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Caring for complex patients — those experiencing a laundry list of conditions simultaneously — can be challenging for any physician. From incorporating multiple specialists to working with social workers, primary care physicians and more, figuring out the right calculus to help these particularly ill patients is often difficult. For hospitalists, that math can be even tougher.

Unlike certain specialists and primary care physicians, hospitalists don’t know the majority of their patients well. They are unfamiliar with their backgrounds, familial and social situations, and often must bridge the gap between multiple practitioners and their opinions. But that doesn’t mean hospitalists can’t bring their own valuable perspective to the table.

“We own all the problems, but we do so willingly,” said Joseph Sweigart, MD, a hospitalist at Georgetown Community Hospital in Georgetown, Kentucky and associate professor at the University of Kentucky School of Medicine, Lexington, Kentucky. “I often joke that I love taking care of the people rather than their organ systems. We get to consider all the issues and then present them to the patients holistically.”

The position has its pros and cons, but more than anything, it means a hospitalist must develop effective strategies for managing these complex patient cases.

Facing the Challenge 

The layers of complexity involved in each patient can range from physical to mental, and may also involve logistics, a lack of social support, and more. While physical ailments are often at the top of the list, psycho-social issues are taking an increasingly larger role in the treatment of complex patients, according to Adjoa Boateng Evans, MD, a critical care anesthesiologist at Duke University School of Medicine in Durham, North Carolina. “A patient may have a severe psychiatric disease and a concurrent addiction, making placement outside the hospital a challenge,” she said. “Or if a patient has survived a critical illness, but is too ill to go home, we have to make decisions about long-term care.” 

Those decisions may be further complicated by issues like lack of insurance or little-to-no support system, which can present additional obstacles for hospitalists. “They are the primary in-patient doctor for many patients in the hospital,” said Evans. “If they’ve got multiple patients and psycho-social issues, too, patient management can be difficult.”

Additionally, hospitalists are in the unique position of managing admissions and discharges, all while keeping abreast of new data and results throughout a shift. “We are seeing these patients often at the sickest points of their lives,” said Maninder (Dolly) Abraham, MD, chief of hospitalist medicine at RWJBarnabas Health, West Orange, New Jersey. “A big challenge is that we don’t know them or their families.” 

This means there is a learning curve when hospitalists take over a complex patient, and due to the severity of the patient’s illnesses, they must overcome this curve swiftly. If patients are bouncing back and forth between the floor and the intensive care unit (ICU), that task can be even more convoluted.

Another issue hospitalists may face is bridging gaps between specialists. “You might have a patient with a fresh stent who comes in with GI bleeding,” said Sweigart. “The cardiologist would say the patient needs blood thinners, and the GI [gastrointestinal] doctor might say to stop those meds to help the gut. Both are right for those systems, but as hospitalists, we get all that information and must make decisions.”

While that can feel intimidating, with good communication and a willingness to collaborate, hospitalists can deliver the quality of care necessary to adequately support complex patients throughout their stay.

The Skills to Manage 

When managing a complex patient, at the top of a hospitalist’s list is a comprehensive evaluation upon admission. From there, collaborating with a multi-disciplinary team becomes essential. “You should review records, reach out to the primary care physician, and reconcile the poly-pharmacy issue so that there are no side effects or adverse reactions,” said Anila Faizan, MD, medical director of the hospitalist program at Cooperman Barnabas Medical Center in Livingston, New Jersey. “You must communicate with everyone involved in the patient’s care.”

You must also establish trust with the patient and their family and hold goals-of-care conversations with them. This requires a holistic approach that addresses social detriments along with the physical condition. Your patient will eventually move on to the next site of care — or their home, ideally — and you must begin addressing this on day 1.

“We’re in-house for 10-12 hours and not running off to offices,” said Abraham. “We see the patients in the morning, look at their labs, and perform interdisciplinary rounds for plan of care and case management. Then, we follow up on rounds a second time, which often gives us a chance to have a conversation with the family. That gives us an advantage in the care of complex patients.”

It's essential that hospitalists take the initiative to establish collaboration with the entire care team, said Evans. “You might be hesitant to reach out to the ICU group, for instance,” she said. “But our breadth of knowledge on these patients is vast, and we’re always happy to help collaborate.”

These conversations can lead to comanagement decision-making, often improving patient outcomes. When hospitalists add their two cents on patient care — and ask for the same in return — it can unearth the best route of care.

Evans said that much of this involves the art of storytelling, even more so than the science of medicine. “We give you a story about the patient, and you do the same in reverse,” she said. “We need to give each other the elevator pitch of what happened with a patient for a good hand off.”

Sweigart is a big fan of communication, too. “You can’t overcommunicate,” he said. “You must be openly and transparently explaining all that’s going on with a patient’s care. We own the transitions process and act as the final decider, and the person who is working with the patients and their families.” 

This may involve levels of uncertainty, but that’s ok, said Sweigart. “Embrace it, often,” he said. “Think about where a path is leading, and when a specialist thinks differently, work together.”

Ultimately, hospitalists are the coordinators of care, said Abraham. “We ensure that everyone is talking to each other — we are the common thread,” she said. “We relay that one message of plan of care to everyone because we see patients as a whole, not just an organ system or specialty.”

With this unique view of a patient, hospitalists should learn to defer as little as possible, advises Sweigart. “It’s ok to double check or read more about the patient’s conditions,” he said, “but do it tactfully so that you’re maintaining ownership. This lets the patient see that we’re in charge of their care and we’ll work with them for the best outcome.”

Managing complex patients can be challenging — and even a bit scary — but it can also be highly rewarding, according to Sweigart. “Our job is to shepherd through these very vulnerable patients,” he said. “When all goes well, it’s engaging, and even fun.”