Private Patients

[Adcadet]

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Hey gang,
I'm looking seriously at a program - BIDMC - who's main downside seems to be the presence of private patients. I've only had one brief experience with private patients, back on my very first rotation on pediatrics that I hardly remember. I'm hoping some of the student and residents who have cared for private patients could voice their varied opinions on how private patients are good, bad, or ugly. How are rounds organized when you have a mix of private and non-private patients? Are teaching rounds less useful since the teaching attending may not know some of your patients? Do you think privates patients interfere with learning significantly? Do you find it annoying to track down private attendings? Are private attends OK to work with? Does a "geographic admitting" structure like what BID uses where all your patients are on one ward eliminate all or most of the hassle with private patients? Does anybody like having private patients, perhaps because you are not stuck with a single attending?

Thanks,
Adcadet

 

[babyruth]

You are referring to docs that do their own admitting instead admit under the hospitalist-associated resident service? Or are you speaking about private pay patients?

 

[Adcadet]

Sorry for the confusion. I'm talking about patients who are admitted and seen by their own physician as opposed to the hospitalist service at the hospital.


I find it confusing to keep track of the possible ways patients can and are seen while in the hospital. Here's one organization:

Group A: patient's who's physician are part of hospital practice; i.e.-a patient in Boston who's primary care doctor is one of the BIDMC faculty members. Technically not a private patient.

Group B: a patient who's physician is not part of the hospital practice. Techincally a private patient.

Either Group A or B can then be divided up many ways:

1. Patients admitted to the hospital's in-house hospitalist service. This is typically what Group A patients and an increasingly large portion of Group B patients. Many hospitals only have this group of patients. It's like being at your school's main teaching hospital, and all of the patients on your resident team are seen by your attending, and maybe by chance a few patients' primary doctor is part of the hospital faculty or is even by chance your attending's clinic patient.

2. Patients from Group B who's private doctor or group contracts with a hospitalist service to round on their patients. Technically a "private patient" although depending on how much time the hospitalist physicians spends in the hospital, working with these attendings might be a very regular occurrence or fairly rare.

3. Patient's who's private physician group designates someone from the group to see the patients, either a full time hospitalist that is part of the the private group practice or an internist who spends some time just covering hospitalized patients. As in #2, depending on how much time the physician spends in the hospital working with these attendings might be a very regular occurrence or fairly rare. The only difference between #2 and #3 is that in #2 the hospital rounder is part of the group practice where in #3 the hospital rounder is separate from the patient's primary group practice.

4. Patients who's internist will see clinic patients along with any of their patients who are currently hospitalized; this group is the prototypical "private patient" group. This group is also becoming increasingly rare as private practices seem to be moving towards #1-3 above. I suppose it's possible that a resident might run into the same private physician and his/her patients frequently enough to become familiar with working with that doc.


Does that make sense?

 

[babyruth]

Yes.

Usually the resident's are assigned a certain patient group. If you are doing an IM month at the hospital, you usually work with the IM team, which is made up of an attending, residents, and interns (possibly students). And then when you are on call, you are on call for a certain set of patients, whether it is the hospitalist's service, the critical care unit, etc. Usually it is more clear when you start who you are responsible for. You might try asking the program, especially one of the residents, how it works there because, depending on the size of the service, the size of the program, and the size of the hospital will determine who you are responsible are. This will also determine if you are part of the rapid response team or code team as well at night.

At a smaller hospital I rotated at, the residents at night were responsible for all 'no-doc' admissions and floor calls for the resident IM service team's patients. They also had to respond to any codes. (So responsible for more but the patient census was less)

At a larger teaching hospital I rotated at, the IM residents were responsible for their own designated patients (the IM resident team's patients which was actually made up into an IM team and a academic team) which included patients from a certain set of primary care physicians and the 'no-doc' patients that didn't get admitted already from the hospitalist group. Another IM resident team covered for critical care because that was the month they were on and would then field calls, codes, and admits to the ICUs in the hospital. (So there were ultimately two residents and interns on call for two separate groups). They also helped with rapid response teams and the codes. (So they were responsible for smaller portion of categories of patients but had a larger patient census.)

Like I said, it is dependent upon the program and the hospital.

 

[Adcadet]

The program in question, BIDMC, has a mix of #1, 2/3, and 4. It seems many of the SDNers who posted opinions in the last few years cite BID's private patients as a major drawback. I'm wondering if other students/residents who have worked in a similar situation found it confusing, frustrating, inefficient, and poor for teaching, or if its really not a big deal.

 

[DoctorSax]

I really feel that you have to have a balance. Taking care of patients who have primary care doctors is a good thing to do during residency, but taking care of only private patients can be frustrating. Most programs try to make sure that if you are taking care of a private attending's patient, that education is not sacrificed and there is a teaching attending whose only purpose in life is to make sure that you are learning from your patients. At my program, if you find yourself learning nothing from taking care of a patient (for example, the 4th patient in two weeks who you are overlapping on heparin/coumadin for that ol' DVT), your resident can push to make the patient "non-teaching."

Either way, it's good to interact with private and hospitalist group attendings because you get a window into how the world works when you get out into practice. But it would be unfortunate if your program didn't include exposure to the "service patient" population as well--some uninsured, some medicare/medicaid, challenging you with complicated medical and social pathology.

DS

 

[lurkerboy]

The program in question, BIDMC, has a mix of #1, 2/3, and 4. It seems many of the SDNers who posted opinions in the last few years cite BID's private patients as a major drawback. I'm wondering if other students/residents who have worked in a similar situation found it confusing, frustrating, inefficient, and poor for teaching, or if its really not a big deal.

I am a BIDMC SAR (3rd yr) and I agree with the description of the breakdown you made above.
The majority of patients (whether they have PCP's or not) are cared for by hospitalists.
Many of these "private attendings" with privileges are actually attendings at HealthCare Associates, the BIDMC IM practice. You see these same attendings every day at conferences, or they are your preceptors in clinic. A few others are cardiologists at BIDMC or internists in the neighborhood. I am trying to count them in my head, but I would guess there are only about 15-20 attendings with privs that are not stationed somewhere inside of the hospital. Compare this to about 10 or so HMED hospitalists and 5-6 APG hospitalists.

In all cases, you will get to know these attendings as well as the hospitalists. These non-hospitalist attendings do not micromanage their patients, so you have a great deal of autonomy in managing their patients.

This is radically different than the the "private patients" I took care of as a medical student at NYU where the intern was paging the attending to check if we could give a tylenol.


Looking at a few ward team censuses right now:

Tullis B (two interns)
has 7 patients, all of whom are taken care of by two different hospitalists ("HMED" and "APG")

Tullis A
has 8 patients, has 6 with one hospitalists, and two patients with one of the HCA attendings.

Kurland A
has 8 patients. There are 6 with the HMED hospitalists, 1 with a private internist, 1 with the geriatrics team.

I hope this helps.

 

[Dr. ZZ]

Usually

private patients/private attendings = a big hit on education

-there usually isnt bedside rounds
-you have no input on what happens to the patient in regards to patient care
-you are a glorified secretary that has to obey the PMD
-you have to contact the PMD for everything....things like..if you want to administer a Multi Vitamin....

 

[sluggo]

This is true for the most part. Be wary of programs that are evasive about this issue!