Background: As more healthcare systems adopt a hospitalist model to care for their inpatients, there has been extensive research into the impact of this change on metrics such as length of stay and cost. We hypothesize that in a hospitalist model, the frequent transitions of care as new attendings and housestaff come on service diminish the quality of the physician-patient relationship. We also hypothesize, based on previous studies, that this effect may be more significant among patients who have been hospitalized for a long time, as these patients’ extensive hospital courses involve multiple transitions and transfers. In this study, we use qualitative research methods to investigate the patient’s perspective on inpatient treatment in a hospitalist system, specifically as it pertains to the integrity of the patient-physician relationship.
Methods: Adult patients who were hospitalized for 21 days or more admitted to a General Medicine, Renal or Cardiology service were included. Semi-structured interviews were conducted at the bedside using a pre-determined set of questions designed to capture meaningful narratives about the patient-physician relationship and the experience of hospitalization more generally. Patient charts were reviewed to collect demographic information and quantitative data on the number of providers involved in the case. Interviews were analyzed by three investigators: two hospitalist physicians and a medical student. The investigators met to compare codes, group codes into clusters, and identify major themes.
Results: Patients identified 61% of the teams involved in their hospitalization. 9 of 20 patients could answer the question “Who is in charge of directing your care?” with the correct attending of record. Patients had an average of 3 attendings in charge of their primary service and saw an average of 21 different providers and 4 consult teams in addition to their primary service. While many patients expressed frustration with frequent transitions of care, citing that this led to changes in the care plan, delays in care, and the need to frequently repeat their medical history, other patients expressed that they were satisfied as long as each provider had reviewed their chart and was familiar with their case. Patients’ most frequently described worries about long-term hospitalization were managing home logistics, becoming sicker while hospitalized due to infection risk or deconditioning, and missing time with family and friends, and they tended to discuss these worries most often with their family members or with members of the hospital staff such as nurses, patient care assistants, and social workers.
Conclusions: Though transitions of care and the involvement of multiple teams and providers were a significant source of stress and frustration for several patients, many other patients were agnostic to this, even in situations where the patient was not familiar with the structure of the care team or the identities of key providers. The physician was rarely identified as someone participants would speak with about their worries about a long-term hospitalization, which tended to center on factors outside of the hospital such as finances and burdening family. Future studies could explore how different services compare in terms of patients’ perceptions of their relationships to caregivers, which may illuminate ways in which services that have different structures could borrow best practices from each other to increase patient satisfaction.