SPECIALIST'S CALL QUESTIONED

It was a Sunday in March when Ralph Skewes started acting strangely. The normally sharp-witted church deacon and amateur photographer was tired, confused, incoherent. By evening, with Skewes' condition worsening, his partner dialed 911. An ambulance raced the retired printer to Northside Hospital.

There Skewes' case was taken over by a hospitalist, a relatively new kind of physician specialist responsible for coordinating inpatient care to eliminate errors and minimize hospital stays.

On his fourth night at Northside, Skewes, 65, went into cardiac arrest. On the 11th day, he died.

One of Skewes' regular physicians has filed an official complaint with state regulators, saying the hospitalist failed to call in requested specialists and order needed tests until it was too late.

The hospitalist isn't talking publicly. His employer, Northside, defends him, but won't talk specifically about the case, citing patient confidentiality.

Skewes' partner of 39 years, baffled at the circumstances of his death, has opened his medical records to the St. Petersburg Times.

The case shines a light on a medical specialty many people know nothing about until they are admitted to a hospital. At a time of increasingly complex medical procedures and soaring health care costs, the use of hospitalists is gaining popularity. By orchestrating inpatient care, hospitalists have been able to shorten hospital stays without adversely affecting outcomes, according to one study.

But experts caution that, depending on how such programs are run, there could be drawbacks for patients.

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At Northside, Skewes was diagnosed with "altered mental status" and examined Monday morning by a resident working under the hospitalist, Dr. Joseph Zalocha. Though Skewes was unable to follow commands and had "spastic" hand motions, a CT scan of the brain taken on admission looked normal. The hospitalist decided to monitor Skewes, putting him on IV fluids, using restraints to prevent falls and asking nurses to check his neurologic functions regularly.

"We will obtain an MRI in the a.m.," the hospitalist's initial report says. The records do not show that the MRI was done.

Later that day, Skewes was seen by his kidney doctor, Dr. Abraham Awwad, who ordered that the patient be seen by a neurologist and a gastroenterologist. Awwad wanted a neurologist to do a more thorough evaluation and manage his sedation. Meanwhile, he suspected Skewes' elevated ammonia levels, known to cause confusion, had been caused by liver damage, hence the need for a gastroenterologist.

But Zalocha did not implement Awwad's orders. "He said it was nothing he couldn't manage," Awwad said. Skewes, who was on Medicare, suffered from diabetes and severe anemia, in addition to kidney disease.

According to medical records and his partner, Skewes was put on antianxiety drugs, strapped in a bed and assigned someone to watch him round the clock. A radiologist took an ultrasound of his kidneys, which appeared unchanged. A feeding tube was inserted.

On Wednesday night, Skewes was found on the floor of his room, not breathing, with no pulse. No one could say how long he had been without a pulse, one doctor wrote in the record.

Skewes was resuscitated and put on a ventilator. For the next week, while he lay unconscious in the intensive care unit, he was seen by two neurologists, a gastroenterologist and a cardiologist, among others.

But Skewes never regained consciousness. A second CT scan showed swelling of the brain from a lack of oxygen. He was taken off life support and died March 31.

Derek Raper, Skewes' partner, learned just hours before Skewes had his heart attack that Awwad's calls for specialists had gone unheeded.

Raper still doesn't understand why.

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Northside started its hospitalist program in March. Among those hired was Zalocha, who graduated in 2003 from Ross University School of Medicine on the Caribbean island of Dominica. He completed his residency in internal medicine at Orlando Regional Healthcare in 2007, followed by a two-year fellowship in critical care at St. John's Mercy Medical Center in St. Louis.

There are more than 30,000 hospitalists working in hospitals around the Tampa Bay area and across the nation.

Art Caplan, a professor of health policy and bioethics at the University of Pennsylvania, said the specialty is a response to an increasingly older, sicker population entering hospitals and the need to provide comprehensive care as expeditiously as possible.

"It's a long way from when your family doctor used to admit you, follow you around and was probably there when you were discharged," Caplan said. "That doctor probably couldn't find his way into today's hospital."

The downside is that the patient and family members have no prior relationship with the hospitalist and may feel left out of the discussion.

The trend toward hospitalists "doesn't necessarily address the patient's desire to know what's going on," Caplan said.

A 2007 study in the New England Journal of Medicine found that hospitalists cut the average inpatient stay by 12 percent, while outcomes were similar regardless of whether patients were treated by a hospitalist, internist or family physician.

Hospitals have a variety of employment relationships with inpatient specialists. According to the Society of Hospital Medicine, a professional association of hospitalists, 40 percent of their members were employed directly by the hospital; 42 percent were members of hospitalist or multispecialty groups; and 18 percent were employed by academic hospital medical programs.

At Northside, hospitalists are employed by an affiliate of its parent company, HCA, the for-profit hospital chain. They are paid a base salary plus incentives for working extra shifts and meeting quality goals. Said Caplan, "Quality is a pleasant way of saying you'll make sure errors don't occur."

BayCare Health Systems, the major not-for-profit hospital network in the Tampa Bay area, also uses hospitalists, but they are independent contractors, paid by the shift.

Dr. David Mokotoff, a St. Petersburg cardiologist, was called in to see Skewes six days after his heart attack. He said he has not had problems with hospitalist programs at Northside or other local hospitals. But he sees the potential for concern when the hospitalists' employer is the hospital.

"There may be a little lack of objectivity regarding how to treat the patient," said Mokotoff. "Their focus may be on the length of stay or not ordering tests."

Northside's spokeswoman, Aimee Bennett, said such fears are unwarranted. Hospitalists are "an asset in the delivery of high quality care to our patients." She declined to provide examples.

Though hospitalists may receive bonuses, she said, "These bonuses are not tied to length of stay or the use of any hospital resources."

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Awwad, the kidney specialist, said Skewes' case wasn't the first time Northside staffers have not followed his orders, though it was the first involving a hospitalist. Awwad, who got a degree in osteopathic medicine from Nova Southeastern and completed his nephrology training at the University of South Florida in 1998, recently filed a dozen complaints with state regulators, citing cases of medication or tests not given as ordered. Among them was his complaint about the handling of Skewes' case.

In mid March, state inspectors responded to anonymous complaints about Northside that Awwad said didn't come from him.They found that one patient never received prescribed blood pressure medicine. In another case, regulators found nurses had not performed neurological checks on a patient every four hours as the doctor had ordered. In both cases, the hospital submitted a correction plan accepted by the state; no penalty was levied.

In Skewes' case, the hospitalist was acting as the patient's attending physician, who traditionally has final say over the course of care.

Dr. Andrew Fishmann, a hospitalist for more than 20 years in the Los Angeles area, said there's no rule of thumb on how to handle disagreements between hospitalists and consulting physicians. He said such conflicts usually stem from poor communication.

"There can be disagreements if it's an immature program and there's no understanding of who's responsible for what," said Fishmann, a member of the Society of Hospital Medicine. "It needs to be worked out in advance so patients or families aren't caught in the middle."

Fishmann said a hospitalist might postpone specialists' consults because he's comfortable handling the patient alone. During his career, Fishmann, who is not a hospital employee, said he has never felt pressure from hospitals or insurers to cut back on tests or specialty consults.

"Calling a consultant sooner than later might expedite the patient's discharge," he said. "The most expensive cost in a hospital is a bed day. My incentive is to get patients in and out of the hospital safely and efficiently, because the shorter the length of stay, the better it is for the patient."

The spokeswoman for Northside declined to speculate on why Zalocha did not implement Awwad's orders, calling patient care a "collaborative process."

"All physicians involved in patients' care are responsible to cooperate professionally to assure delivery of patient care of the highest quality," said Bennett, the spokeswoman. "There are formal processes in place that can be used to resolve concerns."

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Two days after Skewes' heart attack, while he was lying comatose in the ICU, the hospitalist sent for a neurologist. Based on a physical exam, Dr. Lisa Flaherty wrote, "Likelihood of a meaningful recovery in this patient is less than 1 percent."

The following day, the hospitalist wrote a note saying he had spoken with Awwad and to "please hold off on consults and please keep the patient's DNR (do not resuscitate orders which had been approved by family members) in place."

Awwad urged Skewes' family to rescind the DNR and call in other specialists. They dismissed the hospitalist and called in a private practice doctor to manage the case. A gastroenterologist found Skewes had a small bowel obstruction as well as a diseased liver which could have been responsible for his initial elevated ammonia levels.

A second neurologist ordered a CT scan of his brain, which showed irreversible damage from the lack of oxygen.

Mokotoff, the St. Petersburg cardiologist, evaluated Skewes, whose heart functions had been normal on his admission to Northside. Mokotoff wrote that Skewes' cardiac issues were "secondary to multisystem organ failure for which there is no good treatment."

Fishmann said people have cardiac arrests all the time in hospitals, "and it may or may not be affected by the specialists they see."

But Awwad is convinced Skewes' outcome could have been different if he had been seen by specialists sooner.

The whole experience was a painful blur for Raper, Skewes' partner.

"It was out of my control," Raper said. "In the end, all I could do was hold Ralph's hand."

Kris Hundley can be reached at khundley@sptimes.com or (727)892-2996.