As the numbers of hospitalists increase, more primary care doctors are no longer doing hospital rounds.
Communication problems can arise from this, as discharge summaries and other hospital notes often are not transferred back to the outpatient physician in a timely manner, if at all. And indeed, some patients are unhappy with this trend, and prefer to choose doctors who both have an outpatient clinic and perform hospital duties.
As internist Robert Centor says, “Patients are smart. They understand the value of having a physician who knows them well.”
However, blame the current fiscal environment that influences physician behavior as a major reason why the hospitalist profession is thriving. It is likely that the doctor, or “comprehensivists” as Dr. Centor calls them, who does everything will be a distant memory, leaving patients little choice in the matter.
Related posts:
- Do hospital ads work?
- Does alternative medicine work? Or does it harm patients?
- Is the economy giving physicians the upper hand in hospital negotiations?
- What happens if the safety net clinics start refusing to see Medicare or Medicaid patients?
- Unnecessary hospital admissions cost money and can harm patients
- Should elderly patients always be admitted to the hospital?
- Patients waiting for hospital beds
{ 17 comments }
“comprehensivists”?? They just used to be called Doctors. Why does everything and everyone have to be so specialized? I think it was Dostoyevsky who wrote about a doctor that wouldn’t look at someones left hand because he only specialized in the right hand. I don’t think that is too far off from what we are headed to, if we aren’t already there.
Hospitalists are the creation of hospitals as an attempt to garner “market share.” In their distorted reasoning they felt they could build loyalty to their institution by providing their own service. They sold it to primary care physicians as a means to shorten their day and improve their bottom line. This has turned those who choose this route into partial care specialists. When daughter Mary calls about her mother in the hospital and you don’t have a clue about her status, you have reduced your importance to that family. Further you will see a further drop in your income since hospitalist care, considered more intense, adds another cost to the health care bill and diminishes your value. When the ensuing budgets are made up, you will be payed less(NP status) and still the health care bill will go up as more is given to the hospitalist. So this is a lose-lose situation. The primary care physician’s prestige is gone and his income lowered. The patient is upset that there is no continuity of care and it has caused a break in the doctor-patient relationship. The hospitalist bleeds money from the system and makes it even harder to have funds available to support the hospital. Unfortunately all this was put in place without the proper input from the physicians, hospitals, and most especially patients. One day all you young’uns in the profession are going to wake up and say: “How the hell did this happen?” The answer: “We have met the enemy and it is us.”
As a Family Physician who has done both the inpatient and hospitalist route, marketing is marketing and medicine is good care. It takes a team to care for anyone these days and the idea that a single doc can do it all is long gone. I used to wake very early to make rounds at two hospitals, arrive late at my office, try to rush through my paperwork (which never really happened because of liability fears) to rush back to the hospital for evening rounds or new admissions, to rush home to be able to spend a few minutes with my family before they went to bed. It didn’t work!
Now I may just be lucky, but, the hospitalists I work with are part of a team. They don’t do outpatient medicine and I don’t do inpatient medicine. I have them call me daily to update me and I provide the needed information from an outpatient standpoint to be able to better care for the patient on an inpatient standpoint. And I am up front with my patients that they will see a hospitalist, and who that is likely to be, when I initially interview them and establish care.
I do not believe I have lost a single patient because of the system. If anything, because I communicate the system up front, patients are appreciative and seek out the practice more. I could not be any busier and keep my sanity.
I agree with Resident Doc. “Comprehensivists” is taking the specialty thing a little too far.
I’ve done it all in my time on the road. Full practice (a real soul-killer if you’re the only Ped in the county). Clinic only (very isolated – and often boring). Hospital only (taking all the “dumps”). It’s my opinion that, with the tort system the way it is, and hospitals the way they are, nobody can to it all any more and have a life or stay sane.
On “we have met the enemy and it is us”, I have seen some primary care docs treat hospitalists like dirt. The reason being that they did it “all” for so long, and they allowed themselved to be abused (before taking a stand or pulling out) . . . now they feel the need (dare I say “entitled”) to abuse others/take them for granted.
It’s very sad. And counter-productive.
Like Karl, I believe the key to being a good hospitalist is good communication with outside docs and good documentation.
Good point, Dr. Edelmann. I believe that the model of care you provide is actually a good choice. It so happens that this is the model found in the patient-centered medical home. The patient centered medical home is founded upon good communication among the hospitals, labs providing tests and the primary care physician, who is the prime manager and provider of health care for each of his/her patients. One positive thing about this model is that is raises the importance of the primary care physician and actually improves the income of the primary care physicians. In fact, as I pointed out in my July newsletter, primary care physicians who were a part of the TransforMed project saw a raise in their income an average of 14% over a two year period while being able to provide more time with each patient.
Maybe, eventually, better EMR capabilities would allow docs to know what was going on with their patients in the hospital and on discharge.
So the bets are placed. On one side is the divvying up care and putting several steps between the patient and primary care and also increasing the costs(everyone and their offices will have to be paid) and those who have organized their day so they can see their patients int the hospital, respond to patient and family concerns, and still see an appropriate number of patients. For over 30 years, now retired, I also did it all also, hospital, nursing homes, house calls, office work, committee work, community involvement and to boot saw my kids off to school in the am, attended their events, and enjoyed and continue to enjoy my marriage. Yes I even made it home to dinner more than most of the time. Maybe I was lucky too, but it afforded me an excellent income(in the upper 1% for my specialty family practice). I have now in a sense left the field and I caution my younger colleagues to be careful what is dangled in front of them. You should expect the same evidence that it is a road well taken as you do in your clinical work. The medical home is another high cost addition, not a cost saver, and requires even more effective communication. Driving blindly ahead without careful study will set off the law of unintended consequences.
I can’t believe what I’m reading here.
Hospitalist medicine is WIN-WIN-WIN-WIN-WIN-WIN. There is a reason why hospitals subsidize hospitalists on aver age of100K per hospitalist per year. Because the service they provide is indispensable to all the parties involved. Including patients.
Time will tell. The hyperbole of “indispensability” is a bit much. If you read the original Scripps study on hospitalists you will see that the most efficient care was from community physicians who were directly responsible for their patients. You have been sold a bill of goods.
@ Donald Green MD – do you have a link to that Scripps study, I’d like to give it a look.
Methinks happy is a little defensive.
The hospitalist movement is a flawed solution to a flawed system; right now you may have value worthy of your subsidy, but they will start squeezing you more and more, and it will never be enough. Eventually, you will be eschewed in favor of an even more “cost effective” solution. But that’s ok, we can use primary care doctors, be they internists or family physicians, in my community.
Most businesses are not in the business of paying for something they do not value. If the value of hospitalist medicine decreases, the value of the subsidy will as well. If the administrators have the wool pulled over their eyes, I suppose hospitalist medicine would be the greatest scam in the history of medicine.
Until then, the market is telling you that hospitalists hold a greater value to inpatient medicine than do the outpatient internists/family medicine docs.
Let me know when the hospitals start paying the outpatient internists and family medicine docs 100K a year in subsidies to round on their patients.
I am a neurologist and I split my time equally between hospital coverage and outpatient. It is clear to me that with the development of new drugs, new discoveries about disease treatment, and new processes in the hospital – it is hard to keep up with both. At some point I will probably have to do hospital only.
The hospital is a unique world and it seems obvious to me that those who are very familiar with it will become more efficient at using it and probably more effective. They know who to call under what circumstances. They are more familiar with the diagnosis and treatment of acute diseases. They make the hospital run more smoothly by seeing patients in a timely manner and by fielding follow up questions quickly. (Can you image the frustration of the nurses who have to continually try to get in touch with the busy office-based primary care physician? It can be a nightmare!)
We are perfectly accepting of the fact that there are cardiologists (or even EP specialists), neo-natologists, and intensivists. All of these fields offer the patient greater levels of expertise, because there is simply so much more to know. For the very same reasons, we how have hospitalists.
I have a primary physician who is a former hospitalist and does not have admitting privileges. Any hospitalization I have is likely to be covered by one of the far too many specialists in my life.
The benefit is that when I am at my primary care office I am seen on time and have the full attention of my physician. I’ll take the risk.
As a manager of both out-patient practices and a hospitalist practice, my job is to develop processes to bridge the differences between hospital protocols and ambulatory care needs. When the processes work perfectly, it works for the patients, the nurses, and the physicians. When a glitch appears, it takes a lot of communication to find out where the process broke down and repair it. The model is working in this small town where the patients appreciate getting seen more quickly than they did when their PCPs worked in the hospital, and they are slowly getting accustomed to the hospitalists.
Once the system collapses as the government realizes they can’t afford healthcare, and services level out to their true market value, people will be clamoring to take ownership of patients once again. Hospitalists will cease to exist faster than they came into play. Health care reform will only expediate this process – comical really.
By then, “Bad Medicine”, a good many of us on these threads will be over and done – our careers/hopes/dreams eaten up by this mess.
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