Employed house call physicians

(cjs56) #1

Has anyone ever done a house call as an employed physician and felt that the patient might need hospital admission? But, let’s say, the employer may have certain guidelines that could dictate that the patient does not meet the criteria for hospital admission. Vital signs can fluctuate sometimes quickly. So, as an employed house call physician, one may decide to leave the patient behind since the patient does not meet hospital admission criteria according to the company physician owner who may be a hospitalist. In essence, there could be an incentive for a house call group to actually keep the patients out of the hospital and thus create more patients to round on in the following days. Seems to me a potential conflict. Because, we were always taught in residency to trust our own judgment. On the other hand, it seems that many of the house call groups may have the technology to support keeping the patient at home (virtual telemetry for example). But, it seems that X-rays can’t be done for several hours. And, actual physician follow-up can’t be done until the next day. In other words, no provider actually returns later in the same day to check on the patient. It seems to me a potentially uncomfortable situation. I know there is great flexibility in this. But, if the patient needs hospital admission and is not refusing to go, then how would an employed house call physician deal with this expecting contrary arguments from the physician employer?

(Bruce Jung) #2

@cjs56, seems from your posts that it would be helpful to have an ethicist on Hint Community, lol!

  1. First of all, do what you understand to be right! For the patient, morally, medically, emotionally, legally and financially… and probably in that order.
  2. You may need to consider another employer, especially if you are constantly being put into these ethical binds.
  3. The good ole days seem to be gone. It used to be for us country family physicians that we ran the office, did house calls and nursing home visits, pre-and post-office hospital rounds, managed the ICU, saw our patients in the ER and delivered (NSVD or C/S) our own babies and resuscitated them. We also went to our deceased patients’ wakes or funerals. Nowadays, everything is passed off from one provider to the next and the latter blames the former for “dumping” and the former blames the latter for “laziness”. As one of my former partners used to say about Christian doctors, but I think it should apply to any physician, “The Christian physician should do what is right, no matter in which delivery model he/she finds themselves.” And by “right” I mean by the patient.
  4. Understand that there are consequences, not only for doing what is wrong or right, but also for doing what is expedient vs what is thorough. Be prepared to face them… even the bad consequences are best faced when you are firmly convinced that you did what you knew to be best/right.
    Once again, a few rapid fire, random thoughts.

(cjs56) #3

Thanks Bruce. I was just looking at a house call practice company in San Diego. Their medical equipment was very sophisticated allowing what is now called these days…"Hospital in the Home."
I am sure you are aware of it… if… you interact with a few younger generation physicians. The concept is good…telemetry in the home…

all to avoid hospitalizations.

My comments and thoughts…not to confuse you or Robin…

was to pose:

  1. what if the physician felt that the home bound patient really needed hospitalization but the San Diego boos said “no hospitalization”? Don’t forget, this model is based on fee for service and the more patients that remain in the home, the more money for the group. They don’t make money if the patient is admitted to the hospital.
  2. I know the answer…I just wanted to get some other feedback. I do not work for these folks…just met them and tried to learn a bit about their home care model.
  3. As you probably can tell, things are done a bit differently here in California. Some good. Some not so good. It is all a learning process. I believe many physicians outside California would learn many things if they had an opportunity to experience things here.