Attending physician versus hospitalist, insulin management

Diabetes Advocacy Self Advocacy
1

Continuing the discussion from Institutional ignorance can kill us:

@MM1’s reference to the hospitalist’s role in the linked thread prompted me to do some quick googling about what a hospitalist does and how they might influence my ability to manage my own insulin dosing, if capable, while in the hospital.

I learned that the hospitalist is a relatively new profession, only on the scene since about 1996. They are your primary care doctor while you’re in the hospital. If you’re in the hospital for a gall bladder removal, your GI specialist needn’t be concerned with non-GI issues. This makes me wonder if it’s the hospitalist who plays the key role in the typical hospital as to whether I’m allowed to manage my insulin dosing.

Here’s one description of the hospitalist’s role that I found in a registered nurse forum:

rn/writer, RN

17 Articles; 4,168 Posts

Oct 17, 2010

The idea behind the hospitalist is that they can coordinate a person’s inpatient needs better than an attending MD. Yes, the primary care doc knows the patient’s history, but many people have more than one doc, and covering all their needs can become complicated.

For example, if someone goes in for a gall bladder surgery, they may need their cardiac and diabetes meds while they’re inpatient along with any other home meds they take. Their primary doc will not be the one admitting them. The surgeon will. So who orders all the stuff not related to the surgery? The hospitalist. Who will come to see the patient for anything not pertaining to the GI situation? The hospitalist.

The hospitalist team is generally available 24/7. They can call any of the patient’s docs if a consult is needed. And they’ll get through more easily and have their calls returned quicker than the patient would.

Many specialists tend to have tunnel vision for their area. A hospitalist is supposed to be looking at the big picture and providing coverage for the whole person, not just the area of concern at the moment.

I have a relative who periodically goes in for complex ortho or neuro-surgery. Do you think the orthopod or the neurosurgeon wants to order his laxitives and his asthma meds? They will if need be, but they will only order what he’s already on. If something new crops up during his stay, they just want to refer to someone else. The hospitalists now cover the situation, and it’s a whole lot easier to get things accomplished.

Someone else in my family also had surgery a while back for a broken ankle. The surgeons did not want to be responsible for ordering diabetic meds and were actually going to send this person home a day early because they didn’t want to prescribe the wrong things. The hospitalist saved the day and took care of both patient and docs.

In my experience, hospitalists are a great innovation that can spare the docs some headaches and get patients what they need in a timely manner. They also know their way around the hospital and can make things happen in a way a typical attending can’t usually do.

Edited Oct 18, 2010 by rn/writer

I’m thinking that the role of hospitalist, being a relatively new profession, might be more open to partnering with certain diabetes patients to allow them to continue insulin management, if capable. Since the hospitalist profession is relatively new, that likely means that it is staffed by younger and perhaps more flexible doctors open to the idea that a diabetic may be the most experienced and best person to make insulin decisions.

In the linked thread, it was @cardamom who identified the attending physician as the key player in the patient/hospital interaction with deciding who best to manage insulin in the hospital. Perhaps it is the hospitalist who might be our natural ally to safeguard our ability to make insulin decisions, when capable. I wonder what s/he, and others, think about the dynamics of the hospitalist in this scenario?

2 Likes
2

Again, it’s not attending physician vs hospitalist; that’s like asking if you want your food to be flavorful or warm. Two different/orthogonal levels of specification.

Attending: level of training/seniority. This is relevant particularly in teaching/academic institutions, which many major hospitals are. Attendings are fully fledged professionals in whatever specialty. In contrast, residents are recent graduates, so they have an MD, but are still in training as a specific specialist. Fellows have graduated from residency but are obtaining additional specialized training, so more advanced than a resident, less than an attending. You will always have an attending who is leading the team; that is the physician ultimately in charge of all decision-making. That is why you want to speak to the attending directly if you get a no from any staff who reports to them. Again, these ranks apply to all specialties you encounter–if in the hospital you see anesthesia, there will be an anesthesia attending, fellow, and resident most likely.

Hospitalist: a particular role/specialty within the hospital. Doctors are not only hospitalists, but rather this is a newer specialty that they can train in in addition typically to being an internist.

1 Like
3

Please excuse my layman’s understanding of how hospitals work. You appear to have real world insight into the hospital hierarchy that I do not.

From the little that I’ve read about the emergence of the hospitalist role, I realize that different hospital systems fold them into their culture differently.

I’m concluding from your perspective that the attending physician is the ultimate and clear authority about whether a patient will be able to participate in their insulin dosing. In your view of things, any hospitalist will report to a hierarchically superior attending doctor. Do I have that right?

Is it possible that an attending physician may routinely delegate these matters to a hospitalist?

4

I don’t think I’m being clear. A hospitalist can be an attending. “Attending physician” is not an alternative to a hospitalist. It’s a question of content (hospitalist, endocrinologist, anesthesiologist, surgeon, etc) vs rank (attending, fellow, resident, med student). Attending is literally just a rank of seniority. Most of the time in a hospital, you are not interacting with attending level physicians, but rather the residents and fellows on their team, who meet with you and report back to the attending to make decisions. You may only very briefly meet the attending sometimes; sometimes not even at all on certain shifts and in certain situations. My point is whatever specialty you are dealing with, including hospitalist, you may be getting told something by a resident or fellow or even nursing staff. If they are saying no to something you think is important, you should ask to speak directly to the attending (you can say attending, or attending physician–physician here is just a synonym for doctor, all attendings including hospitalist attendings are “attending physicians” by definition). So first step when getting a no is to clarify what role the person has on the team if you aren’t sure. If it is anything except attending, asking for the attending is the medical equivalent of asking to speak to the manager, whatever the specialty you are dealing with is.

So my point is the premise of your question and of the thread title is flawed (very understandably as these things are complex and often not clear to lay people). I work in academic medical centers and have worked on these teams, so yes, I am trying to pass along insider insight into how to advocate for yourself in these settings.

3 Likes
5

Thank-you for this clarifying comment. Your message was not as clear to me in the previous comment. I now see the flaw in my title but will leave it for now for the sake of continuity.

Just so you know, a few years ago I reached out to my regional teaching hospital to gain a better understanding of how decisions affecting my ability to treat my own diabetes if admitted to their hospital.

I ended up communicating with the hospital ombudsman office and after many phone calls over many weeks, I had no better understanding of the questions I posed. It was as if they did not want to talk about a hypothetical situation. I gave up pursuing the inquiry.

I don’t think that the current hospital system understands just how vulnerable people like me feel. And I don’t think that they duly respect the level of knowledge and expertise that some of us exercise day after day, year after year.

If my physical and cognitive capacities are working, the average medical professional can not even begin to approximate my ability to dose my own insulin. Their value judgments regarding insulin management are flawed as they overweight avoidance of hypoglycemia as an over-riding emphasis. That reality alone disqualifies them from taking over my glycemia, especially in the hospital.

I thank-you for the insight that you give to me and other readers here.

By the way, I should know this since you’ve been participating here for many years, but I don’t. Will you share what your connection is to diabetes, @cardamom?

6

Cardamom - I understand what you are saying, but I think that mostly applies to teaching hospitals. In small community hospitals, interns and residents do not see patients, rather, the patient’s care is totally in the hands of either the pcp, the hospitalist, or (in the case of special surgery like knee replacement) the admitting surgeon.

I love my local community hospital and the main reason is that when I’m there, my pcp who is also my endo is always in control of managing my diabetes. His way of managing it is to write in my chart that “patient is in charge of managing her diabetes, bg tests, and administering insulin.”

On the one occasion that I ended up in the ER with a stroke, I was admitted and put under the hospitalist’s care for the first night. She insisted on taking my pump off, and I was too aphasic to argue with her. My wonderful pcp came in the next day, threw a fit, and got his PA to come in and reattach my pump.

Unfortunately, my local hospital got flooded out two years ago and is in the process of being totally rebuilt, so I hope I don’t need a hospital for at least the next two years.

2 Likes
7

At my hospital when I am admitted say for a surgery, the surgeon takes care of the main reason i am there and the hospitalist deals with all else.

Unless my endo is invited in by the hospitalist into the case they manage the insulin pump. That seems simple. right?

Well my hospitalist the last two times did not believe in long acting insulin, carb coverage or giving me my pump. same guy twice. I had to ask the surgeon to request my endo be brought in. At one point I had gone 32 hours with no insulin.

Yeah never again.

8

That is horrible! What are you going to do if you ever have to have surgery again Rphil2?

9

Ugh! That certainly motivates stashing some emergency insulin in your personal kit.

2 Likes
10

The first one I was in surgery / ICU for 29 hours post-surgery, so there was not much I could do. Immediately when I got out, I called my endo. It took 3 hours and an argument between my endo and the hospitalist to get insulin.

The second time, the same hospitalist, I was only in for 28 hours total. I called my endo on call, and by 5:00 AM, I had insulin, and I was out at 1:00 PM.

How will I stop it in the future? I will not allow them to tell me they have it. My endo will be more aware, and I doubt my wife will ever leave the room until she knows the BS is under control.

3 Likes
11

To ask the question, why the hell do they print detailed carb counts on the menu if you are going to give me 1.5U per meal of fast-acting insulin regardless of my BS or what I eat? When you explain that, I will be silent and go along to get along.

I was not silent.

3 Likes
12

You will never go low on their watch! If they gave me 1.5 units of insulin, I could eat a tablespoon or two of peanut butter or a four ounce steak. Or you could just tell them you’re not eating until more insulin shows up. Most of us can afford to miss a meal or two.

13

Same Terry, I usually run between 50 and 60 U per day in my pump. The first time I was a tad over 400 when the insulin arrived, the second time over 300. I sure as heck was not going low anytime soon.

They brought in 1.5 U for dinner 4 hours post-dinner, and I refused it. Saying take that 322 BS and correct that. Forget giving me 1.5U for dinner 4 hours ago. The hospital responded by saying I would need to wait until breakfast for insulin since I refused the 1.5 dose at 11 PM.

The poor management of T1 in hospitals is off the charts. I am not a tough guy to get along with. I like the hospital. I go there each time, and they employ all my doctors.

Good lord almighty.

3 Likes
14

I don’t really think it is safe to be in the hospital without having someone along who can watch what is going on, question what meds are being given if the patient can’t speak for themselves and speak out for us if our diabetic needs are not being met.

I know that when my parents were older, I would be that extra person, even if it meant spending nights in the hospital. Now that my husband and I are older when one of us is in the hospital we are both there for the most part.

4 Likes
15

I have T1D, dx age 10, now approaching middle age.

Yes, as I think said at some point (may be in the other thread this was pulled from), definitely mostly relevant for teaching/academic hospitals, which many larger hospitals tend to be. However even in smaller settings, sometimes you get a no from a nurse or someone else because something is the default practice; in those cases, definitely ask to speak to the MD in charge. And my original point was also about asking that person to document the refusal in the medical record; that part is even more important.

3 Likes
16

@Rphil2 – Since you’ve had more than one instance of stingy insulin administration in the hospital, I’m curious about one thing. Since almost all of us who use insulin are rarely separated from our insulin kit, how was it that you didn’t have access to your own insulin in these situations?

Did you surrender your kit to the hospital? Was your wife prevented from bringing in some insulin to rescue you from persistent very high blood glucose?

1 Like
17

So the first time I knew I was going to ICU post surgery and would be incapacitated for a fairly long period. We (my wife and I) decided to give up the pump, since there was no way I could run it reliably.

The second time I knew it would be overnight and I figured worst come to worse it was about 24 hours. I mean how much harm could the hospital do? Well turns out a lot when the doctor says look I am not happy releasing you until we have the BS under control.

24 hours or not, my BS at such high levels I wanted it fixed. My wife had to leave once i was awake post surgery (again 24 hours seemed like a short time).

So the first situation I would still have given it up, but the second will never happen again.

I recall what my family used to say: Since about 70% of all US deaths occur int he hospital- stay the hell out of the hospital.

I really have no idea how may people die in hospitals but it is fun to say that.

1 Like
18

Bring your own insulin. Inject your own insulin at your own schedule. There is no way a doctor or nurse is going to wrestle it away from me.

1 Like
19

I think as long as you are not on strong pain meds, and able to think clearly, this would work for most.

My last hospital stay was just one overnight, and there was no issue with me dosing and wearing pump. The only problem was the food police tried to limit my choices, but i brought plenty of my own food anyway.

But had previous stay with IV insulin during extended (robotic assisted!) surgery that also went well. IV insulin and glucose continued until day after surgery, with constant pain meds/drip. Then moved to “normal” wing, and was on my own, although they wanted to see my logs, and had required endo to approve prior to agreeing.

2 Likes
20

After a hospitalists tried to kill me by ordering a “standard” 20 units of regular insulin for a single meal (which I adamantly refused since my TOTAL insulin for one day is usually 18 - 21 units), I was ready to check myself out. The medical professionals argued, but I told them I either would take my own insulin or I would leave AMA. They finally agreed to let me go. I contacted my endocrinologist who said to NEVER go into the hospital without letting her know, and that I should insist she be “on call” in an advisory status for any procedures I might face. We all are SO unique with our own special needs that no hospitalist has the time to learn what we need. If you are going to be incapable to managing your own diabetes, then have a relative or friend who can advocate for you.

7 Likes