Esteban Peña

1. Are U.S. residency training programs producing internal medicine physicians that are able to keep up with modern health care needs?THE APPROPRIATE USE OF CONSULTATIONS Esteban Peña

2. TEACHING ATTENDINGS “Who we are is what they become”

3. CASE 1 • 37 yo WF with significant history of chronic ETOH intake admitted for acute alcoholic hepatitis. Treated with Trental and she improved her LFTs. • Unfortunately, the patient developed difficulty ambulating. Symmetric, bilateral LE weakness predominantly distal, with patellar and ankle areflexia. No sensory level and DRE showed an intact sphincter tone.

4. What is the best step in the management of this patient?

5. BUT…. ROAD BLOCK

6. Impact of an early Neurology consultation for IM residents. • Do residents understand how to diagnose symmetric bilateral lower extremity weakness? • What is the most cost-beneficial test to promptly achieve a diagnosis? • Do they feel encouraged to read on medical literature to achieve the diagnosis as soon as possible? • Does it delay patient care? • Is all the testing recommended by Neurology required “right off the bat”?

7. “Referrology”- the approach to promptly diagnose a patient? • Pleural effusion= Pulmonary consult • Pancytopenia= Hematology consult • Bilateral lower extremity weakness= Neurology consult. • Chest pain= Cardiology consult. • Troponin elevation= Cardiology consult • Abnormal LFTs= GI consult. • Bacteremia= ID consult. • Death row= Palliative care. • ARE WE TEACHING RESIDENTS AND STUDENTS TO REFER PATIENTS TO PROVIDE A DIAGNOSIS? • IS THE IM SERVICE BECOMING A SPECIALTY THAT ONLY DEALS WITH SOCIAL ISSUES?

8. Case #2 • 27 yo WM. No significant history. ED physician requests admission for excruciating chest pain and “hyperdynamic t waves” on EKG to rule out ACS. Cardiology said: “ADMIT TO MEDICINE” • When interviewed patient states pain started immediately after ingesting coke and candy (Mentos®)

9. Coke and Mentos

10. “ THE GLORIFIED H&P PROVIDER”

11. ACP INTERNIST “I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery”—the reality of our referral patterns in today’s health care system has gone to the opposite extreme and can be equally dangerous. Joseph W. Stubbs, FACP

13. US physicians are twice likely to refer patients to a specialist

14. Internal Medicine training in Europe and other countries takes 5 years. • Training in the U.S needs to be extremely efficient to achieve the same goals in 3 years, or • The result is to produce less effective internists. • IS THIS THE CAUSE OF THE INCREASING REFERRAL PATTERN IN THE INTERNIST TODAY? • DOES THIS BEHAVIOR THREATENS THE PRACTICE OF INTERNAL MEDICINE?

15. Hospital Statistics • Intensity of care has increased in 47% 1997-2006. • Hospital ownership: Government 14%, Non-profit 73%, For profit 13% • 86% Community Hospitals- not all specialties are available. • ALOS in the country is 4.6 days and remains the same since the year 2000. • Common diagnosis are common- should the internist be well prepared to deal with them with low need of consultation?

16. LOS

19. Lets look at some data… • C. B Forrest: “High use of specialists physicians and specialized procedures coupled with low exposure to primary care are distinguishing traits of the US health care system.” • Physicians and consulting physicians disagreed on both the reason for consultation and the principal clinical issue in 14% of consultations studied. • Both primary and specialty care physicians thought that many referrals were potentially avoidable but failed to agree on 34% of the cases. for outpatient referrals.

20. Communication… • Purpose of the referral was explicit in only 76% of cases. The referring physicians fared even worse: consultants communicated their findings to the referring physicians in only 55% of the consultations. McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144(6) 1265-1268. • 32% of specialists received consultative information from the referring PCP, while 75% of referring physicians received communication back from the specialist. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-631.

21. Specialist survey- opinions • 60% of referrals were for conditions that should be easily manageable by general practitioners with access to the right information (dermatology, cardiology &orthopedics). Guidelines partly explain differences in referral rates BMJ. 2002 November 16; 325(7373): 1177. • Interventional study: 28% Improved unnecessary referral in CKD 3 patients to Nephrology (Spain)

22. Specialist vs. PCP • Specialists are more likely to provide evidence based medicine. • Co- management improves outcomes. • 50% of consultations are “self referrals”. Mostly related to patient dissatisfaction. • 19% repeated referral (poor communication or inadequate knowledge) • Intervention study: 1 out of 10 patients when screened truly required a face to face visit with a specialist. • 52% of referrals bypassed the PCP to another specialist. • Asthma study: worse outcomes from an internist than from an asthma specialist. RCT 3 years.

23. Appropriateness of referrals • Only 16 articles published. • 0.7- 65% pediatric orthopedics • Under referral 19% stage III and IV colorectal Ca for adjuvant therapy. • 87% retinopathy screening in DM and HTN • Adherence to existing guidelines. • Judgment by the provider • Does it change the diagnosis or management • Procedure required

24. What are the consequence of inadequate referral ? Under referral: • Delayed diagnosis. • Delayed treatment. • Increased risk of malpractice suits (5%). • Increased morbidity and mortality (CKD) Over referral: • Reduced continuity of care. • Polypharmacy. • Increased risk of malpractice suits. “CYA” (20% poor communication and unclear lines of responsibility with specialist) • Increases cost

25. Referral decisions is heterogeneous amongst internists • Presenting problem • Patient’s expectation • Certainty of diagnosis • Type of training (specialist will likely refer for issues not related to his specialty) • Number of years of experience- the more years in practice the more referrals or extremely young physician. • Concerns about malpractice • Practice environment. • Prior interaction with specialists • Female physicians

26. Similar pattern in pediatric population • Routine care provided by specialists to children and adolescents in the United States (2002-2006). BMC Health Services Research 2009, 9:221

27. What is the most probable future of IM in acute care? • Slowly disappears as ER doctors can recognize and place referral for any abnormality. Social issues can be dealt by a more efficient system. Do we really need two doctors to triage and consult? • The cost-effectiveness of referrals is too expensive. IM service admits the great majority of the population (chest pain, CHF, etc.). Are residents prepared for this possibility?

28. WHAT IS A HOSPITALIST? • Internal Medicine Physician- provides acute care to hospitalized patient in the area or internal medicine. • The branch of medicine that deals with the diagnosis and (nonsurgical) treatment of diseases of the internal organs (especially in adults).

29. Hospitalist • Diagnostician. • Acute care/ Internal Medicine. • Prevention and treatment of disease. • Specialty referral- inpatient or outpatient. • Cost for patient, insurance companies and hospital. • Quality improvement.

30. How Hospitals get paid? • Case-based payments (D.R.G.’s) • Set amount of dollars per day of inpatient stay (per-diem payments) • Fees for individual services and supplies (fee-for-service or F.F.S. payments). • The levels of these payments are set unilaterally by the state governments. In many states these payments are much lower than the full cost of providing the services.

31. Length of Stay • Patients who stay for a shorter period of time generate more money for the hospital. • Hospitals are often anxious to get the patient stable and discharged quickly. • Insurance companies offer rewards for the hospitals who have shorter stay times for their patients. • Guidelines are closely followed that determine the length of time a patient with a specific diagnosis can remain in the hospital. • Doctors who insist on longer stays are many times denied treatment for their patients in the future at particular hospitals.

32. Does over referring a patient increase length of stay? • The studies available are only for the OUTPATIENT setting.

33. Only one study • Infectious disease consultation: Impact on outcomes for hospitalized patients and results of a preliminary study. Classen MD • 496 (intervention) vs. 3117 (control) • Control: Longer LOS Longer ICU Higher antibiotic cost.

34. HOW TO BE PART OF THE SOLUTION? • Believe that there is a problem. • Internists performance should be measured and compared. • Guidelines and training. • If patients are almost always referred- should there be an internist in the care of the patient?

35. Efficiency? • “Efficiencyin general describes the extent to which time, effort or cost is well used for the intended task or purpose.” (Dictionary) • Physician’s productivity (ACP): • Number of patients per hour • Ability to bring profit to the facility and reduce cost. • Reduce fatigue and increase job satisfaction. • Improve quality of healthcare (patients and society)

36. HOW TO EVALUATE HOSPITALISTS EFFICIENCY? • Length of stay • Readmissions • Avoidable days • Participation in quality improvement meetings • Mortality • Patient/Peer surveys • Evidence based guideline.

37. Report efficiency evaluations as a group and individually to attending physicians every 6 or 12 months. • Publish this data to encourage change in other academic programs and be able to compare performance. • Targeted training for attending physicians according to their efficiency evaluation result. • Systematic or algorithmic approach to main problem to approach diagnosis efficiently. • Create guidelines that include indications for referring a patient.

38. BIBLIOGRAPHY • Improving the Primary Care–Specialty Care Interface, ARCH INTERN MED/VOL 169 (NO. 11), JUNE 8, 2009 • Arch Intern Med. 2012 January 23; 172(2): 163–170.Trends in Physician Referrals in the US, 1999–2009 • Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis. BMJ 2002;325:370 • Guidelines partly explain differences in referral rates BMJ. 2002 November 16; 325(7373): 1177. • Mehrotra, Dropping the Baton: Specialty Referrals in the United States, The Milbank Quarterly, Vol 89 N1 2011 • . Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106-112. • McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144(6) 1265-1268.

39. Reasons for Choice of Referral Physician Among Primary Care and Specialist Physicians, J Gen Intern Med. 2012 May; 27(5): 506–512. • HCAP Facts and Figures, Statistics on Hospital Based Care in the United States, 2012. • Data Bulletin, Results from HSC Research, N35, September 2009 • Rosenblatt, Culture and Medicine: Physicians and rural America. West J Med, 2000. • US Department of Health and Human Services, CDC, National Center for Health Statistics, GENERALISTS AND SPECIALTY PHYSICIANS: SUPPLY AND ACCESS 2009-2010. • Is general practice effective?, Support Summary of a sytemic review, May 2011. • Barnett, Trends in Physician Referrals in the United States 1999-2009. Arch Intern Med 2012;172(2)

40. Garcia, Results of a coordination and shared clinical information program between primary care and nephrology, Nephrologia 2011 31(1) • Forrest, A typology of specialists’ clinical roles, Arch of Internal Medicine 2009 169(11) • Baker, Quality of care in patients with asthma and rhinitis treated by respiratory specialists and primary care physicians: 3 year randomized and prospective follow up study, Annals of Allergy and asthma & Immunology 2006 97(4) • Franks, Why do physicians vary so widely in their referral rates?, Journal of General Int Med 2000 15(3)