“We need to help hospitalists better understand what information we want and why the timeliness is important. These are patients we advocate for.” She offers an example of a hospitalized patient with inflammatory arthritis and Crohn’s disease whose imaging study uncovered inflammation of the aorta and retroperitoneum.
A biopsy was performed, but the patient was discharged two hours before inadequate sampling results came back indicating lymphoma. Because of a hitch in transmitting this information, Dr. Gensler says, “there was a three-week delay before the next appropriate opportunity to perform tests needed to confirm the lymphoma diagnosis. This was not optimal for patient care.”
Dr. Gross
Andrew J. Gross, MD, the Rheumatology Clinic director at UCSF, says many rheumatologists have been frustrated by consultations requested by a hospitalist that should have happened sooner, especially if the patient has already been started on steroids. “The hospitalist may request an urgent evaluation at a time when we are still seeing patients in clinic, or right before the patient’s discharge, which can make it challenging for the rheumatologist to provide an adequate evaluation,” he explains.
“But it is important for rheumatologists to recognize that hospitalists are under tremendous pressure to reduce length of stay and to be effective stewards of hospital resources. For them, anything that slows the process can be frustrating. They feel it would be faster for the rheumatologist to just come and take a look at the patient, and they get frustrated with indecision.” It can also prove frustrating when consulting specialists request more extensive workups, such as biopsies, which increase resource utilization, delay treatments and prolong hospitalization, Dr. Gross says.
When It Works Well
Bradley Monash, MD, a hospitalist at UCSF, says these types of conflicts represent the minority of interactions between hospitalists and rheumatologists at UCSF. “We have an incredible relationship with the rheumatology consult service. There are many situations where it would be helpful to have a rheumatologist weigh in, and we take advantage of that. They are an essential aspect of our care,” he says. “I recently met with Dr. Andrew Gross from the rheumatology service, who requested more routine engagement of rheumatologists with patients admitted to the hospital medicine service.”
