What Stands Between You and Your Doctor?

09/28/2012 14:33


The sanctity of the relationship between doctors and patients is often the first thing we talk about when discussing medical care. The widely held belief is that the content of your care should be between you and your doctor; reality is, intrusive forces between you and your doctor already exist and new rules are coming that will further jeopardize the doctor-patient relationship.



 Patients probably are not aware that their hospitalization in an accredited hospital, for any illness or procedure, is constantly subject to scrutiny by a Hospital Oversight Committee composed of administrative nurses. Each admitting diagnosis and procedure carries with it a DRG (Diagnosis Related Group).  The DRG ascribes a number of days of hospitalization justified as “typical” for the diagnosis. The DRG is tied to the concept of Standard of Care. The concept of the Standard of Care (SOC) was originally a legal term used by attorneys to determine if your care was adequate. Unfortunately, SOC has become a quasi-medical term to define “enough” care.

The present concept of Standard of Care ignores the fact that your doctor may not be “typical”. He could be more informed, more experienced or better educated than most physicians. Your doctor may have precise reasons why the Standard of Care is not adequate in your case. One size does not fit all. The problem surfaces when your doctor believes the best care violates the guidelines of the DRG. Now begins the struggle between “enough” care and the “best” care

If the DRG days are exceeded because of what your doctor knows to be the best care, these extra hospital days must be justified to the Oversight Committee. Theoretically this can be done in a doctor’s chart note. But the “watching” Oversight Committee may not accept the cryptic chart note.  In many cases the patient’s condition is not easily codified and a simple note in the chart is not adequate for the Committee to understand the doctor’s thinking. The doctor in fact might have to write a thesis for the less educated Committee to understand why the patient should remain in the hospital.

 There are other simple reasons unknown to the committee why the doctor may want the patient to remain in the hospital.  Maybe the patient’s home situation is not stable or trustworthy in terms of time of delivery of medication, or taking frequent temperatures, or making sure the patient has scheduled testing, or walking only when accompanied, or bed rest with legs elevated. Perhaps the patient is more fragile or diabetes or obesity creates additional concerns. The reasons can be subtle and difficult to encapsulate in a chart note, but are critical to the outcome of patient care. 



 If the doctor in charge does not satisfy the Committee, s/he may be subject to intra-hospital discipline and in some cases even State License Board review.  If the patient’s chart is tagged for over hospitalization, the doctor may take the easy route and simply discharge the patient rather than put up with the bureaucratic nonsense he sees on the horizon. The result is a premature discharge. Regulation has now interfered with the doctor patient relationship



Ten days following back surgery a patient develops swelling in his right leg. This new persistent development prompts a visit to the doctor. Testing reveals Thrombophlebitis (clots in the legs). Treatment requires anticoagulant therapy, Heparin injections, followed by an oral anticoagulant, Coumadin. The doctor has difficulty stabilizing the Coumadin dosage.  Questioned closely the doctor may have wanted the patient to have a stronger and longer course of Heparin therapy than called for by “Standard of Care” and the limits of the DRG. The Coumadin dosage may require more daily blood tests to reach the correct, stable dosage. After five days the Oversight Committee thinks the patient should go home. They don’t initiate a conversation with the doctor, and are nowhere to be found when the doctor makes his early morning rounds. The patient is no help; patients always want to go home.

 The patient needs to be asking his doctor if he actually is ready to go home.  The doctor needs to engage in a dialogue about the patient’s home situation. Only the patient knows the realities of his home environment.  Someone needs to speak up for the patient in this bureaucratic regulated mess and that may be the patient himself.  Without input from the patient, the doctor will be pressured into a premature discharge. Ideally, the doctor should explain and the patient should accept that he should stay in the hospital several more days, legs elevated, with only supervised periods of walking, and more testing. The oversight committee should understand and accept these facts. Instead the patient is discharged.

 Three days after discharge the patient is re-hospitalized with severe chest pain and shortness of breath. Diagnostic testing reveals the dreaded and potentially lethal complication of pulmonary emboli (currently an epidemic in our hospitals related to premature discharge).   Portions of the clot in his leg have broken off and gone to his lungs. This complication could have been avoided by longer and stronger Heparin therapy followed by the correct dose of Coumadin and close supervision of the rules of “bed rest with legs elevated.”  The patient’s care and now his life have been compromised by a regulation limiting the patient’s care with extra hospital days.





With Obama Care, re-hospitalization will trigger a new regulation intervention – a new oversight problem. Under Obama Care, all readmissions in less than 90 days from a discharge will be “investigated” and charged with poor quality of care. The hospital will face a sizeable fine. Since hospitals do not budget for fines in their charges and subsequent reimbursements, bankruptcy could result. The Hospital could be forced to close. An entire community could be left without a hospital. OR if hospitals attempt to project into their costs possible fines, the costs will rise dramatically and be passed along to the citizens through Obama Care.

To start, rules and regulations can result in premature discharges. And now, rules and regulations may jeopardize an entire hospital or raise the overall cost of hospitalization. Bureaucrats in this case, even the nurse bureaucrats, have caused a very big problem. The doctor and the hospital will be squeezed from both sides, by the admission DRG and its discharge mandates and now the by the hospital itself through readmission regulation. A doctor could have followed his own judgment and initially kept the patient in the hospital longer. The intervention by the DRG and SOC is wrong.  Early discharges, I feel, are responsible for many complications and repeat hospitalizations.

Rules and regulation have come between the patient and his doctor. A doctor is no longer the ultimate director of a patient’s care. Care is and will be determined by rules and regulations from committees. Your “doctor-patient” relationship is compromised, leaving you in jeopardy of less than quality medical care.