests.” He spends about 15%-20% of his day at the computer.
Afternoon: The Pace Picks up
After a quick lunch, during which he catches up with his fellow hospitalists and other colleagues, Dr. Reinstein begins his busy afternoon. On Wednesday, this starts with a 12:30 team conference. This is an important meeting in which all of the team members—social workers, physical therapists, occupational therapists, nurses, and Dr. Reinstein’s resident—meet to discuss every patient in detail and prepare each for discharge.
At the meeting, conversations focus on patient functioning, physical therapy progress, medical condition, and pain control. The group discusses arrangements for community support and/or family education needs for some patients and subacute care options for others. The team also addresses patient goals and how they can help meet these. For example, one patient has requested an assistive device. While the equipment is not considered medically necessary by the insurance company, the group discusses how to arrange this in order to satisfy the patient’s wishes.
Following the team conference, Dr. Reinstein spends most of the afternoon on consults. Today, he has been asked to see a number of patients in order to determine if admission to the rehab unit is appropriate for each one. Patients’ attending physicians make these referrals, and Dr. Reinstein works with them to make a final decision. In a typical day, he sees five to six new consults—most of them the day after surgery. At the same time, he follows up with four to five patients a few days after he first saw them to check progress, finalize decisions, and—when appropriate—prepare them to transfer to the rehab unit.
“I try to see the patients first who will be admitted to our unit today. We want to do the admits earlier. There are staff onsite to help them settle in, and it frees a bed for the hospital,” explains Dr. Reinstein.
Each consult starts with the patient’s chart, which he reviews carefully. In addition to medical issues, he looks at relevant social information, such as whether the patient lives in an apartment or a two-story house. This can affect goals and how much rehab the patient will need to function post-discharge. Dr. Reinstein checks medication regimens, vital signs, lab data, and other information on a nearby COW (or computer on wheels). These are located throughout the facility for easy access by clinicians.
After pulling and reviewing the chart, Dr. Reinstein goes to the patient’s room armed with a special form he uses to record his assessments and final recommendation. Following a greeting, he conducts a brief physical exam and asks the patient about pain and other relevant issues. He also considers weight-bearing status, a big issue in rehab.
The consults, which can take several hours, usually result in some new admissions to the rehab unit and the need for some follow-up visits that he will have to conduct in two or three days.
Preparing patients for discharge can be like playing “Beat the Clock” for Dr. Reinstein and his team. “Insurance companies will only approve a certain number of days, and there have to be strong medical reasons for an extended stay before they will pay,” he says. He emphasizes that his decisions are based on several factors that have to do with the patient’s well being and health rather than on an insurance company’s criteria. He also stresses that the patient is part of this decision making.
In particular, he mentions one individual who was waiting for an assistive device and expressed concern about going home before she had it and could get used to it. “I’m not going to push someone like this out the door,” he says. “We have to weigh the pros and cons and—ultimately—do what is best for each individual patient.”
Most of Dr. Reinstein’s patients—the majority of whom are 65 and older—want to get back to their homes and communities, and the team works hard to make that happen. In fact, 80% of patients are discharged to the community, with 20% going to a nursing facility or subacute unit.
Private insurance companies require prior authorization before patients can be admitted to the rehab unit following surgery or a fracture. “The main problem here arises when the insurance company decides that the patient doesn’t need this level of rehab,” says Dr. Reinstein. “At this point, we have to sit down with patients and families [and discuss] the options—including self-pay or transfer to a less expensive subacute facility.”
Hospital rehab can be expensive—up to $1,000 per day—so payment plans are often part of the discussion.
The majority of Dr. Reinstein’s patients have Medicare insurance, and this has some advantages because these individuals don’t need prior authorization to enter the rehab unit after surgery. Of course, he adds, Medicare does have a right to conduct a post review.
With Medicare patients comes the Medicare prescription drug benefit, and this has presented some challenges for Dr. Reinstein. He recalls one patient whose drug plan refused coverage for a prescription medication. Frustrated and in pain, she called Dr. Reinstein in a panic. He contacted the drug plan and tried to wade quickly through the red tape, but was unable to help. In frustration, he finally suggested that the patient contact her Congressional representative. She called Dr. Reinstein back an hour later to say that she had gotten her prescription filled. “Sometimes you have to be persistent and creative to get things done,” he says.
Dr. Reinstein has a great deal of experience fighting claim denials and other insurance-related issues, and he is not afraid to go to bat for his patients. “If I think there is a medical reason to keep the patient here, I will do so,” says Dr. Reinstein. “And I will fight the insurance company later.”
Of course, dealing with insurance companies isn’t his only challenge. In fact, Dr. Reinstein notes that his major frustration is that “I set high standards for myself and others. Sometimes, things don’t work the way I would like them to. I want everything done right, and I can’t control all of the details.” He adds that such frustration “is not unique to this setting. It actually is a larger societal issue that we all face.”
Smooth the Way with Communication
Working—and potentially clashing—with private-practice physicians can be a challenge for many hospitalists. Dr. Reinstein has mastered this skill.
“The key to working with primary-care doctors is communication,” he says. “The first thing we do here is to write on the patient’s chart all of the physicians involved in his or her care—their specialt[ies], phone number[s], and so on. Then we keep these practitioners abreast and involved. The patient’s primary care doctor may have seen this person for 20 years and knows things that we don’t, so reviewing issues with this practitioner is key.”
Dr. Reinstein also stresses communication as part of ensuring a smooth transition from the hospital to community care. For example, “We type a discharge summary on discharge day,” he says. “We give a copy to the patient and fax or mail one to his or her referring physician. We also keep a computerized copy.”
He also has the patient’s family bring in the bottles for all of the medications the patient is taking, and he goes over every one to make sure prescriptions are up to date, filled as necessary, and not likely to interact with other medications. “This only takes a few minutes, and it is an important part of great patient care,” he explains.
What Keeps Him Going?
“I take a lot of personal satisfaction in my work here,” says Dr. Reinstein. “When patients come here, they can’t do much. When they leave, they are prepared to take care of themselves. We make sure that they have the level of functioning, medications, assistance, and personal confidence they need to continue their progress and resume their lives.”
Watching his community-based colleagues rush from the hospital back to their offices or to other hospitals, Dr. Reinstein appreciates the fact that he spends his entire day at one facility.
“I don’t have to spend time running around from place to place, so I get to spend more time on direct patient care,” he says. “That is a real plus for me.” At the same time, being part of an institution means that “everything happens right away. If someone has chest pains, I’m there in a few minutes. I can order tests, have them done, and get results back quickly.”
Dr. Reinstein likes the control he has over his schedule: “I don’t have the same time pressures that you do in private practice. Basically, by the end of the day, I need to have seen all consults and follow-ups. But I can pace myself.”
He also likes the abundance of educational opportunities he has at Sinai. “I can conduct and participate in educational activities without leaving the building,” he says. He also enjoys working with residents and providing hands-on teaching.
Not having to deal with the business aspects of private practice is another advantage for Dr. Reinstein. “I’m salaried by the hospital, and my position removes me from a lot of the economics of medicine,” he explains. “For example, I complete a billing form on each patient every day, but that’s my only dealing with the billing. I don’t have to worry about census, overhead, hiring or firing staff, or the bottom line.
“You’re not your own boss, and some see this as a disadvantage,” cautions Dr. Reinstein. “A lot people become physicians because they want to be their own boss. This is the antithesis of that. You are part of a company.”
Overall, however, the advantages of hospitalist life far outweigh the disadvantages. “I get a lot of personal satisfaction from my work, I get to work with a consistent team, and I get four weeks of vacation,” he says. He adds that when he goes on vacation, he doesn’t have to worry about his patients. He knows that they are cared for and that his department is running smoothly in his absence.
Despite his enthusiasm for his work as a hospitalist, not all of Dr. Reinstein’s residents follow in his footsteps. “The ambulatory/orthopedic field is very lucrative and more attractive to many,” he says. “Being a hospitalist is not for everyone, and some want the experience of being in private practice.”
The Day Is Done: Satisfaction
“You have to decide how you want to live your life and what you want to do. I follow my own pace,” says Dr. Reinstein. “I do work I love. I collect a steady paycheck and get to focus on caring for my patients.”
His work day is long; but at the end, he gets to go home to his wife of 39 years knowing he made a difference today and that he will return to the same place and work with the same team to make a difference tomorrow. TH
Joanne Kaldy is frequent contributor to The Hospitalist.