Where's My Doctor?

Doc: Why doesn't my physician see me anymore when I'm in the hospital? 

A: It usually isn't because your physician doesn't want to, rather, it has more to do with the mechanisms of actually caring for a patient in a hospital becoming so complex.  

A trend in medicine began in the mid 1990's for some physicians to only work in a hospital, caring for patients admitted for treatment, whether it be a regular floor room or ICU, and then discharging the patient home to see their family physician for follow up.  It began as a service for physicians in large groups who would have to drive long distances to a hospital, often spending more time on the road than actually seeing patients. 

The New England Journal of Medicine then coined the word "Hospitalist" in 1996.  It has become a commonly used phrase now for the physicians who only work in a hospital caring for admitted patients. These are usually highly skilled physicians for whom the sickest and most critical patients are as routine as the sun coming up in the morning. The studies have shown they provide excellent care in most cases. 

The trend has rapidly increased with momentum as there are now residencies (the three to six years of training a physician undergo after medical school) which focus on training physicians for this roll and groups of physicians who work to staff several hospitals in a region as their sole focus. 

At first glance, quite a few patients may think that their physician is simply now taking the easy road and trying to coast along toward retirement not wanting to be with their patients in a hospital when they are the sickest.  Nothing could be further from the truth.  The fact is it takes nearly three times as long to deal with the process of managing a patient's care than it does for actually diagnosing and deciding what to do for that patient.  

This is true of all hospitals, not just a select few, because of the government, credentialing, and insurance regulations and requirements. 

All admissions to a hospital are reviewed for appropriateness simply because an unnecessary admission, in the eyes of the payer, will not be reimbursed.  This means it is critical for the nurses, pharmacists, physical therapists, social workers, discharge coordinators, dietitians and physicians to document, document, document.  Document everything because someone, sitting hundreds of miles away, will review the admission and one simple thing can cause the entire admission to be denied meaning no payment for the hospital or physician. This is the primary reason a discharge takes over 4 hours in most cases. 

I clearly remember sitting next to a talented hospitalist in the doctor's dictation room as she was on the phone to "case review" physician in Minneapolis trying to convince him the patient actually needed to be in the hospital.  She had been on the phone for nearly forty minutes to no avail and he was going to deny the admission in spite of the fact that she,  skilled physician looking at the patient, was adamant the patient was sick. 

At that moment, the nurse ran in the room informing the hospitalist that the patient was "coding", meaning had gone into cardiac arrest. She slammed the phone down and ran to care for the patient. 

If the hospitalist had been with the patient, instead of trying to convince a physician hundreds of miles away that the patient was sick, it is arguable that the patient would not have coded.    

The requirement of electronic medical records is a reason some physicians have left hospitals, and even more are leaving the profession altogether.  Anyone who has ever purchased a new computer, or upgraded, or obtained a new word processing software, knows how frustrating it can be to learn.  Imagine being responsible for a very sick patient and the only way to enter orders is through a program which may, or may not, have been well designed by people who actually use it. 

Case review is also time consuming.  Even months after an admission has been completed a physician may have to spend time clarifying details of an admission to satisfy regulations and requirements in place by the payers of healthcare. It can be extraordinarily difficult figuring out why a person behind a desk in another state is picking apart an admission for denial of payment. 

Many physicians will still make "social" rounds to see their patients because of the bond they feel with those they see in the office. 

The realities of time and complexities of satisfying regulations have created this hospitalist trend.  It is the further "industrialization of medicine" and in the hearts of many physicians, including my own, who try to be old-school - it is a sad, but understandable, reality.   

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  

The Medicine of Marriage

Q:  Doc, my wife made this appointment because she's worried about me.  I think I'm okay.  

A:  Well, it's nice to see she still loves you in spite of how stubborn you are.  Medical research now says you might live longer because of your marriage. 

I was told once by a patient who had known both good and bad marriages that a good marriage was like living on a mountain of joy and happiness and a bad marriage was like living in the valley of hell-fire on a daily basis.  He spoke with authority. 

Modern research is (again) noticing the advantages of marriage as a study was released this past weekend at the American College of Cardiology 2014 Scientific Session.  The results of studying 3.5 million people across the United States showed a 5% reduction in cardiovascular (CV) disease for married couples over single, divorced and widowed individuals. 

The married individuals were noted as having less cerebrovascular disease (stroke), coronary artery disease (heart attacks), abdominal aortic aneurysms, and peripheral vascular disease.  

Curiously, being divorced or widowed was associated with an increased risk of all vascular disease compared to people who have had never been married. Maybe it isn't better to have loved and lost than to never have loved at all. I doubt it. 

One of the commenters on the study, Dr Vera Bittner (University of Alabama, Birmingham) made this interesting quote:  "This . . . drives home the point that we cannot estimate CV risk purely on metabolic abnormalities that we can measure; psychosocial variables can also be very important. [This] adds to the literature on domains such as depression, hostility, stress without control, and social support and in general deserves further exploration."

In short, personal and mental stress causes heart attacks, strokes, etc. and a loving spouse may likely reduce the risk of this. On the other hand, a nasty divorce with a bitter ex- might lead to it. And yet, the loss of a long time beloved spouse may also be a significant contributor to cardiovascular disease. 

We discuss diets and exercise, measure our blood pressure and cholesterol, think about our medicines and whether or not they are helping, and worry over commercials that blare from the television.  Now science is warming to the idea that the worry, or "depression, hostility, stress without control" might be leading to cardiovascular disease.  

Nice to see science catching up with common sense.  

I can't count the number of times I've been asked "does stress lead to heart attacks?" usually from a person who is under a tremendous burden. 

But personal stress, the kind that hits to the core of us, who we are behind closed doors, from the person who knows the most about us, seems to have a real, physical impact on the level of the arteries.  The opposite, close loving support and a positive relationship, seems to provide some protection.  

It is remarkable to see a spouse who has lost their partner of over fifty years grieve with tears on every breath.  Teenagers and young adults seem to feel they have a corner on passionate and deep love, but my experience tells me otherwise. It is a lie to believe that all marriages are most loving at their inception and less so as the years go by.  There's no other way to put it.  Some marriages in their fifty plus years humble me in how they care for each other, with an occasional grumble, but a quick smile or touch of the hand and all is well.  There is powerful medicine in that kind of love, harmony, acceptance-with-all-faults-known, and forgiving kindness.  

The opposite is unfortunately true, too.  I've seen spouses released from a bondage of trapped torment when their marriage is over, either by death or divorce.  It is like watching someone walk out of prison to enjoy a new life of the things they missed out on.  These are the couples who look nice and happy in public and church, but behind closed door live a life of harsh words, separate beds, lots of alcohol (in spite of a public teetotaling perception) and hours on the computer or TV to take their minds off their personal life. Their health clearly takes a toll from the negativity of a difficult relationship, as we can lie to the world forever, but we can't lie to ourselves for long. 

There is a practical component to the positive effects of a good marriage.  I recently saw a man in the office who was convinced for four days his chest pain was reflux.  If his loving wife had not persisted, he would be in a grave right now.  His scar from his bypass surgery is healing nicely. She also is making sure he takes his medicine and makes his follow up appointments.  

The research, no doubt, will continue into the impact of the mind and emotions on our physical body.  

To anyone who has been in a stressful, anxious and hostile relationship and then lived in a loving, accepting relationship, there isn't much about its impact on the physical body they don't know.  I've seen everything from rashes to heart attacks caused by stress.

A wise older man who's been married to a 'determined' (I was told not to use the phrase 'high maintenance') woman for over sixty years told me this, "You fall in and out of love many times over the years.  You just keep trying and make it work.  And it does."

Hopefully, the vast majority of us will know that kind of love.  It's good medicine. 

Eric J. Littleton, M.D. is a Family Physician in Sevierville, TN.  His new office is located at 958 Dolly Parton Parkway. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician.  Send questions to askdrlittleton@gmail.com.