Student Hospitalist Scholar Grant: Understanding the Experience of the Long-Term Hospitalized Patient with Provider Fragmentation: A Qualitative Study
Student: Ilana Scandariato
Mentor: Dr. Ernie Esquivel
Co-Investigator: Dr. Maya Hogg
The primary objective of this study was to develop a conceptual framework for understanding the impact of provider fragmentation on the experiences of long-term hospitalized patients, specifically on the physician-patient relationship. Our study endeavored to explore the nature of that relationship through in-depth interviews with patients who have endured several transitions of care during a long-term hospitalization. By analyzing patients’ own words by qualitative methods, we aimed to gain insight into their emotional experiences, attachments and connections to caregivers, and how these are shaped by the structure of the medical service.
We found that patients identified on average 45% of the teams involved in their hospitalization. Only 8 out of 17 patients were could answer the question “Who is in charge of directing your care?” and of those 8, only 4 were able to state the attending of record by name. Patients had an average of 3 attendings in charge of their primary service and saw an average of 19 different providers and 4 consult teams in addition to their primary service. While many patients expressed frustration with frequent transitions of care, citing that this led to changes in the care plan, delays in care, and the need to frequently repeat their medical history, other patients were agnostic to provider turnover and expressed that they were satisfied as long as each provider had fully reviewed their chart and was familiar with their case. We also asked patients “What worries you most about being in the hospital for a long time?” and “Who can you talk to about these worries?” and found that patients’ most frequently described worries were managing home logistics, becoming sicker while hospitalized due to infection risk or deconditioning, and missing time with family and friends, and that they tended to discuss these worries most often with their family members and then with members of the hospital staff such as nurses, patient care assistants, and social workers.
These results are significant because they suggest areas for improvement. For example, a newly renovated floor in our hospital has installed screens in each patient room that displays the patient’s care team by name and photo and is linked to the medical record, so that this information is updated in real time. If this were expanded throughout the hospital, it would address one of the issues we illuminated in our study; that patients are often unfamiliar with the roles and identities of people involved in their care. Another significant finding is that the results in many ways different from our expectations and hypotheses – we had thought that transitions of care and the involvement of multiple teams and providers would be a significant source of stress and frustration for patients, which certainly held true for many patients in the study, but other patients were not bothered by this and put a sort of “trust in the system” that all of the providers at our institution would be well equipped to care for them. Finally, we found that patients often turn to other members of their care team to discuss their worries, reaffirming the importance of an interdisciplinary approach to inpatient care.
One compelling avenue for future work would be elaborating further on the concept of patients’ worries, which, as described above, tended to center on factors outside of the hospital such as finances and burdening family, rather than on their medical conditions. A follow up study could delve more deeply into the reasons why patients name these as their primary worries and how the medical team can better address these, as patients rarely named their doctors as the people they could talk to about these worries. Perhaps this could be an interdisciplinary study undertaken in collaboration with nursing or social work.
Another plan for future work would be to explore how different services compare in terms of patients’ perceptions of their relationships to caregivers. For example, we noted that patients on the Heart Failure service noted that often the attending physician on their case was also their outpatient provider with whom they had followed for many years. There was a similar pattern among patients on the Nephrology service, while comparatively, patients on a General Medicine service would be cared for by hospitalist attendings whom they had not necessarily met before. Since our sample size was limited and our approach was qualitative, we are not able to draw distinct conclusions about the differences between services, so another follow up study might be to survey patients about their experiences and take a more quantitative approach with a greater sample size of patients. This may illuminate ways in which services that have different structures could borrow best practices from each other to increase patient satisfaction.
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