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The Hospitalist Movement

A popular media view of the hospitalist movement

Wednesday, February 01, 2006

Skeptical as I am about the media’s handling of health care issues I found in this newspaper article form Colorado an interesting and balanced portrayal of some of the tensions between the hospitalist model and the traditional primary care model. It profiles a hospital in Fort Collins Colorado with a 5 physician hospitalist team. Like most programs it appears to be a voluntary program—primary physicians can follow their own hospitalized patients or turn them over to hospitalists.Although the hospitalist program is generally well received there many family physicians continue to see their own patients across the continuum of care. Among them is family physician Mark Paulsen, chief of staff of the hospital, who believes that is “part of his personal vision of what it means to be a family doctor.”I’ve stated my personal views about this before. The availability of a hospitalist program offers physicians an option. Those who feel they can maintain skills adequate to meet the ever increasing complexities of hospital medicine alongside their ambulatory practice should continue to care for hospitalized patients.

posted by R. W. Donnell @ 9:16 PM

Hospitalists - pros and cons

My regular disclaimer - I function as an academic hospitalist, attending on the VA wards 4 or 5 months each year. I no longer have an outpatient practice.Dr. RW has accomplished a difficult task - giving a balanced view of the hospitalist movement - A popular media view of the hospitalist movement

Skeptical as I am about the media’s handling of health care issues I found in this newspaper article form Colorado an interesting and balanced portrayal of some of the tensions between the hospitalist model and the traditional primary care model. It profiles a hospital in Fort Collins Colorado with a 5 physician hospitalist team. Like most programs it appears to be a voluntary program—primary physicians can follow their own hospitalized patients or turn them over to hospitalists.

The article - Doctors find sole niche at hospitals

The hospitalist movement has advantages and disadvantages. Many patients do get better inpatient care when they have a dedicated hospitalist. I believe this is most applicable to comanagement of surgical patients.

This newspaper article does a very nice job of defining the opposing possibilities. Certainly we do a better job of the discrete hospitalization (on average) when we have more experience in the hospital. However, the patient’s care after hospitalization may suffer compared with the traditional model.

My only fear, as the hospitalist movement matures, is that family docs and internists will retain the option of doing both hospital and outpatient care. If we lose that option, then the hospitalist movement will have caused important harm (in my opinion).

Posted in Medical Rants February 2nd, 2006 by rcentor |

2 Comments

  1. I’ve been trying to not comment on this post, but I just can’t help myself. A few months ago, I wrote to another hospitalist blogger about my thoughts on this issue.Although I can understand the practical advantages of the “hospitalist” movement, as a patient, I’m not at all fond of it.When someone is at their sickest, more than likely a bit frightened … is exactly when they most want to feel that they are in the hands of the person they’ve so carefully chosen for themselves as their primary care physician. They’ve developed a working relationship with their physician, and share a mutual trust and understanding - this has taken time and effort.Being in a hospital, under the control of other people, sick, in pain, frightened, and then having to open up and be candid with someone you’ve never seen before, and trust that person completely … is a real challenge for some of us.Our local hospital has led the way in our area - there are a half dozen hospitalists, almost all of them are foreign, and I can barely understand them when they talk.Ever since I realized that my own physician would no longer see me when I’m admitted, I’ve stopped seeing him. The entire idea is just too threatening to me. I’ve been told that all of the physicians at my hospital are doing the same thing now, and so I’ve been considering going to a different hopsital - nearly 20 miles away … and perhaps trying to find a PCP down in that area instead … except that I have feeling that the “hospitalist” model is going to spread to all of the local hospitals now that it’s begun, so it may not be worthwhile to bother.

    I believe that, under circumstances when it’s possible, patients should be given an option of whether they will accept the care of a hospitalist over their own PCP, since the patient is fully half of the equation in the physician/patient working relationship. You might be surprised how many opt out of being cared for by hospitalists when given a choice.

    I feel strongly enough about this subject that I will simply not see a PCP again … since when I need him most, I now know I’m going to end up with a stranger anyway. Over the last year or more, I’ve discovered that I’m not the only one who feels that way. Most of us haven’t said anything to our physicians, we’ve just stopped seeing them.

    The hospitalist model would be fine - if it were optional, not only from a physician’s perspective, but also from a patient’s perspective. It’s great for those who don’t have a PCP, or with a PCP who is on vacation … or to deal with inpatient emergencies when the PCP can’t be there. Otherwise - the patients also need to be allowed to make a choice.

    In my opinion, this is just another thrust toward the depersonalization of medicine from the patient’s perspective, and it will help widen the gap in the patient/physician partnership. Continuity is destroyed, communication falters …

    Comment by Moof — 2/3/2006 @ 10:19 am

  2. the above commentor chooses to personalize the issue. It is well she should.Primary care doc’s are too overwhelmed with patients to do hospital work.the “thrust for depersonalization” is reaction
    to the fact that we live in a society where decisions for care are made based on economics.sadly, this is the way the world works. Economic pressures affect everythingComment by primary care doc — 2/3/2006 @ 6:53 pm

Listen to Moof comment on the hospitalist movement

While this resides in the comments section, I believe the message is so valuable that it also belongs in the main area of the blog. Thanks greatly for your thoughts Moof

I’ve been trying to not comment on this post, but I just can’t help myself. A few months ago, I wrote to another hospitalist blogger about my thoughts on this issue.

Although I can understand the practical advantages of the “hospitalist” movement, as a patient, I’m not at all fond of it.

When someone is at their sickest, more than likely a bit frightened … is exactly when they most want to feel that they are in the hands of the person they’ve so carefully chosen for themselves as their primary care physician. They’ve developed a working relationship with their physician, and share a mutual trust and understanding - this has taken time and effort.

Being in a hospital, under the control of other people, sick, in pain, frightened, and then having to open up and be candid with someone you’ve never seen before, and trust that person completely … is a real challenge for some of us.

Our local hospital has led the way in our area - there are a half dozen hospitalists, almost all of them are foreign, and I can barely understand them when they talk.

Ever since I realized that my own physician would no longer see me when I’m admitted, I’ve stopped seeing him. The entire idea is just too threatening to me. I’ve been told that all of the physicians at my hospital are doing the same thing now, and so I’ve been considering going to a different hopsital - nearly 20 miles away … and perhaps trying to find a PCP down in that area instead … except that I have feeling that the “hospitalist” model is going to spread to all of the local hospitals now that it’s begun, so it may not be worthwhile to bother.

I believe that, under circumstances when it’s possible, patients should be given an option of whether they will accept the care of a hospitalist over their own PCP, since the patient is fully half of the equation in the physician/patient working relationship. You might be surprised how many opt out of being cared for by hospitalists when given a choice.

I feel strongly enough about this subject that I will simply not see a PCP again … since when I need him most, I now know I’m going to end up with a stranger anyway. Over the last year or more, I’ve discovered that I’m not the only one who feels that way. Most of us haven’t said anything to our physicians, we’ve just stopped seeing them.

The hospitalist model would be fine - if it were optional, not only from a physician’s perspective, but also from a patient’s perspective. It’s great for those who don’t have a PCP, or with a PCP who is on vacation … or to deal with inpatient emergencies when the PCP can’t be there. Otherwise - the patients also need to be allowed to make a choice.

In my opinion, this is just another thrust toward the depersonalization of medicine from the patient’s perspective, and it will help widen the gap in the patient/physician partnership. Continuity is destroyed, communication falters …

Posted in Medical Rants February 3rd, 2006 by rcentor |

7 Comments

  1. I am a neuroradiologist at a busy suburban hospital. I get a wonderful lateral view of health care at my hospital. I can tell you which doctors are good, which are top notch (the ones I send my family to), and which are in neither category.We have some excellent internists and surgeons. Unfortunately, the hospitalists are a notch below, although with a few bright exceptions.Why did this happen? Try looking at the most powerful motivator, money. What is the reimbursement for inpatient care? Certainly not in the league with surgical fees, outpatient visits, cardiac testing, or endoscopy fees.If there were a groundswell of support to have internists and surgical specialists provide hospital care to their own patients, and not farm it out to hospitalists (or even PA’s), this could be done with regulations, evil as they are. Increase the fee for inpatient care (unlikely to happen in this cost-cutting age), or tie the fees for more expensive procedures to the admnistration of inpatient care. I don’t know exactly how to implement this.

    I will say that most family docs are far removed from providing inpatient care, but then, by the time the patient is in hospital, usually a specialist is on board.

    By the way, we don’t see any pediatric hospitalists, do we. ALL of the local pediatricians provide inpatient care to their patients when the rare hospitalizations occur. and they seem good at it. Appropriate specialists are consulted, such as pulmonologists or surgeons, but you always see the pediatrician follow the patient, as well. What a great relief for the parents.

    Comment by AKS — 2/3/2006 @ 2:27 pm

  2. I agree that a hospitalist is not my first choice of who will see me in the hospital. I am an RN and appreciate the hospitalists for what they do for nursing staff and the primary MD’s. However, I had a small stroke and was in the hospital overnight and had this person, who was at best impersonal and in a great hurry, deal with me and he was not a great help to me at all “see your primary when you leave”. No referral to neurologist, no referral to Physical therapy,and after I asked, he offered a OT referral. (I could not handle my fork with my right hand.) I felt he was very dismissive of what for me was a traumatic event. I have permanent disability, an went through a period of severe depression which is very common. It would have been nice to have his perspective on what I could expect. Instead, in his d/c summary he wrote that I was very anxious. Well, after 3 mds, 2 ers and 38 hours after my stroke, someone finally believed me that I was having a stroke (when they were able to see the actual damage on a head CT….). I think he would have been anxious too!Comment by CMS — 2/3/2006 @ 3:46 pm
  3. why are hospitalists becoming so common?it is the same reason why physicians choose not to work in primary care.it is economics.did you know that the large majority of hospitalist were working as primary care docs but quit outpatient care due to the frustration of having to see people on a 10 minute allotment?

    hospitalists are paid much more per hour than primary care docs are. so why the surprise?

    did you know that there is a huge drop in the numbers of doc’s training to become primary care docs?

    why? economics.

    it is the same reason why doc’s choose to become specialists such as Gastroenterologists, cardiologists, pulmonologists, radiologists,dermatologists etc….

    no mystery here.

    Comment by primary care doc — 2/3/2006 @ 6:45 pm

  4. With respect to the first comment by AKS: I have a good deal of experience working with PEDIATRIC hospitalists. I can assure you they are alive and well. Based on my interactions with both adult and pediatric hospitalists, I have to say that I am much more satisfied with the care rendered to my pediatric patients. I find the hospital based internists all too ready to hand off responsibility for the patient to whoever is the easiet target. The pediatricians on the other hand take a great deal of pride in owning their little patients and championing their cause to any and all specialists they call in to assist in the management of these children. This discrepancy has not been explained away to my satisfaction. This has been my admittedly limited experience in two large community hospitals over the course of some 15 years. My observations may not hold true in other settings.Comment by Dr. Kranky — 2/3/2006 @ 7:30 pm
  5. About a decade ago, when they introduced the hospitalist concept into our group, it was optional. I was vehemently against participating, feeling that it would interfere with my relationship with my patients. I feared that I would lose something w/o directly experienceing the admissions. And, in many cases, I was proved right.However, when faced with the strong possibility of a third miscarriage in little over a year, I abdicated. My patients were important, but so was my unborn child. Shortly thereafter, the HMOs with which we worked made it mandatory, for the HMO patients at least. We had some say (but not a lot) over the choice of hospitalist. For the patients not governed by those HMOs, we cobbled together various constellatins of coverage. Some were in house docs, taking a week off to round in the hospital. That was usually good, albiet uneven. For a while, we had a hospitalist who took loving care of my patients. She treated them so well, that my patients fell in love with her. She was quoted from the altar at the funeral of one of my patients. But, she burned out. It is very hard to find someone who takes the care of my patients as I would.So why don’t I sign up to be a hospitalist? Because a) I value my office practice & my patients and b) I have a husband & small kids and they need me too. And, sad to say, I’ve gotten rusty. Hospital care is something you have to practice to remain sharp at, same as any other job. When you don’t use those muscles for a few years, you are not as efficient and constantly fearful that you’ve forgotten something.To make this work welll, there has to be some communication between the in-house & out-house docs. I try to see my folks while in the hospial, to at least reassure them that I’m in the loop. And they are reassured that I’m in on it. It has worked to my satisfaction, when the hospitalist calls me daily & we work as a team. It fails dismally when the hosptalist doesn’t bother to call & gives only the bare-bones info.It is not perfect. But, boy is it the fashoinable thing to do!!!!Comment by V — 2/3/2006 @ 7:34 pm
  6. “almost all of them are foreign, and I can barely understand them when they talk.” Moof, this is why I stopped going to the Vetrans Hospital for care. The VA budget cuts have driven away most good physician, I have chosen to do without health care rather then beg for medication with someone I can not understand and who obviously has no interest in providing Military Vetrans with treatment.Comment by Wm H — 2/3/2006 @ 10:38 pm
  7. Wm H-I’m a little surprised to hear you say that, most people I know have been very happy with the improvements made by VA over the last several years. How long had it been since you went there?Comment by Anne, NREMT-P — 2/5/2006 @ 8:59 am

Hospitalists - This Patient’s Take

February 3rd, 2006 at 3:47 pm by Moof

Usually, I like keeping the really serious stuff off from the front of my blog. I’m a persistent comment dropper … especially when I think I can sneak in a word or two on someone else’s blog … particularly if they touched upon something I’m intensely interested in. Some pretty engaging conversations can take place in comments - virtually invisible to visitors unless they stick around and do a bit of exploring. Also, I don’t mind occasionally posting something that evokes a bit a thought on my own blog … but I generally try to keep the controversial stuff off from the front page. I’m going to break that rule today.Earlier today, I posted a comment on Dr. R. Centor’s Medrants. Yesterday, he put up a post about hospitalists, and was asking for people’s input. I’ve commented on hospitalists before … and was really drawn to doing so again - but had decided to keep my distance. When the same post was still at the top of his blog this morning, it was more than I could bear, and like a moth is drawn to a flame, I fluttered in close enough to get a whiff of singed wings.It seemed like only a few moments after I’d finished that my Bloglines warner beeped at me, and I checked to see who had just posted … it was Dr. Centor … and here was the title: “Listen to Moof comment on the hospitalist movement.” There was my entire comment - as a post. - Oh my. Caught! Red faced. - So much for a low profile.

Once my face stopped burning, I decided that he may actually have done me a favor … the ice is broken now, so why not write what I think about issues that concern me? Why not indeed. So - here goes. Those of you who only drop in for Bean Stories and light Musings can consider yourselves forewarned …

A few years ago, I was diagnosed with a chronic illness. It’s given me some ups and downs, and for a while, it seemed as if I spent more time as an inpatient than as an outpatient. Our hospital had just started using hospitalists, and on my second time as an inpatient, I was dismayed when I only saw my own doctor once - more as a “guest” than a physician. It was not at all comfortable dealing with this new fellow who’d been dropped on me seemingly out of nowhere, even if he was very nice, and seemed to be a good doctor. I didn’t know him.

Before I continue, just a bit about myself to set the atmosphere … I’m one of those people who is not comfortable with the physician/patient venue. In fact, before my chronic illness, I had seen one in 16 years … and if I had not gotten ill, it would now be over 18 years. After I was diagnosed, and it finally got through to me that life was simply not ever going to be the same again … that I was going to have to deal with these fellows in the white coats whether I wanted to or not, I tried to put a good face on it and do my best to be a “good patient.” I hope my PCP never sees this blog … he’d probably have an aneurysm from laughing so hard. But I did try … I still try. It took some major effort on my part to even begin being candid with these people whom I don’t know. With trial and error, I found that I did better with writing than I do nose to nose … but then I still had to overcome the obstacle of letting the dear man know that I had written something. *sigh* I know that not everyone faces the same problem with being forthcoming with their physicians, but in my own case, I had to work very hard at developing some sort of relationship with my PCP … and with the other specialists which I had to see. To more or less of a degree, I’m certain that most patients have to work hard to learn to be candid about intensely personal things with people they don’t know …

You can perhaps begin to get an inkling of how difficult it would be for someone like myself - and others who have similar difficulties, and even some who don’t - to cotton to the idea of hospitalists. Yes, I can understand the logistics behind the position … it really does free up the PCP for spending more time with his patients in his office … more time with his family … and the inpatient benefits from the promptness of the medical attention/decisions they need without having to wait until their own physician can get away for his hospital run.

That said - there are some other issues to consider. I will briefly touch upon some of them, in no particular order:

  • When a patient is at his worst, sick, in pain, frightened, perhaps uncomfortable at being under the control of other people, is exactly when he wants the comfort and security of seeing the doctor he’s so carefully chosen for himself - the one he feels most able to communicate with candidly. During hospitalization is precisely when you want your own doctor. What’s the use of working so hard on a relationship with a medical person if you only see him when you’re well, and as soon you most need him, he’s guaranteed to not be there - you’re going to find yourself dealing with someone who only knows you from a chart and phone instructions … ?
  • The continuity from perhaps years of office visits is broken when another physician takes over the primary care of a patient during such a critical time as when they’re ill enough to be hospitalized. The knowledge the PCP has of the patient isn’t being drawn from except by word-of-mouth or charts, and afterward, the PCP will not have the full picture of what transpired while his patient was in another person’s care. Also, depending on if the patient was comfortable with the experience of dealing with a stranger during his hospital stay, he may even be feeling betrayed by his PCP. This could permanently damage the relationship.
  • There seems to be two basic hospitalist models being used - one which allows a physician to choose to use hospitalists, and another where all of the generalists are using hospitalists. I’ve noted that in the last instance, most of those generalists run offices which are “A Department of Blankety-Blank Hospital.” Fighting having a hospitalist forced on you in the latter case is a bit like fighting city hall - pointless. I want to state that, first of all, physicians should be allowed to choose whether their patients will be seen by hospitalists or not, and secondly, the patient, who is, after all, half of the physician/patient equation, needs to also be able to choose if he will accept the care of a hospitalist. I can appreciate that there will be instances when this will not be possible … however, both patient and physician making the choice of whether or not to use hospitalists should be the standard rather than the exception.

    • And now for a few more personal/quirky considerations:

  • A friend who winters in Florida was hospitalized for nearly two weeks last year. He dragged himself over to a neighboring city, and a hospital he was unfamiliar with, simply because he thought that if he were at that hospital, he would get to see his own doctor. That never happened. In fact, he was told that no, his doctor was not receiving the test results, and no, his charts and so on were not going to be forwarded to his doctor afterward. To this day, he’s still angry over it, and I don’t blame him. He no longer sees that physician.For myself - once I realized that my own physician was always going to dump me on hospitalists, I stopped seeing him, too. Although it’s been more than a year, I haven’t begun hunting for a different one, because I’m afraid that no matter who I choose, it will end up the same way. I’d rather just not see anyone than expend the effort to be intimately open with someone when he’s going to pass me over to a stranger when I need that familiarity the most.How many of you have lost your patients after a hospital stay … and you don’t know why? Did they end up seeing a hospitalist? Did you inquire if they would have preferred to see you? That sort of attrition is going to continue - because the very people who have a hard time dealing with hospitalists are the same ones who would rather vanish from your office, and either see someone else, or no one at all, than confront you. And if they don’t leave, has the trust between you been damaged? Have you asked how they felt about hospitalists? In fact, have any of you even considered asking patients their opinion on such a thing - considering they’re the ones who are going to be forced to deal with the experience?
  • I hope no one is offended by this, but for personal reasons, I choose to not see women doctors. Whether my reasons are good or not from another person’s perspective is immaterial … the fact remains that I am seriously uncomfortable with women physicians. I have nothing against women becoming physicians, and if I were younger and know what I do now, I would be doing that rather than Medical Informatics, but still, I personally can not turn to one with a medical problem. Of our 6 hospitalists, 4 are women. On my next admission, unless I made an issue of things, I could be forced to have a woman doctor. I know that I’m not the only one with this concern … since it comes up fairly often in conversations with other women. Some women want only women doctors … and some do not. I’ve met more women who feel strongly about the issue than I have women who are indifferent. One shoe does not fit all …
  • Of our 6 internists, a majority are foreign. I’m not prejudiced, and have nothing against foreigners. However, if I’m sick, in a hospital, in pain, I want to be able to communicate with my doctor. If I have to make him repeat 4 or 5 times in order to understand what he’s telling/asking me, and then he goes on to misunderstand my inadvertently used colloquialisms, there could be unpleasant consequences … not the least of which is the fact that I’m going to feel as if I can’t make myself understood - a problem I already struggle with where my “English as a first language” physicians are concerned.

    • Medicine is becoming so impersonal … from the point of view of a patient with a chronic illness, that’s pretty scary/uncomfortable/nightmarish. Hospitalists themselves are not the problem … I think that having doctors who are hospital based is a good thing … but I think that if ever a primary physician willingly turns the full care of his hospitalized patient over to another physician, then he needs to ensure that the patient isn’t lying through his teeth about how he feels just so he can get out of the hospital and away from a situation he may find is even more uncomfortable than his medical problem.

    If I’m cultivating a relationship with a dear friend, and the minute I have a problem which calls for a shoulder to cry on, that friend fends me off on someone else they know (It’s ok! They have a lot of experience at being friends!) any previous trust engendered by the relationship is going to plummet.

    Some of your patients don’t just see you as white jackets. Some of us see you as people - and we learn to relate to you as individuals. We are not just seeing you as what you are, we are also seeing you as who you are, and that part can’t be substituted by just any other white coat.

    Archived under Gritches & Groans, Health & Medicine

    7 Responses to “Hospitalists - This Patient’s Take”

    1. wolfbaby Says:February 3rd, 2006 at 10:29 pm I know what you mean about Docters and the trust factor. My PCP is very important part of how comfortable I feel in certain situations. She unfortunatly dosn’t see patients in the hospital. However, if I have to go to the hospital she sends me to the ones she has connections to and she gets all the information and updates and personally talks to whomever when needed. Im not one hundred percent comfortable with this but as busy as she is I understand it. She knows how I am with Docters and if I don’t like them I will not deal with them at all. So she is very careful who she sends me to and if she dosn’t know them well and how they deal with patients she wont send me to them. I was lucky when I had both of my children. My Obgyn works next to the hospital I stayed in, litterly down the hall so to speak, and he came to see me and check on my war wounds lol every morning. My OB is awesome and anytime I have anything done -which has been alot- he is always there to answer any questions even after surgery when most Dr’s take off. He knows I like to have answers as soon as I wake up and I don’t like to wait for two weeks afterwords to find out something. This is very comforting especially given his field. I would honestly feel better if my PCP did the same and fortnatly I have not run into a situation where she was needed like this.
    2. Wm H Says:February 3rd, 2006 at 11:43 pm “Listen to Moof comment on the hospitalist movement.” I went, I read, and I left a comment. I am total agreement with the state of our health care, being a vet. I stoped going to the VA Hospital out of disgust with foriegn doctors.
    3. Shelly Franz Says:February 4th, 2006 at 12:46 am You said what I’m sure many, many patients feel. I myself am where you were before your illness; I haven’t seen a doctor since I was hospitalized for pericarditis before I moved to Illinois. And before that, I hadn’t seen one since I had my son, which was 1996.I finally, though, have health insurance (no matter how temporary it may be due to the sale of Jewel to SuperValu), and I’m thinking it’s probably time to try to find a PCP and a GYN here in Illinois. I’m on the opposite pole from you, however, I much prefer a woman doctor, especially for a GYN. I’m not looking forward to this process of finding someone with whom I have to share intimate details about my physiology, though, and knowing myself as I do, I’m probably going to keep putting it off until either I am forced to do it as a result of an illness, or my health insurance gets terminated due to the change of ownership of the store I work in.
    4. DB’s Medical Rants » Blog Archive » What I believe Moof and the commenters are saying Says:February 4th, 2006 at 8:48 am […] and for more from Moof on this issue - Hospitalists - This Patient’s Take […]
    5. Moof Says:February 4th, 2006 at 9:19 am Wolfbaby - thank you for your comments - it’s important to have physicians you can relate to, and it seems as if you mostly do. Have you considered talking to your GP and being open about what sort of response you’d like from her?William … thanks for the comments dear. You wrote “I stoped going to the VA Hospital […]” … I hope that you’re still going someplace, though … right?

      Shelly! The newly wed! Welcome back to my blog. Listen my friend - don’t wait until just before your insurance runs out to make an appointment - if something’s wrong with you, you’d find yourself in a real bind. *poke poke!*

    6. John Crippen Says:February 5th, 2006 at 8:56 am Hi Moof,I think I want to get involved in this, but I need some definitional help. I almost hesitate to ask because it seems like such a stupid question.

      What does “hosptialist” mean?

      Is this just any doctor who works in hospital, so what we would call “a hospital doctor” of does it have a more special meaning? Is it something to do with “hospices” as opposed to hospitals?

      As a PCP I would, predictably enough, very much sympathise with your position, but would you just help me with the definition first, please.

      John

    7. John Crippen Says:February 5th, 2006 at 9:12 am
    8. Hi again Moof
    9. Right it’s Sunday afternoon, and I have time, and I have been following your comments around. I guess a hospitalist is just a hospital doctor.You said:

      “I feel strongly enough about this subject that I will simply not see a PCP again … since when I need him most, I now know I’m going to end up with a stranger anyway. Over the last year or more, I’ve discovered that I’m not the only one who feels that way. Most of us haven’t said anything to our physicians, we’ve just stopped seeing them.”

      Initial reaction from a PCP like me is one of sadness… but I see the point. In the UK the PCP is a gatekeeper and is not involved in hospital mangament. And frankly, we do not have the expertese to do hip replacemnts or mangae complex internal medicine cardiac problems.

      BUT what happens to someone who gets a terminal illness? My own strong belief is that they are going to be better at home with family and friends and being managed by the PCP at home. Of course, GPs in the USA do not do home visits very often (or do they? they cerainly did NOT when I was doing family practice in Chicago) so what happens? How do you get medical support?

      John

    10. Flea Says:
      February 5th, 2006 at 8:50 pm Hello Moof,Sorry to take so long to add your link to my blogroll, but I’ve done it.

      Listen, I don’t like the hospitalist trend any more than you do.

      1. Loss of control. I’m a control freak and I cannot abide what we call in our business “fragmentation of care”. Definition of this is basically two docs managing the same problem. It’s bound to create problems.

      2. Loss of revenue. We get paid to take care of patients in the hospital. The payors seem to think our input is valuable enough to pay us well for it. Work done by hospitalists is money out of our pockets. [BTW, it needs to be said that, as a pediatrician, I rarely have patients in the hospital. When I do, I often send them to the big city hospital because that’s the only place that can provide the highly specialized services they need!]

      One reason the hospitalist train is bearing down on us full steam is our fault (the PCPs, that is). It makes our lives easier - no getting up early and coming home late. No calls from the hospital at 2 AM.

      Of course, all the payors and hospitals care about is that hospitalists tend to shorten stays. This is undeniable.

      best,

      Flea

    11. Moof Says:
      February 5th, 2006 at 9:41 pm Dr. Flea … thank you so much for your comment - and thank you for adding me to your blogroll - I’m honored!Your comment is extremely interesting to me, because that’s how I see hospitalists too, when I try to see it from a PCP’s perspective.

      The “fragmentation of care” … I didn’t say anything about that in my post, but I should have. I think I will try to post on that particular issue, if I can scrounge up enough courage to be adequately candid. At one point last year, I had 8 different doctors in two states … one was my PCP, and all the rest were specialists … 6 in NH, and 2 in MA. Honestly Flea, no one knew what the others were doing. The PCP was supposed to have a handle on it … but he really didn’t.

      Looking back and reading the OR reports, and the tests and scans results which I carried back and forth between the home specialists and Lahey, I figured out what “the” central medical problem was … but I’ll make you any bet that none of my docs, PCP included, have any idea to this day.

      At this time, I’ve trimmed it all back to seeing one physician: a nephrologist. Can’t do without him and keep blogging (or much else, for that matter. 0.o )

      As far as “loss of revenue” goes … gee Flea … from what I keep seeing, others are saying that that they lose money seeing inpatients. Since I don’t know how finances work in the medical world yet - I’m still learning that as I work on my Medical Informatics degree - I can’t figure how some of you do better by seeing your own inpatients, and some do not. Is it perhaps the hospitals you belong to?

      You said you’re in New England - well, I’m in the Dover, NH area. Locally, we have Wentworth-Douglass (Dover), Frisbie Memorial (Rochester), Porstmouth Regional (Portsmouth), Exeter Hospital (Exeter), and just across the line in Maine, York Hospital (York) and Goodall Hospital (Sanford). That’s all in a 25 mile radius … although, if you’re from NE, you realize that Dover/Portsmouth is not a “big city” area, it’s just a highly medical area. In Dover, nearly all of the generalists have offices which are “A Department of Wentworth-Douglass Hospital,” (I can think of only two who are not) and of those who are, all use hospitalists, and/or “on call” trade offs with each other. You’re almost guaranteed to not be cared for by your own physician as an inpatient.

      Bad enough that the insurance companies have both sides of medicine (providers and patients) over a barrell, this wholesale “sell-out” by generalists is only making things worse.

      I want to reiterate that I think hospital based physicians are a good idea. If my PCP is vacationing, or I don’t have a PCP, then a hospitalist would be quite nice. Also, if my own PCP is in his office seeing patients, or unable to be reached, or it’s 2 AM in the morning, and I’m an inpatient having some sort of medical crisis, then again, a hospitalist is a very nice commodity. But to have them completely take over my care as a matter of course is another thing altogether.

      And now, on a different note - you’re in New England, you make house calls and also do not use hospitalists? Just how young do your pediatric patients need to be … ?

      *blinks innocently!* ;-)

      .

    12. Flea Says:
      February 6th, 2006 at 5:27 am LOL! If you can blog, you’re too old for me!Good luck in your research Moof. I too would like to know how docs lose money on hospitalized patients.

      best,

      Flea

    13. bruce Says:
      February 9th, 2006 at 1:49 pm Doctors lose money by seeing inpatients because of the inefficiency of driving back and forth to the hosptial everyday (or even walking from their office to the hosptial each day). One of the people above explained she liked to have her doctor answer her questions “first thing in the morning!”. I would like for my lawyer and accountant to answer my questions in person at a place that is convenient to me, but not them, but they don’t. And no one else besides doctors do that. You go to where they are at. If you spend 7 minutes driving to the hospital and 7 minutes driving back that is 15 minutes driving. That is an extra patient you could see in the clinic. The price you get paid for a follow-up in the hospital is roughly equivalent to the price you get paid for a follow-up in the clinic.Additionally, if you don’t take hospital call, you don’t get out of bed at 2Am when someone is dying in the ER. You can awake refreshed, get to work a little earlier, and see an extra clinic patient.

      The other side to this is that patients are rational consumers. They want to see an “expert” for their problem at a low cost at a time that is convenient to them. Internists and family practioners are not experts. Hospitalists know more about acute illness than doctors who practice solely in clinics. Patients have asked for and recieved more specialized care, but in the process have to accept externalities. Dr. Welby will not be there in the morning to pat your hand. Welcome to reality.
      b

    14. Moof Says:
      February 9th, 2006 at 2:19 pm Bruce, I can’t help but notice that you made that comment anonymously, but that you come from a medical center of some sort, and I find that rather interesting. Hospitalist, maybe?You certainly have it very cut and dry … some physicians would rather save 14 minutes in driving rather than let the patients who’ve learned to trust them have the reassurance that at least in some way, someone they’re familiar with knows what’s going on.

      And any physician who tells me that he’d rather wake up a bit earlier, refreshed, than see a patient who’s trusted him, and is dying in the ER … wow! I’m sure plenty of docs feel like you do, Bruce … I guess that’s perhaps one of the reasons why I’m no longer seeing any of you.

      You know Bruce, medical emergencies almost never happen at a patient’s most “convenient time,” either. We don’t necessarily want to see an “expert” at a “low cost at a time that is convenient to us” … we want to be able to see a physician when an emergency arises. We know it will probably not be our PCP … under the circumstances - but being completely abandoned by a trusted PCP to the hands of strangers over a hospital stay is another thing altogether.

      I don’t know what frame of mind some people go into medicine with … but I’ve met a lot of different kinds of doctors in the last few years. Those who are practicing medicine for the love of medicine, and yes, even for the love of those they take care of … can’t hide it. You can feel it when you’re with them, and it engenders an amazing trust. Those who see it as a business - resenting the time they’re giving to people - doing a job … also can’t hide it.

      Most of us aren’t looking for Dr. Welby, dear heart … most of us are just looking for someone we can actually count on when we need them the most … even if they are not the ones administering the care at that time.

    15. mchebert Says:
      February 10th, 2006 at 3:06 pm Thanks for an interesting post, Moof. There are pluses and minuses to the hospitalist issue, and I will try to visit them in the future here or on my site. Let me just say this: I have always seen my own patients in the hospital, but this is not easy. I usually think of myself as having two jobs, my hospital job and my office job. When I finish 8 hours in the clinic I then get to look forward to hours more of hospital work.Also consider that hospital work is a 365 day proposition. I can close my office Christmas day. Can’t sent all my patients home Christmas eve. Hospital work means getting called at 4 am by the ER. It means getting phone calls all day in the office, which disrupts my office schedule.

      Worst of all, there is nothing more frustrating than having to leave patients in the waiting room because you have to run to the hospital to take care of a hospital emergency. A few really sick hospital patients can wreak havoc on the best-planned day at the office.

      I continue to hang with it but sometimes it can be overwhelming to handle both. Medicine has succeeded in keeping sick people alive longer and the result is that the acuity of illness among inpatients has greatly increased in the last few decades. If people keep getting sicker it may simply be impossible to keep doing both.

    16. Moof Says:
      February 10th, 2006 at 4:45 pm Dr. Hebert! Thank you kindly for dropping in!You know, I believe you’ve probably expressed it best of all … and from that perspective, it makes a great deal of sense. I could almost hear myself saying the same things, under the circumstances you’ve just described. I can also “hear” your own regret as you assess the situation …

      I believe that hospitalists are an inevitability, especially as more and more physicians are specializing, and generalists are becoming more and more overworked - not to mention underpaid by comparison.

      I see the common sense in the fact that a physician trained in emergency medicine might do better in the ER … or that a hospitalist might be better at dealing with in-house crises and so on. I can also see that the dual juggling would also be very disruptive of the regular care of your out-patients.

      Isn’t there a way to compromise?

      Perhaps … let the ER deal with the emergencies, as long as they know to contact you when faced with something unnusual - which you, being familiar with the case, may be able to clarify.

      Perhaps, while letting a hospitalist do the bulk of the inpatient care, involve yourself in the following ways whenever possible: seeing your inpatients when you can; remaining aware of what’s happening with them, and having a hand in the decisions surrounding their care … but most importantly, allowing them to know that you are aware of their situation, and are actually taking an active part in their care …

      This wouldn’t be perfect for anyone, I know. Not for the patient, who would more than likely prefer to have you do all of it … not for the hospitalist, who would find himself working as more of a team member with each generalist, while still doing the bulk of the work … and not for you, since you’d still have to make time for more than just the clinic.

      But - it would also be a better balanced approach than the impersonal “take it or leave it” it’s becoming now - or the all or nothing, “go it alone” … headed for burn-out … which seems to be the other side of the coin.

      You know what really bothers me? The idea that medicine seems to be becoming a job instead of a calling.

      When the pastor of a church takes on the “job” of “feeding his flock,” he knows that he’s going to be called out at all hours to deal with emergencies, and that he’s never going to have a week end off! He enters the ministry with the idea of “serving” as a “minister.”

      When I went to nursing school, it was with altruistic motivations. I had no notions of easy hours, large paychecks … and since I’d already been working in a hospital for years before that, I had no rosy dreams about what I was facing. The fellows that I knew who went off to medical school went with the same ideas - to serve. To help alleviate pain. To try to make living better for those around them.

      No, none of us were climbing up onto a sacrificial altar, but we knew what we were getting into - we each chose our own aspect of medicine, knowing what kind of job it would be.

      Don’t those who go into medicine today do it for the same reasons? I can’t believe people have changed that much over the years.

      Hang in there, Dr. Hebert … and do what you have to do to keep going. If you care for your patients, they’ll always know it. Even those of us who are really opposed to “one size fits all” medicine understand that there’s only so much you can do. Just don’t stop caring.

    What I believe Moof and the commenters are saying

    Moof’s comments appropriately stimulated several heartfelt responses. In considering Moof and the commenters I propose some thoughts which may put these reactions into context.My original post - Hospitalists - Pros and Cons
    Moof’s comments - Listen to Moof comment on the hospitalist movement
    and for more from Moof on this issue - Hospitalists - This Patient’s Take1. For too many hospitalists (we can add many other specialties here - particularly ER docs and radiologists), medicine is a job. Hospital work becomes predictable and high paying, but also represents a lifestyle choice.

    Since when did medicine become a job. The traditions of medicine value being a professional, a healer, a physician. Most physicians had difficulty separating their role as a physician from anything else in their life. Previous generations of physicians had (on average) a greater committment to the patient than many physicians have today.

    Too many hospitalists choose hospital medicine not as a desired career, but as a default. A look at the numbers may add to our understanding. Hospitalist numbers have exploded over the past 8 years. This explosion almost guarantees that many hospitalists are not committed to the highest ideals of hospital medicine.

    2. We make a mistake when we criticize hospitalists as a group, rather than criticizing individual experiences. Many hospitalists do a great job. Many hospitalists understand the context of hospital medicine. However, some hospialists do not understand.

    We must remember that hospitalists should have several characteristics. They should be able to quickly develop empathy with a new patient. They should know how to put the current illness into context of the patient’s health history. They should understand what will happen after discharge - and what outpatient care can (and cannot) provide.

    Perhaps, a weakness of some hospitalists comes from not understanding outpatient medicine. Outpatient medicine has a different pace. Many internal medicine houseofficers dislike their outpatient experience. The rewards of outpatient medicine take much longer to realize. The outcomes in outpatient medicine take longer to evolve.

    I personally believe that my inpatient style and sensibility is greatly influenced from the years I spent caring for outpatients. That experience informs my decision making, appreciation for the prehospital care and understanding of post hospital possibilities. Too many entering hospitalist jobs are missing that context.

    3. I must take exception to the criticisms of international medical graduates. Several posters are guilty of profiling. I work with a number of outstanding IMGs. Some of my best teachers were IMGs. Malcolm Gladwell has written about profling recently, I urge those who quickly stereotype to read this article - TROUBLEMAKERS: What pit bulls can teach us about profiling.

    ================

    There are legitimate reasons for internists or family physicians to focus their efforts on inpatient medicine. Clearly, that is my current choice. As I stated in the post which started this series,

    My only fear, as the hospitalist movement matures, is that family docs and internists will retain the option of doing both hospital and outpatient care. If we lose that option, then the hospitalist movement will have caused important harm (in my opinion).

    I would add to that comment with a caution to the field of hospital medicine. Unless hospitalists work hard to understand the context of hospitalization, they will be doing a job rather than caring for patients. Naming a career choice does not produce a field that necessarily improve patient care. This young field is growing too fast. The fast growth will cause problems which may reflect poorly on the good intentions of SHM’s founding fathers.

    Posted in Medical Rants February 4th, 2006 by rcentor

    8 Comments

    1. Per your first point. My wife and I both have graduate degrees, as do most of our male and female friends. We are always shocked at social gatherings at the hard business attitude of doctors.Doctors quickly move off into a corner and get in heated debates on how to code to acheive a $5.00 increase in per patient visits. They attack my business professor friends for business ideas and justifications dealing with their practices.When I go to a doctor and am subject to tacky sales pitches or watch data being spun to produce income I am appaled. When you are told you need an invasive test “just to be sure” when there is no data you become very skeptical of all doctors.

      I see no joy or sense of satisfaction in the doctors I meet. Only a gritty desire to earn more money and a sense of victimhood.

      Comment by Steve Lucas — 2/4/2006 @ 8:27 am

    2. Steve, your last paragraph is perceptive. Due to numerous external factors doctors, especially primary care docs, are losing professional satisfaction. There’s just too much baggage. It may be the reason many physicians choose to become hospitalists. Hospitalists are free to concentrate on what they love doing—practicing medicine. Hospitalists are free of the pressure to “produce” by seeing more patients in limited time (most hospitalists are not paid by production) and are not awash in paperwork.DB, your comments are thought provoking as always. You may be right that the hospitalist movement is growing too fast. The demand for hospitalists may outpace availability. This has already caused some hospitalist programs to collapse from burnout and may also lower the quality of candidates for hospitalist positions.Comment by Robert W. Donnell — 2/4/2006 @ 10:14 am
    3. Db…you make some good points, but it must be pointed out that the hospitalist movement started from primary care outpatient doc’s who were burnt out from the factory pace of the outpatient setting.There would be no Hospitalists if the environment in primary care was more tolerable for the practitioner.Hopsitalists did not start out as an academic movement by Internists/ or FP’s. The SHM resulted from the obvious flight of internists from primary care and the evolving needs of this group of doc’s to rally under one banner.

      Despite the faults of hospitalists, they will prosper. As most hospitalists can tell you, hospitalists can stop working after 45-50 hours/week…but when they were oupatient doc’s 65-70 hour work weeks were the norm. Women are now equally represented in the profession. They do wan’t to have at least some home life. In oupatient care, the odds of being home are stacked against you. Hence, Hospitalists flourish.

      as for nostalgia of the good old days and your questions of “since when did medicine become a job”, incomes for most primary care physicians were at all time highs from 1969-1990,

      The past 15 years has seen a rapid decline in income for primary care physicians yet costs of training in real inflation adjusted dollars has gone up 5 fold. I do not think primary care doc’s were giving away their relatively high incomes then. I would guess that most are living on comfortable retirement funds generated by the good incomes of that era.

      docs who chose primary care 20-30 years ago saw primary care as a way to work in a esteemed career AND make a good income as well.

      THIS is the reason why medical school applications were at all times highs in the 1970’s. College students recognized medicine as job security and as a rewarding profession. Likewise students have always recognized the societal good of the teaching profession, but due to the low income thers has never been a competition for teachers in training.

      Again, I suspect it was because the income in teaching was far less than that could be earned in medicine.

      Perhaps things were different 40 years ago, but everything in the good old USA is far different today than 40 + years ago. I do agree that our society emphasizes greed, hedonism, self rights above the need to be virtous and work for the common good. (Teaching is the most important profession but pays the least)

      No doubt that as primary care is devalued by insurance companies and society, college students will continue go to medical school knowing that primary care cannot pay off the enourmous debt incurred from medical training.

      (Also, medical school is now very easy to enter as college students choose other careers where the economic rewards match the finacial, time, and personal investment.)

      we all are complicit in this mess. We all value our money more than the common good. We have no shame buying products made by third world countries where child labor and inhumane condtions predominate, as long as it well save us our precious money. We all moan about the massive loss of doc’s doing primary care, but spend our money on cable TV, access to OPRAH, broadband, cell phones and other toys. We spend more time watching the TV than helping our neigboor. We spend more in incarceration than prevention. We are this mess.

      Comment by pj — 2/4/2006 @ 4:23 pm

    4. To pj: very well said. I closed my rural solo OB/Gyn practice last May in large measure due to burnout. I was spending up to 60% of my time in non-patient-care activities. The time out has been great for me and my family. I will never go back into solo private practice.2nd story. My primary care physician, a female internist who has practiced with her internist husband in this rural area for 15 years quit private practice a year ago and now works for a large self-contained HMO. I recall her stating that her first paycheck was larger than what she and her husband combined would earn for a comparable period.Solo primary care in rural areas is in its death throes.

      Comment by el — 2/5/2006 @ 12:18 am

    5. Hi,I’m a PCP or GP in the UK. I have just picked up on this debate from MOOFs blog, where I have just posted:It’s Sunday afternoon, and I have time, and I have been following your comments around. I guess a hospitalist is just a hospital doctor.

      You said:

      “I feel strongly enough about this subject that I will simply not see a PCP again … since when I need him most, I now know I’m going to end up with a stranger anyway. Over the last year or more, I’ve discovered that I’m not the only one who feels that way. Most of us haven’t said anything to our physicians, we’ve just stopped seeing them.”

      Initial reaction from a PCP like me is one of sadness… but I see the point. In the UK the PCP is a gatekeeper and is not involved in hospital mangament. And frankly, we do not have the expertese to do hip replacemnts or mangae complex internal medicine cardiac problems.

      BUT what happens to someone who gets a terminal illness? My own strong belief is that they are going to be better at home with family and friends and being managed by the PCP at home. Of course, GPs in the USA do not do home visits very often (or do they? they cerainly did NOT when I was doing family practice in Chicago) so what happens? How do you get medical support?

      +++++++++

      I am keen to follow this debate through. In the UK the GP/PCP has a gatekeeper role. ALL patients have a GP (virtually whether or not they wish) because the way the system is set up you cannot really access secondary care without going through primary care.

      The goverment over here is currently putting a huge amount of resources into primary care with the objective of reducing the costs of secondary care. It remains to be seen whether or not it will work.

      Given that as I understand it AMericans can access , for sake of argument, an internist or paediatricain directly, some of these guys must be going bonkers dealing with utterly trivial illness. Or is this not the case?

      John

      Comment by Dr John Crippen — 2/5/2006 @ 8:18 am

    6. Hospital work is complex and time consuming. Hospitalists create efficiencies and I think that the hospital movement might save general internal medicine. The problem is that we haven’t found a good way to integrate the hospitalist movement into the delivery of care. Hospitalists and outpatient primary care physicians should have a solid relationship and when patients choose primary care doctors they need to inquire about the PCP and hospitalist relationship.Comment by oskie94 — 2/5/2006 @ 8:20 am
    7. I could not possibly read all the posts before commenting on this, DB, so I apologize for any conceits that sound original but aren’t.For pediatricians, there are two sides to the hospitalist movement.Pro: Pediatrics today is all about lifestyle. Hospitalists will admit patients, stay up late and wake up early for you.Con: Man, is this ever money out of our pockets! In the era of shrinking reimbursements, hospital-related charges are a significant portion of my income.

      It’s important for you to know that absolutely do not admit patients who do not meet admission criteria. I have at most one admission per month, and this is often a patient who goes to the ED without calling me and gets admitted (often without aforementioned admission criteria met).

      best,

      Flea

      Comment by Flea — 2/5/2006 @ 1:46 pm

    8. We all did internships and residencies. The hospitalist movement is an outgrowth of two things. First, inpatient care is an impediment to efficient outpatient care. It cramps our style and doesn’t pay for time invested. Second, for some, and a growing number of, physicians, being a hospitalist is a reversion back to the pure medicine of residency, with a defined schedule and no out of pocket start-up costs. For many that’s attractive. Whether it will mitigate any present problems in medicine remains to be seen.Comment by el — 2/5/2006 @ 2:38 pm
    9. I’m not adverse to having a hospitalist take care of me if I were in the hospital, but I would hope they would communicate well with my family doctor. Do hospitalists have to write reports, just like specialists do, that are addressed to a person’s primary care doctor?I would also hope that when a patient is discharged from the hospital in these instances, that they get paperwork to go along with any discharge instructions - copies of the last bloodwork, last radiology reports, a copy of the last day’s chart etc, plus in writing (even if it’s on handwritten) why they are being discharged and when they need to see their family doctor again. I don’t think it would work well if a patient is simply told, “YOu’re being discharged because you’re not sick enough to be in the hospital anymore. Go back to your family doctor.”

      Comment by Renee — 2/6/2006 @ 3:10 pm

    10. I’m a family medicine resident in a private hospital. As an intern on my Medicine rotation, I’m sort of a colleague and equivalent (in the eyes of the attendings and nurses) to the PAs working for the 3 hospitalist groups.It gives me an opportunity to see what the hospitalists here do, and hear the staff’s comments about them. What amazes me is the high turnover. It seems like the average hopitalist here lasts about 8 months. It feels like half of the ones that are here today were not here when I started in June. A few of our 3rd year residents moonlight with them and are getting job offerings from the group.

      I can see the appeal of painlessly continuing doing what you were doing last week, except with fewer hours and more pay. But I would be skeptical of employers with such high turnover.

      It interests me one complaint I get about hospitalists from the nurses “they don’t do anything.” I had always thought of the hospitalist as someone who, because he/she spends all day on the wards, is proficient at handling the acutely ill patient. I would think they would use less consultants than someone with patients waiting in the office. Yet nurses complain that the hospitalists are much quicker to consult an endocrinologist, pulmonologist, and cardiologist and hand off the care to others. In the same patient, the residents would be more likely to do everything themselves.

      Comment by Matt S. — 2/7/2006 @ 3:27 am

    11. As the mirror image of MOOFs comments - I am a primary care family physician in private practice - I can attest the the fact that I have lost patients due to the fact that I do not admit my own. Of course, neither does anyone else around here, but the patients have to find that our for themselves.Also, though, the hospitalist movement has contributed to the shrinkage of the PCP scope of practice. 95% of my day is blood pressure, diabetes, cough-and-cold, and musculoskeletal pain. Which is partly why, after 7 years in practice I’m leaving.

      Comment by Dr. Steve — 2/7/2006 @ 1:41 pm

    A hospitalist’s response to DB, Moof and other commenters

    Patient satisfaction with hospitalist care has been generally good though not universal. One of my favorite commenters and bloggers, Moof, offers a patient’s perspective on one of the down sides of hospitalist care—discontinuity. Her comment at Med Rants and a more lengthy post at her own blog make compelling reading. I was struck by this statement: “The hospitalist model would be fine - if it were optional, not only from a physician’s perspective, but also from a patient’s perspective.” We like to think of hospitalist programs as being optional. But as Moof points out, it’s optional only from the PCP’s perspective. The patient often doesn’t have a choice.
    Much of the anxiety for patients comes when they are blindsided—all too often surprised on admission to learn that their long term PCP no longer makes hospital rounds. Advance discussion between PCP and patient could avert some of the frustration as well as offer the patient a choice to find another physician.
    There’s another dimension for the patient worth considering. The family doc who tries to do it all, holding down a busy office practice alongside hospital duties finds it difficult to stay on schedule. Moof, like most patients, wants seamless continuity. My years in traditional internal medicine practice taught me that such continuity comes with a trade off. The price for assuming continuous care of hospitalized patients was chaos in the office. With no house staff at the hospital I often had to leave the office abruptly to tend to more urgent needs of my hospitalized patients. I was often behind schedule and cancellations were commonplace. While patients in the hospital were thankful that I was “there for them”, my clinic patients found it difficult to understand when I was behind, often accusing my staff of “overbooking.” There are two sides to this issue of patient satisfaction and we can’t always have it both ways. Since becoming a hospitalist I’ve often encountered the question “Where’s my doctor?” Sometimes I’ve been able to defuse the patient’s anger by suggesting that perhaps their doctor gave up hospital medicine in order to be more available and stay on schedule in the clinic.

    Finally, to remind readers of the historical perspective, the hospitalist movement is a bit like the blogosphere, arising not by anyone’s personal agenda but almost as if out of thin air. About a decade ago changing practice patterns in pockets of California with heavy managed care penetration captured the attention of Robert Wachter and Lee Goldman who published this prescient article in NEJM in which the term “hospitalist” was coined. Economic pressures were the initial driving force. As the movement gained momentum it came to be driven more and more by its original detractors, the family docs who, for a variety of reasons, chose to eliminate their hospital practices.


    As I’ve said before in these pages it is a special breed of doctor who can care for patients across the continuum. I hope organized medicine can come up with incentives to keep that breed alive.

    posted by R. W. Donnell @ 11:18 PM

    Collapse comments

    Moof said…
    Dr. Donnell … you wrote:

    I hope organized medicine can come up with incentives to keep that breed alive.

    Can you offer some suggestions?

    .

    4:20 PM

    R. W. Donnell said…
    Moof,
    In my humble opinion a reimbursement system that compensates PCPs better for time and cognitive skill is needed. DB at Med Rants has several posts on this subject.

    2:14 PM

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