The Hospitalist’s StoryThe Hospitalist’s Story

Over the telephone, the patient sounds typical of our county hospital clientele: a homeless drinker with an ejection fraction of 19% and a triad of recent hospitalizations for his failing heart. He stays at a shelter near the city's fashionable bars. Three days ago he began coughing and developed a fever, the emergency department physician tells me. The last discharge note had him taking the usual cocktail of cardiac medications, but like many of our recurrently hospitalized patients, he hasn't filled the prescriptions or visited a primary care physician.

The emergency physician coaxes: “He's a real nice guy. How about dry him out and send him on his way.” I check the x-rays on the computer as I listen, noting the pleural effusion and pulmonary edema, neither of which are new.

The patient's name is Marv. I meet him when he arrives on the hospital floor. He is bone thin with a canary yellow hair pick planted in his Afro. His long legs stretch to the end of the mattress. I wonder whether his malnutrition can be attributed to his peripatetic wanderings; maybe something gnaws slowly at him. He seems sober enough. We talk about the cough and the fever, and listening to the corner of his chest I hear what is unmistakably a gallop. He lies back, sits up, lies back, and turns his head left, as I watch his neck veins fill and refill.

“Are you drinking?” I ask.

“No, I quit.”

“When?”

“Today.”

“Okay. We’ll give you intravenous medicine for your heart.”

“You do what you need to do.” He is nice. I wonder why he doesn't go to a primary care physician, who might have prevented this decompensation.

In the afternoon, the chief resident sweeps in with a pack of medical students, all neatly groomed and smiling shyly. The patient sits up, lies back, sits up, lies back until all hands and stethoscopes have discovered the rales and the S3, watched the internal jugular vein pulsate, percussed the lung fields. As the students circulate about the room, I think about the pleural effusion. It's old; it's probably from heart failure. But he does have a fever.

“I’m soaked every time I wake up,” Marv says as I unwrap the thoracentesis tray. I nod, pull on sterile gloves, and paint his skin with a shining, translucent coat of antiseptic. Pleural fluid draws smoothly into the syringe; it is the color of rubies. I press my lips together.

“Now that feels much better,” Marv says. “Didn't hurt one bit.”

The fluid lymphocyte count is suggestively high, which means tuberculosis until proven otherwise. The nurses hustle him into respiratory isolation; I tally up the dozens of PPDs to be placed if he proves infectious. Marv seems unruffled. He coughs specimens into the plastic sample cup, screws on the lid, writes his name on the jar, and rings the nurse's bell. I order four antibiotics.

When I’m in to visit him with the results a day later, he's moving easily around the bed, tucking in his sheets. He wears a terry cloth headband.

“I know how busy it gets for the nurse,” he says. He finishes making his bed and tells me that he hasn't talked to his family in years, but he's going to call his daughter today.

“I have some news for you,” I say. “You're not infectious.” The sputum samples don't show any acid-fast bacilli; the pleural fluid does.

“Thank the Lord!” he declares. “You all taking such good care of me.” He seems genuinely relieved.

“You have to take antibiotics for nine months.”

“That's all right!”

“And the water pill for your heart.”

“That's all right!”

“What about your drinking?”

“I quit. I’m done with that.”

“AA?”

“I can do AA.”

“I asked the social worker to bring a list of AA groups and a list of treatment centers.”

“Yeah, that would be good. I can do Tuesdays or Thursdays.”

I say, “What you really need is a primary care doctor.” And as it happens, I have my own primary care panel, which makes me a hospitalist with a clinic who tries to think like an old-fashioned general internist. Or more accurately, a hospitalist whose parochial tendencies are checked by her outpatient practice. This is a useful arrangement in an enormous county hospital system with limited outpatient staff and a two-month wait to establish care. I’ve brought a handful of “difficult” or “noncompliant” patients into my clinic, patients with a track record of using the emergency department and hospital as their only source of medical care. So far, the “noncompliant” patients seem to materialize for their appointments, like a young man who I cared for during his third successive hospitalization for intractable vomiting last year. He comes to clinic every three weeks and has remained at home since discharge, ill as he is with end-stage cancer.

Outpatient practice helps me recognize a certain continuity in hospital medicine. Twenty-five percent of our inpatients are admitted on a regular basis; a number of these have no primary care physician. I know some of these inpatients as well as I know my long-term outpatients, and I’ve often wondered whether a different patient-physician bond develops in the hospital. The hospital bond feels deeper than two people sharing the patient's dramatic story of recovery from illness; maybe the relationship turns on the patient's vulnerability in the hospital, the acute illness and physical weakness, the separation from clothing and possessions, the embarrassing admission that he's confused about his disease and medications after all.

And so Marv and I bonded in the hospital, and maybe he’d go to the primary care clinic of a physician he already knows. But there's a glitch in this plan: my clinic is limited to refugees. Giving him a slot means taking one from someone who requires an interpreter and uses culture-specific services, so I discharge him with follow-up in the adult medicine clinic, where the next person to care for him, a resident or midlevel, will learn of him from a computer. If he shows up for that, he’ll get a second appointment with someone who could become his permanent primary physician. Marv says he understands. As he heads out the door, he reminds me that he's finished with drinking.

I learn of Marv's death some months later from the coroner, who telephones to say, “We need your signature.”

“I’m sorry?”

“He was found in his hotel.”

“I’m the hospitalist.”

“The family needs a doctor's signature to claim the body.”

“Who's his primary care physician?”

“The family says it's you,” the coroner says. I access the computer record and click on the primary care provider tab, which says NONE. Indeed, I am the last to have seen him, a year prior. I feel sad now for what Marv suffered, and frustrated, because Marv may have died of something an internist would know how to treat. Why didn't he follow up? Maybe I should have bypassed the appointment system, put him into my clinic as an African refugee perhaps, until the county hospital's outpatient world became familiar and he could move elsewhere.

I’m frustrated because hospitalist practice can reinforce a disconnect with the outpatient setting, and this disconnect is particularly challenging for indigent patients. As a hospitalist, I can say that the path of least resistance is to call Marv “noncompliant” and put the responsibility on him, to shrug over the formidable barriers that indigent persons face in accessing health services: limited primary care appointments, long waits, constantly changing clinicians, lack of transportation or telephone, inadequate education, and illiteracy. Did the hospitalist model not make sense to Marv? Did he think that hospital discharge meant his physicians didn't want to take care of him any more?

Now the coroner puts Marv’s daughter on the phone. We agree to meet shortly, so the family can get on with the business of burying Marv. After work I ride the bus through an old, decaying neighborhood, noting the scaffolds, the fresh paint. My stop arrives; I cross the street and stand by Ezell's Fried Chicken with groups of teenagers, their gym shorts hanging loosely. I savor the warm, salty smells, eye the steaming packages that leave with customers. A young woman approaches.

“I’m the daughter,” she says, shaking my hand. In her I recognize his hair and soft mouth.

“He was one of our favorite people. We never forgot him. We always wondered what happened to him.”

Marv died in his sleep, she tells me. She’d seen him a lot lately, and they’d gone to church together. He had recovered from tuberculosis and had quit drinking for good.

“It was his time,” she says.

“He was young.”

“He was ready to go. He had made his peace.” She is resolute.

I take and sign the death certificate, and I say, “It was a pleasure to be his doctor.”

“Thank you. You're probably really busy,” she says. She closes the folder around the document. As she hurries off into the cool spring evening, I remember, for some reason, that Marv made his own bed at the hospital. I think of how, for him, his doctor was the person he chose, and I think of how he chose without regard for his specific kind of sickness and without regard, even, for what his doctors recommended.

Editor's Note: The two authors shared in the care of the patient and created the manuscript together. It was written in the first-person singular for ease of reader comprehension.