Who is the "attending physician"? In the “old days,” the answer was straightforward. The attending physician was nearly exclusively the patient’s primary-care physician, having a long-standing relationship in the outpatient setting. Involvement of other specialties was only required when the care management required skill sets outside of the attending. Patients and their families could expect to interact with a single physician throughout the hospitalization.
In the last 2+ decades, patient care has been increasingly fragmented. While many place the blame on the rise of hospitalists, the roots of fragmentation extend well beyond the hospitalist movement. The transition from the solo practitioner, to large group practices, led to shared call schedules between multiple providers. Increased employment by hospitals or large national provider groups has also contributed to a shifting mentality regarding the doctor-patient relationship. Mergers between healthcare systems and other factors have led to an increasingly mobile physician workforce, further fracturing the long-term relationships between physician and patient. Marketing practices developed by insurance payers have led to patients frequently jumping from plan to plan, and shifting their primary care physician to remain “in-network.” Despite these and other pressures affecting the doctor-patient relationship, the pivotal role of an attending physician remained strong through the early days of the hospitalist movement.
Today, the role of the “attending,” is a far cry from the idealized, traditional model. There is instead, a growing majority of physicians working in the hospital setting, acting as “Attending In Name Only” (AINO). My roles as a Physician Advisor, and a practicing hospitalist have given me a front-row seat during this transition. Working with hospitals from the East Coast to the West Coast and all points between has revealed this to be a national trend, not a local phenomenon.
There’s a special subset of the AINO, and for lack of a better term, we will refer to this group as an “Involuntary AINO (I-AINO).” These hospital attendings are found wherever practice patterns, contractual obligations, or hospital policy, require a physician to act as the attending, despite having little to no direct involvement in the management. As a hospitalist of 30 years, I can personally speak to the frustration of being forced to act as the I-AINO. The two most common situations involve surgical patients and admissions to the intensive care unit.
As a practice at some hospitals and regardless of the diagnosis, surgical patients are admitted under the hospitalist. There are pros and cons to this approach, And whether the practice meets the criteria for I- AINO, depends on whether there is mutual respect, coordination and collaboration between the specialties. Consider the following:
When done poorly, the hospitalist as I-AINO, can be a nightmare for the patient, nursing, and hospitalist. Many times I’ve been left to discharge a patient, with no communication from the surgeon regarding critical elements such as his/her preferred wound management, weight bearing status, plans for follow-up imaging, removal of sutures, or other aspects of postoperative care. In addition, if the surgeon is a poor communicator, the medical physician often is left trying to muddle through explaining the surgical plan to the patient or family. Even with good communication, there have been a multitude of times where I provided the patient a detailed explanation of the plan given to me by the surgeon, only to be contradicted by the same surgeon a short time later.
The second scenario involves admissions to the Intensive Care Unit (ICU). Here, the hospitalist or Primary Care Physician (PCP) is assigned as the attending, while the intensivists act as the true attending physician. Again, if structured correctly, there are benefits to this arrangement. More often, the structure is poorly designed, with negative outcomes for the patient, physicians and facility. When structured well, the hospitalist acts as an intermediary and coordinator between the multiple specialties involved in the case. He/she works to ensure that care is timely, appropriate, and length of stay is optimized. The hospitalist may lead discussions with the patient and family, attend family conferences, and clarify the goals of treatment.
Poorly designed or implemented systems lead to confusion as to who is in charge, create conflicting care plans, and inconsistent information provided to the patient and family. I have personally worked in intensive care units as the official attending, only to have the critical care physician yell “don’t touch my patients.” Too often the I-AINO is not an active member participating in the care plan. This is reflected in progress notes that are clones of other clinicians, a copy and paste from previous visits, or add little to no value to the overall patient management. Hospitals in this category typically have chronic issues with excessive Length Of Stay (LOS) in the ICU, excessive testing procedures, and other negative metrics.
There are a multitude of reasons a hospital may be burdened with the AINO. Effective intervention to minimize the negative system effects requires a deep understanding of the health system, and an ability to focus efforts at leverage points that are most likely to lead to positive outcomes.
Solutions may include:
The trends in healthcare are leading to increasing numbers of AINO’s, and if you work within a hospital, there are likely several at your facility. Their negative impact on the health system is not inevitable, and steps can be taken to minimize this impact. Targeted interventions under the guidance of a physician advisor or physician champion can reap positive benefits in terms of patient care, and general hospital performance. For those facilities with a more systemic issue with AINO-like behavior, the interventions are likely to require a data-based solution, EMR modifications, or involvement of an AI program. Contact us for more information and assistance.