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Passing the clinical baton: 6 principles to guide the hospitalist
Passing the Clinical Baton: 6 Principles to Guide the Hospitalist Lee Goldman, MD, Steven Z. Pantilat, Winthrop F. Whitcomb, MD
MD, and
Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients’ outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.
q
n modern medicine, numerous situations arise in which the principal care of a patient is passed from one physician to another, either temporarily or permanently.’ Some of these transitions are dictated by chronic conditions, such as when a nephrologist assumes principal care of a patient with dialysis-dependent renal failure or when an oncologist assumes principal care of a patient with advanced cancer requiring ongoing chemotherapy. Other transitions are temporary, such as when a patient is referred to a surgeon for an operation, a patient’s physician-of-record becomes an intensivist or cardiologist during respiratory failure or acute myocardial infarction, or a physician expert in rehabilitative care assumes responsibility for a patient during the interval between hospital discharge and the return home. Perhaps most common is the transfer of care from one physician to another during a physician’s vacation, weekend, or night off. Even for the briefest transitions, available data suggest that the lack of familiarity with the patient may increase the
Dis Mon 2002;48:260-266. 0002-9343/01/$20.00 + 0 doi:l0.1067/mda.2002.125272 DM,
April
2002
likelihood of errors or suboptimal outcomes, unless special efforts are made to reduce these risks.223 More recently, these transition-related issues have become relevant for hospitalists, who not only assume principal responsibility for patient care from the primary care physician during hospitalization, but also must quickly return this responsibility at the conclusion of the hospitalization. This bidirectional transfer of responsibility, not unlike those historically faced by physicians, must be exercised with skill and grace to optimize patient outcomes and satisfaction. In 1983, Goldman and colleagues proposed 10 commandments to guide medical consultants in their relationship with physicians who requested their consultative skill~.~ This article will likewise propose 6 guidelines for receiving and returning the “baton” of responsibility for the hospitalized patient. In using this analogy, it must be emphasized that, in this relay race of responsibility for clinical care, the patient is not a passive baton but rather an active participant whose goals and needs transcend the simple fear of being dropped.
The Problem A recurring problem with hand-offs is the loss of information and efficiency, with the potential for adverse effects on quality of care and patient satisfaction.5’6 Although some information is purely factual and can be transmitted orally or by electronic means, more subjective and subtle impressions and judgments are difficult to explain, let alone transfer, to another physician who may never before have seen the patient. The hand-off can also be confusing for the patient, especially when the transfer is to a nonproceduralist whose role is more difficult to distinguish from what would historically be expected from the patient’s primary physician, on whom the patient has previously relied in times of need. The hand-off also can disrupt an established relationship, including the feeling of trust and reliance. As a result, the hand-off creates challenges for the primary care physician as well as for the hospitalist.
Responsibilities
of the
Primary
Physician
The first responsibility of the primary care physician is to provide key background information.7-9 This responsibility is no different from what is expected when patients are referred to surgeons or oncologists. However, the overlapping expertise of the primary care physician and the hospitalist can lead to tension or disagreements regarding care in domains of perceived mutual competence.* The primary care physician must endorse the legitimacy of the hospiDM, April 2002
261
TABLE 1. 2. 3. 4. 5. 6.
1. Six Pillars of the Hand-off
Communicate, but do not irritate Consult the primary care physician Timeliness is next to godliness Partner with the patient Make it clear that you are the patient’s advocate Pass the baton as graciously as you received it (or even
better,
more
graciously)
talist. The relationship between the 2 physicians will flounder badly if each does not support the other. The primary care physician must emphasize that the hospitalist is a true expert who will be responsible for inpatient care while the primary physician stays involved, monitors progress, provides needed advice and expertise, and is prepared to reassume responsibility at the time of discharge. Ideally, the primary care physician will remain in contact with the patient and family. lo Sometimes a telephone call is a very effective way for the primary care physician to achieve this goal. Key decision points, such as do-not-resuscitate orders and posthospital placement, may arise for which involvement of the primary care physician is essential and will be highly valued by the patient and his or her family.
The 6 Principles
of the Hand-off
For the hospitalist, of course, hand-offs occur with every patient and become a cornerstone of daily life. In approaching the hand-off, several principles can provide helpful guidance (Table 1).
Communicafe But Do Not lrrifufe Communication with the primary care physician is imperative, but too much of a good thing can be a bad thing. Hospitalists should use the least disruptive methods and seek a systematic approach that works well for all involved. Although many primary physicians want telephone communication, others prefer a fax.” More recently, many hospitalists have switched to e-mail. Each hospitalist or group of hospitalists must find the way that works best for the majority of the physicians they serve and find other methods for interacting with the exceptions. When necessary, both the method of communication and the form of the reports should be customized. For example, in a recent report from a cardiac catheterization laboratory, scripted phone calls were a successful method for communication.i2 The primary care physician must always be sufficiently informed so that any call from the patient or family can elicit an appropriate 262
DM, April
2002
response. The primary care physician’s biggest fear is to be embarrassed by being ‘“out of the loop.” The caveat is to inform without overwhelming the primary care physician with redundant or unimportant information. For example, 1 study showed that few primary care physicians want daily communication. l1 If daily updates are to be useful, they must be sufficiently focussed and nondisrupting. As with consultative notes,‘3’14 communication should focus on key information rather than excruciating detail to increase the likelihood that the primary care physician will find the communication useful.
Cord
the Primary Cure Physician
The primary care physician is an invaluable source of information, and the patient will be comforted by knowing that all of his or her physicians are in agreement and working as a team. l5 It is crucial to create a collegial relationship and to involve the primary care physician in sensitive decisions, such as code status, surgical recommendations, and discharge plans.8’9 The patient should not receive conflicting messages. If conflict is a possibility, the physicians must communicate with each other, determine what they believe is the most appropriate course of action, and transmit that single message to the patient.‘,16
Timeliness Is Next fo Godliness Hospitalists should notify the primary care physician at the time of admission and prospectively at major decision points before a potentially irreversible decision is made. The primary care physician must hear important news from the hospitalist before hearing it from the family. Discharge information must be transmitted to the primary care physician before follow-up occurs-key information immediately, with background and details to follow. The hospitalist must remember that “‘news,” by definition, must be prompt and timely; “late news” is an oxymoron.
The patient is not a passive object being exchanged by 2 doctors running at full speed. The patient is an active participant in the .process,17 and the primary care physician can best inform the hospitalist about how the patient wants to and should participate in the process. The patient must understand the diagnosis, treatment, test results, and follow-up. The hospitalist must develop a bond with the patient, especially because the interaction is occurring at 1 of the most critical times of life. Whether or DM,
April
2002
263
not the patient can function as an active partner, the hospitalist seek a similar relationship with the patient’s family.
should
Make It Clear that You Are the Patient’s Advocate In this era of cost containment, there is a risk that the hospitalist will be seen as “the system” rather than the doctor, especially because many hospitalists are actively involved in improving efficiency. An institutional role in designing and implementing critical pathways, guidelines, and cost-control measures cannot interfere with the hospitalist’s role as a patient’s doctor. l8 Beware of situations in which the hospitalist is cast in an undesired role as a gatekeeper in conflict with the patient, family, or primary care physician regarding access to specialized or potentially life-saving resourcesl’ This perceived potential conflict of interest is perhaps the biggest threat to acceptance of the hospitalist model.
Pass the Buton as Graciously Better, More Graciously)
as You Received It (or Even
Be sure follow-up is appropriate, be available to the patient, and make it clear whom the patient should contact. Regardless of whether the primary care physician passed the baton awkwardly, discharge is not the time for retribution. Even rocky relationships should improve if everyone tries to make them better.
Skilled
Nursing
Facilities
and
Home
Care
Whereas the 6 principles we propose apply in all circumstances, discharges to skilled nursing facilities and to home with home care require special considerations.
Skilled Nursing
facilities
Because patients transferred to skilled nursing facilities are often still ill and require ongoing care, more information about the hospitalization may be needed. In addition to providing a concise, detailed, and timely discharge summary, hospitalists should provide pertinent physician and nursing progress notes, consultant reports, advance directives, do-notresuscitate forms, and insurance information for patients discharged to a skilled nursing facility. In addition, a l-page nursing transfer summary that includes basic information, such as diagnoses, medications, allergies, diet, code status, and contact information, can ensure the rapid transfer of key data. 264
DM,
April
2002
Home Care For patients discharged home with home care, the hospitalist may need to sign home care orders until the primary physician can see the patient. For treatments with potential complications, such as intravenous antibiotics or hyperalimentation, the physician signing the orders should follow the patient after discharge. Because hospitalists are often unable to provide care after hospitalization, they may wish to authorize only 2 or 3 days of therapy until the primary physician can see the patient and assume responsibility for the treatment. Alternatively, if the primary provider visits the patient in the hospital, he or she can review and sign the home care orders.
Conclusion In summary, hospitalists can learn from other situations in which patient care responsibilities are transferred temporarily from one physician to another during acute illness. If these issues are addressed explicitly, both the hospitalist and the primary care physician will pay more attention to them, and the system of hospitalist care can provide positive professional interactions as well as better outcomes.‘X-22 References 1.
2.
3.
4. 5.
6.
Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA 1998;279: 1364-70. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qua1 Improv 1998;24:77-87. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983;143:1753-5. Auerbach AD, Nelson EA, Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med 2000;109:648-53. Wachter RM. An introduction to the hospitalist model. Ann Intern Med 1999;130: 338-42. Pearson SD. Principles of generalist-specialist relationships. J Gen Intern Med 1999;14(suppl l):S13-S20. Pantilat SZ, Alpers A, Wachter RM. A new doctor in the house: ethical issues in hospitalist systems. JAMA 1999;282:171-4. American College of Physicians Ethics Manual, 3rd ed [comment]. Ann Intern Med. 1992;117:947-60.
DM, April 2002
265
10. 11.
12. 13. 14. 15. 16. 17. 18.
19.
20.
21. 22.
266
Simon SR, Lee TH, Goldman L, McDonough AL, Pearson SD. Communication problems for patients hospitalized with chest pain. J Gen Intern Med 199813:836-g. Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med 2OOl;ll l(supp1 9B): 16S21s. Blankenship JC, Scheiber JF, Menapace FJ. Telephone reporting of cardiac procedure results to primary care physicians. Am J Cardiol 1997;79:984-6. Emanuel LL, Richter J. The consultant and the patient-physician relationship. A trilateral deliberative model.. Arch Intern Med 1994;154:1785-90. Pupa LE Jr, Coventry JA, Hanley JF, Carpenter JL. Factors affecting compliance for general medicine consultations to non-internists. Am J Med 1986;81:508-14. Deyo RA. Tell it like it is: patients as partners in medical decision making. J Gen Intern Med 2000;15:752-4. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med 1992;116:920-6. Kerr EA, Hays RD, Mitchinson A, Lee M, Siu AL. The influence of gatekeeping and utilization review on patient satisfaction. J Gen Intern Med 1999;14:287-96. Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med 2000;108:621-6. Fernandez A, Grumbach K, Goitein L, Vranizan K, Osmond DH, Bindman AB. Friend or foe? How primary care physicians perceive hospitalists. Arch Intern Med 2000;160:2902-8. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: the Kaiser Permanente experience. Ann Intern Med 1999;130:355-9. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med 1999;130:350-4. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA 1998;279:1560-5.
DM,
April 2002
MD, and
Hospitalist systems make it increasingly common for responsibility for a patient to be passed from one physician to another. During such transfers, patients’ outcomes and satisfaction can benefit from better communication between hospitalists and the primary care physicians whose patients they care for. We propose 6 principles to guide such communication, to ensure that critical information about patients is not lost and to optimize the quality of care. We also discuss special considerations for patients discharged to a skilled nursing facility or to home with home care.
q
n modern medicine, numerous situations arise in which the principal care of a patient is passed from one physician to another, either temporarily or permanently.’ Some of these transitions are dictated by chronic conditions, such as when a nephrologist assumes principal care of a patient with dialysis-dependent renal failure or when an oncologist assumes principal care of a patient with advanced cancer requiring ongoing chemotherapy. Other transitions are temporary, such as when a patient is referred to a surgeon for an operation, a patient’s physician-of-record becomes an intensivist or cardiologist during respiratory failure or acute myocardial infarction, or a physician expert in rehabilitative care assumes responsibility for a patient during the interval between hospital discharge and the return home. Perhaps most common is the transfer of care from one physician to another during a physician’s vacation, weekend, or night off. Even for the briefest transitions, available data suggest that the lack of familiarity with the patient may increase the
Dis Mon 2002;48:260-266. 0002-9343/01/$20.00 + 0 doi:l0.1067/mda.2002.125272 DM,
April
2002
likelihood of errors or suboptimal outcomes, unless special efforts are made to reduce these risks.223 More recently, these transition-related issues have become relevant for hospitalists, who not only assume principal responsibility for patient care from the primary care physician during hospitalization, but also must quickly return this responsibility at the conclusion of the hospitalization. This bidirectional transfer of responsibility, not unlike those historically faced by physicians, must be exercised with skill and grace to optimize patient outcomes and satisfaction. In 1983, Goldman and colleagues proposed 10 commandments to guide medical consultants in their relationship with physicians who requested their consultative skill~.~ This article will likewise propose 6 guidelines for receiving and returning the “baton” of responsibility for the hospitalized patient. In using this analogy, it must be emphasized that, in this relay race of responsibility for clinical care, the patient is not a passive baton but rather an active participant whose goals and needs transcend the simple fear of being dropped.
The Problem A recurring problem with hand-offs is the loss of information and efficiency, with the potential for adverse effects on quality of care and patient satisfaction.5’6 Although some information is purely factual and can be transmitted orally or by electronic means, more subjective and subtle impressions and judgments are difficult to explain, let alone transfer, to another physician who may never before have seen the patient. The hand-off can also be confusing for the patient, especially when the transfer is to a nonproceduralist whose role is more difficult to distinguish from what would historically be expected from the patient’s primary physician, on whom the patient has previously relied in times of need. The hand-off also can disrupt an established relationship, including the feeling of trust and reliance. As a result, the hand-off creates challenges for the primary care physician as well as for the hospitalist.
Responsibilities
of the
Primary
Physician
The first responsibility of the primary care physician is to provide key background information.7-9 This responsibility is no different from what is expected when patients are referred to surgeons or oncologists. However, the overlapping expertise of the primary care physician and the hospitalist can lead to tension or disagreements regarding care in domains of perceived mutual competence.* The primary care physician must endorse the legitimacy of the hospiDM, April 2002
261
TABLE 1. 2. 3. 4. 5. 6.
1. Six Pillars of the Hand-off
Communicate, but do not irritate Consult the primary care physician Timeliness is next to godliness Partner with the patient Make it clear that you are the patient’s advocate Pass the baton as graciously as you received it (or even
better,
more
graciously)
talist. The relationship between the 2 physicians will flounder badly if each does not support the other. The primary care physician must emphasize that the hospitalist is a true expert who will be responsible for inpatient care while the primary physician stays involved, monitors progress, provides needed advice and expertise, and is prepared to reassume responsibility at the time of discharge. Ideally, the primary care physician will remain in contact with the patient and family. lo Sometimes a telephone call is a very effective way for the primary care physician to achieve this goal. Key decision points, such as do-not-resuscitate orders and posthospital placement, may arise for which involvement of the primary care physician is essential and will be highly valued by the patient and his or her family.
The 6 Principles
of the Hand-off
For the hospitalist, of course, hand-offs occur with every patient and become a cornerstone of daily life. In approaching the hand-off, several principles can provide helpful guidance (Table 1).
Communicafe But Do Not lrrifufe Communication with the primary care physician is imperative, but too much of a good thing can be a bad thing. Hospitalists should use the least disruptive methods and seek a systematic approach that works well for all involved. Although many primary physicians want telephone communication, others prefer a fax.” More recently, many hospitalists have switched to e-mail. Each hospitalist or group of hospitalists must find the way that works best for the majority of the physicians they serve and find other methods for interacting with the exceptions. When necessary, both the method of communication and the form of the reports should be customized. For example, in a recent report from a cardiac catheterization laboratory, scripted phone calls were a successful method for communication.i2 The primary care physician must always be sufficiently informed so that any call from the patient or family can elicit an appropriate 262
DM, April
2002
response. The primary care physician’s biggest fear is to be embarrassed by being ‘“out of the loop.” The caveat is to inform without overwhelming the primary care physician with redundant or unimportant information. For example, 1 study showed that few primary care physicians want daily communication. l1 If daily updates are to be useful, they must be sufficiently focussed and nondisrupting. As with consultative notes,‘3’14 communication should focus on key information rather than excruciating detail to increase the likelihood that the primary care physician will find the communication useful.
Cord
the Primary Cure Physician
The primary care physician is an invaluable source of information, and the patient will be comforted by knowing that all of his or her physicians are in agreement and working as a team. l5 It is crucial to create a collegial relationship and to involve the primary care physician in sensitive decisions, such as code status, surgical recommendations, and discharge plans.8’9 The patient should not receive conflicting messages. If conflict is a possibility, the physicians must communicate with each other, determine what they believe is the most appropriate course of action, and transmit that single message to the patient.‘,16
Timeliness Is Next fo Godliness Hospitalists should notify the primary care physician at the time of admission and prospectively at major decision points before a potentially irreversible decision is made. The primary care physician must hear important news from the hospitalist before hearing it from the family. Discharge information must be transmitted to the primary care physician before follow-up occurs-key information immediately, with background and details to follow. The hospitalist must remember that “‘news,” by definition, must be prompt and timely; “late news” is an oxymoron.
The patient is not a passive object being exchanged by 2 doctors running at full speed. The patient is an active participant in the .process,17 and the primary care physician can best inform the hospitalist about how the patient wants to and should participate in the process. The patient must understand the diagnosis, treatment, test results, and follow-up. The hospitalist must develop a bond with the patient, especially because the interaction is occurring at 1 of the most critical times of life. Whether or DM,
April
2002
263
not the patient can function as an active partner, the hospitalist seek a similar relationship with the patient’s family.
should
Make It Clear that You Are the Patient’s Advocate In this era of cost containment, there is a risk that the hospitalist will be seen as “the system” rather than the doctor, especially because many hospitalists are actively involved in improving efficiency. An institutional role in designing and implementing critical pathways, guidelines, and cost-control measures cannot interfere with the hospitalist’s role as a patient’s doctor. l8 Beware of situations in which the hospitalist is cast in an undesired role as a gatekeeper in conflict with the patient, family, or primary care physician regarding access to specialized or potentially life-saving resourcesl’ This perceived potential conflict of interest is perhaps the biggest threat to acceptance of the hospitalist model.
Pass the Buton as Graciously Better, More Graciously)
as You Received It (or Even
Be sure follow-up is appropriate, be available to the patient, and make it clear whom the patient should contact. Regardless of whether the primary care physician passed the baton awkwardly, discharge is not the time for retribution. Even rocky relationships should improve if everyone tries to make them better.
Skilled
Nursing
Facilities
and
Home
Care
Whereas the 6 principles we propose apply in all circumstances, discharges to skilled nursing facilities and to home with home care require special considerations.
Skilled Nursing
facilities
Because patients transferred to skilled nursing facilities are often still ill and require ongoing care, more information about the hospitalization may be needed. In addition to providing a concise, detailed, and timely discharge summary, hospitalists should provide pertinent physician and nursing progress notes, consultant reports, advance directives, do-notresuscitate forms, and insurance information for patients discharged to a skilled nursing facility. In addition, a l-page nursing transfer summary that includes basic information, such as diagnoses, medications, allergies, diet, code status, and contact information, can ensure the rapid transfer of key data. 264
DM,
April
2002
Home Care For patients discharged home with home care, the hospitalist may need to sign home care orders until the primary physician can see the patient. For treatments with potential complications, such as intravenous antibiotics or hyperalimentation, the physician signing the orders should follow the patient after discharge. Because hospitalists are often unable to provide care after hospitalization, they may wish to authorize only 2 or 3 days of therapy until the primary physician can see the patient and assume responsibility for the treatment. Alternatively, if the primary provider visits the patient in the hospital, he or she can review and sign the home care orders.
Conclusion In summary, hospitalists can learn from other situations in which patient care responsibilities are transferred temporarily from one physician to another during acute illness. If these issues are addressed explicitly, both the hospitalist and the primary care physician will pay more attention to them, and the system of hospitalist care can provide positive professional interactions as well as better outcomes.‘X-22 References 1.
2.
3.
4. 5.
6.
Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA 1998;279: 1364-70. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qua1 Improv 1998;24:77-87. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983;143:1753-5. Auerbach AD, Nelson EA, Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med 2000;109:648-53. Wachter RM. An introduction to the hospitalist model. Ann Intern Med 1999;130: 338-42. Pearson SD. Principles of generalist-specialist relationships. J Gen Intern Med 1999;14(suppl l):S13-S20. Pantilat SZ, Alpers A, Wachter RM. A new doctor in the house: ethical issues in hospitalist systems. JAMA 1999;282:171-4. American College of Physicians Ethics Manual, 3rd ed [comment]. Ann Intern Med. 1992;117:947-60.
DM, April 2002
265
10. 11.
12. 13. 14. 15. 16. 17. 18.
19.
20.
21. 22.
266
Simon SR, Lee TH, Goldman L, McDonough AL, Pearson SD. Communication problems for patients hospitalized with chest pain. J Gen Intern Med 199813:836-g. Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med 2OOl;ll l(supp1 9B): 16S21s. Blankenship JC, Scheiber JF, Menapace FJ. Telephone reporting of cardiac procedure results to primary care physicians. Am J Cardiol 1997;79:984-6. Emanuel LL, Richter J. The consultant and the patient-physician relationship. A trilateral deliberative model.. Arch Intern Med 1994;154:1785-90. Pupa LE Jr, Coventry JA, Hanley JF, Carpenter JL. Factors affecting compliance for general medicine consultations to non-internists. Am J Med 1986;81:508-14. Deyo RA. Tell it like it is: patients as partners in medical decision making. J Gen Intern Med 2000;15:752-4. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med 1992;116:920-6. Kerr EA, Hays RD, Mitchinson A, Lee M, Siu AL. The influence of gatekeeping and utilization review on patient satisfaction. J Gen Intern Med 1999;14:287-96. Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med 2000;108:621-6. Fernandez A, Grumbach K, Goitein L, Vranizan K, Osmond DH, Bindman AB. Friend or foe? How primary care physicians perceive hospitalists. Arch Intern Med 2000;160:2902-8. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: the Kaiser Permanente experience. Ann Intern Med 1999;130:355-9. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med 1999;130:350-4. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA 1998;279:1560-5.
DM,
April 2002