Hospitalists are killing primary care, and other myths debunked

Those who hate hospitalists believe that students and residents are choosing hospital medicine over primary care so hospitalists are to be blamed for the primary care shortage. They also believe that the rise of hospital medicine has made primary care less attractive. Then, there is the salient argument that care transitions are more inherent and vulnerable due to hospitalists.

Of course this hatred is not new. As a resident, I remember watching Larry Wellikson, CEO of the Society of Hospital Medicine, back in 2002 publicly berated by some very smart people at a conference calling the organization a “SHaM.” Ironically, this was a conference on how to ‘Revitalize Internal Medicine.’ Given the dramatic rise of hospital medicine since then, it is still surprising when the hatred reemerges in the public domain.

It appeared in a recent issue of the Annals of Internal Medicine. I just returned from the Society of Hospital Medicine conference, and learned there are now 30,000 hospitalists. Hospitalists are here to stay – so what to do? Well, let’s explore these myths one by one.

Is the declining interest in primary care due to hospital medicine? While I am very concerned about the lack of interest in primary care, the answer to this question is no. If hospitalists did not exist, there would still be declining interest in primary care among medical students and residents. The decline in entry into primary care among medical residents is largely explained by the rising interest in subspecialty medicine, in which 2/3 of internal medicine residency graduates intend to enter.

This choice is largely driven by the financial disparity between high paying subspecialties and you guessed it, primary care physicians. In fact, hospitalists are losing candidates left and right to subspecialty fellowships also! As a result, most residents are not deciding between hospitalist and primary care — but between one of them and pursuing a fellowship.

Is it all financial? Well, I personally believe that residents are also uncomfortable with knowing “a little about a lot” and desire a focused area of practice in the ever expanding domain of medical knowledge. And, who could blame them? As a hospitalist, I feel that way often. This is something we need to prepare our residency graduates for -– caring for the undifferentiated patient -– whether it be in the outpatient or inpatient settings.

It is important to note that the primary care problem starts much earlier than residency. A widely cited report shows that only 2% of graduates are interested in entering general internal medicine, and less than 20% overall in primary care fields. The biggest competition is the “ROAD” – Radiology Ophthalmology Anesthesiology or Dermatology – or any other competitive specialty that is lifestyle oriented – meaning high pay with controllable hours.

For any non-medical person in the world, who would not pick the high paying job with controllable hours? This is why we need to reduce the disparity between physician specialties in the US and ensure that both primary care and hospital medicine are seen as viable and yes, glamorous careers.

Has hospital medicine made primary care less attractive? For the sake of argument, let’s imagine the answer is yes -– what would that mean?

It would mean that a busy primary care physician would desire to go to the hospital to follow their patients early in the morning before clinic and after clinic to round. They would constantly get pages from the nurses during the day even though they were off premises. The hospital would require that the primary care physician participate in the latest quality improvement project to improve metrics.

While this may still be possible in more rural areas with less acute patients, the reality is that hospitalized patients today are sicker than ever before. Hospitals and frankly the government are demanding that physicians are in house to help meet their quality metrics improve patient safety as opposed to rounding on an as needed basis.

A new analysis shows that the probability of hospitalization for a patient who was cared for by a primary care physician fell before the hospitalist movement started. Hospitalists emerged as a way to make it easier for primary care physicians to work in the office and not go through the trouble of going on rounds. So, in other words, hospitalists appear to be helping primary care physicians since not many of their patients are in the hospital. Not surprisingly, a survey demonstrated that 2/3 of primary care physicians thought hospitalists were in fact a good idea.

Do patients prefer seeing their own doctor in the hospital? This question was recently put forth by GlassHospital. While they may long for the early days of that type of continuity, most patients and their families want to see a doctor immediately when their family member is sick.

Poignant stories from patient safety advocates highlight the need for emergent evaluation by a physician when their loved one is ill. They can’t wait until clinic ends. Care by hospitalist is also cheaper and associated with better outcomes, certainly something desirable in healthcare.

Lastly, there is some data from our group that suggests that roughly 1/4 of patients prefer their PCP to see them in the hospital, 1/4 prefer their hospital doctor, and the remaining have no preference. Patients are also not willing to pay for their primary care physician to see them.

Are hospitalists responsible for suboptimal care transitions? Well, this is the great sticking point for hospital medicine. In that same survey where 2/3 of PCPs liked hospitalists, only 1/3 felt they received timely communication about a patients discharge.

A recent review in JAMA supports this assertion. Since that time, however, hospitalists have realized this problem and have adopted care transitions as part of their core mission. Care transitions are a core competency of hospital medicine. With funding from the Hartford Foundation, the Society of Hospital Medicine has launched Project BOOST – Better Outcomes for Older Adults Safe Transitions which has been implemented nationwide and in a consortium of hospitals in Michigan and is about to go live in California. So, while this is the one area that continues to be “unfinished business” in hospital medicine, it is also the area where the greatest progress and improvements for patient safety are being made.

So, can hospitalist haters bury the hatchet?

I hope so. After all, hospitalists need primary care physicians. This year, when I’ve been on service, I’ve noted that a primary care physician who accepts new patients is an endangered species. As a result, I have begged some of my colleagues or other members in the community to follow some of these complex patients. Since the patients have to leave the hospital when they are medically clear even if their follow-up is spotty, I continue to sign home health orders, receive pages from patients to field their questions, and field questions from subspecialists who are seeing the patient in follow up.

As a result, I have a handful of patients who actually identify me as their physician when they go to an ER in our community. While I am suddenly reminded of the great pride it is to be known as someone’s doctor, I know that what we all really need is a good primary care physician.

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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  • KP Internist

    Hospitalist have made primary care less attractive. Ask any internal medicine resident if they feel that they have been influenced during their training to pursue a hospitalist position. Hospitalist have to recruit also to fill their spots. We are drawing from the same pool of residents. Some residents have told me that they have been told that they are too smart to go into primary care by their hospitalist attendings. Unfortunately, internal medicine training is most inpatient and they present to hospitalists 90% of the time and they are told that their responsibilities for inpatient work more important than their clinic responsibilities. So, hospitalists do harm primary care recruitment. They are a benefit to our efficiency. But, they do influence the number of primary care doctors that are practicing.

    • jsmith

      What KP internist said. The pool of primary care=x; hospital medicine takes h, so x-h are left, and x-h<x. QED

  • ninguem

    “…….Patients are also not willing to pay for their primary care physician to see them……”

    Well, that pretty much says it all doesn’t it.

    It gets downright insulting after a while. People want the world from their primary care doctors, but for free.

  • stargirl65

    The system of using hospitalists mimics that which occurs in most other health care systems. The US is one of the only large countries that allows primary care to care for patients in and out of the hospital.

  • http://glasshospital.com GlassHospital

    Thanks for the shout out, Dr. Arora!

    Yes, I wrote a popular post about a frustrated patient who called me feeling betrayed by his former PCP–the PCP never told him or his wife that over the years he’d stopped going to the hospital to follow his patients.

    When the wife needed hospitalization, they were shocked to learn of the new truth.

    In the end, the patient didn’t switch to me since I couldn’t promise that I’d follow him in the hospital either. I do attend, but only 1 or 2 months a year as a teaching attending.

    Here’s the post, in case you missed the link above:

    http://glasshospital.com/2010/01/20/take-2-aspirin-but-dont-call-me-when-you-really-need-me/

    -Dr. John

  • Randall

    The quality of hospitalists is very variable depending on the hospital, whether they have residency program, whether hospital makes money by referral system, culture of the hospital. I have seen good hospitalists manage so many things without any help in an efficient manner. There is room for both hopsitalists and Internist to co exist should the internist want to continue do both out patient clinics and In Patient work. Hospitalists tend to duplicate many tests that are done because there is no incentive to coordinate and spend an hour getting reports for tests done outside. I am constantly puzzled why hospitalist are at bottom and so underpaid for what they do, most are younger and maybe their society is not as powerful as Cardiology society.

  • ninguem

    Seems in my hospital, the hospitalist groups change every time I turn around. The hospitalists themselves are employees, they have no ownership in the management group, yet they get noncompetes forced on them anyway. So the group changes, and the individual docs have to leave. They start out with a decent deal during the “honeymoon”, then more and more work gets forced on them, finally it goes too far, things break apart, and we end up with a new hospitalist group. I dunno, it looks like a crappy offer to me. Like being an intern forever. Maybe it’s just a bad situation in my own hospital.

  • Terry

    stargirl65 is correct that in most other countries (usually with socialized care) that there are ‘Staff Doctors’ and interns (or medical officers) that run the hospitals. When I interned in New Zealand it was rare to see a PCP in house. In Canada the country hospitals were run by GP/FP’s and we did all our own inpatient work but mainly in the large cities now very few PCP’s look after their own patients.

    I appreciate Hospitalists greatly nowadays. Not having to do rounds AM and PM, admissions after clinic hours and phone calls from the hospital at all hours is priceless and inpatient work was paying less and less by the hour of time spent there. More power to ‘em!

  • anonymous

    the title says myths debunked? i don’t see any debunking, just one opinion.
    for example are hospitalists losing physicians to fellowship or more likely (imo) they are waystops for people destined for fellowship anyways? absolutely hospitalists are contributing to the decline in primary care. another way of looking at it is how many hospitalists came from the ranks of primary care? while certainly some may have gone on to pursue fellowship if the hospitalist entity had not developed, most would not have been able to afford it or be willing to retrain themselves for many reasons. do we need good hospitalist programs? absolutely! but imo, we need good primary care physicians even more.

  • LynnB

    Its pretty simple–IM grads can do hospital work, long days ,mostly busy but occasionally there is a slow week, guaranteed time off, and doing what they trained to do. Or they can be a l “LMD” or “PCP” who earns the contempt of the attendings (who have never been a PCP and don;t differentiate mid-levels form MD’s) doing something they are not trained to do that they know is not economically viable . I think being the PCP is like being the mom–everything is your job, everyone else enjoys your work, the appreciation is rare but heartfelt the pay sucks, and you have no personal life. But its still the best thing you can do with your life, I think. Luckily my youngest completes college soon so the fact the ER nurses make more per hour will soon bother me much less. .

    So the growth of hospital medicine is a sign of the death throes of outpatient general internal medicine, but it isn;t the cause , Since there are no internists out there in clinic anymore, the hospitalists really need to shape up the discharge process.

    … is hospital med harming patients?………..
    I work hospitalist shifts about one week in 6 (1/3 time) and clinic the other 5. Transitions to outpatient care from our very good , very stable hospitalist group are really lacking !!!!! BOOST looks like a start, but check out Project RED , ttp://www.bu.edu/fammed/projectred/. As an internist I am supposed to believe only internists can do the job right, but this looked at the paperwork , which is usually a burden for us, minimal benefit to anyone but JCAHO.

    Discharges are time consuming to do well. It is impossible to get pulmonary rehab, coagulation clinic, and followup CT scheduling off hours. Why the heck we can’t do that by secured electronic communication l I will never understand. So we just don’t schedule them when we discharge, we fill out a paper which may lead to an appointment later, but WAIT! now I am off hospital duty and when there is a question (there is ALWAYS a question) , it gets punted to the limitless resources of primary care docs.

    When I am in-hospital I spend a lot of time on the discharge med list. I do the orders , then something changes, –the insurance won;t cover drug A, but they do cover drug B , or the patient unbeknownst to the admitting team (even with the med rec process) had a two year supply of simvasatin at home, or was allergic to sulfa, or there is an interaction between what we gave and their eye drops or some darn thing. Then I dictate it and something else changes. Why the heck aren’t we benefiting from the electronic age and entering these changes into the outpatient EMR. In our system even though there are several EMR’s most people use them. Instant communication is possible, and it would improve care at lower costs for the “health system” as a whole . But wait–the hospital won;t pay the tech to update the physicians records and some of the clinics think the hospital pharmacy wants to steal their secrets so instead this is shoved into the 15 minute double-booked visit , if the records arrive on time . Plus good old JCAHO is worried that we are giving better care for those whose docs have an accessible outpatient EMR,so we have to keep everyone at the minimum we use for out of town patients. Besides, if this system was so good wouldn’t all the big referral hospitals with all out of area patients where it could never work use it?

    It also requires some knowledge of the clinic schedule and capabilities .Saying to a PCP , work in this patient in two days , when you are already double booked in 3 of your slots and you had planned to leave 1/2 hour early to go to the dentist (we don;t HAVE weeks off) is just not reasonable. If the patient need a daily weight, exam and labs they should not be going home for “close outpatient followup” .Some more-custodial arrangement needs to be made . Some clinics have in house lab and X-ray some don;t , some are in the same block as the hospital some not even in the same city. Some get hospital lab and X-ray reports same day some must wait a week.

    Many of our hospitalists have never managed outpatients. One example : Elderly patients probably shouldn’t go out on a correction scale of insulin unless they just had vascular surgery or a joint replacement or some horrible infection (my opinion). There is risk of higher risk of patient dosing error -induced hypoglycemia when they are tired, still sick, on a whole passel of new things and worried about their illness.I was going to link to my favorite articles, but just Google glycemic goals elderly, my favorite is JI Wallace 1999, an oldiesbut a goodie . I realize that I am one of just 5 docs in the US who are geeky enough to care.

    Hospitalists have never dealt with non-adherence , or with innumeracy, although they do deal with the consequences. In house someone gives the meds AND the patient is scared and sick and likely to take the statin you recommend vs the soy milk their brother in law recommends. . They just don;t have any bag of tricks for dealing with the problem. So the discharge plans often fall apart. But this is attributed not to poor discharge planning, antiquated communications, insurance company shenanigans , patient financial constraints but PCP “inaccessibility” .

    Hospitalist groups need to enter the real world and help the patient by helping the PCP .
    .

  • TrenchDoc

    I gave up the hospital 2 years ago to concentrate on the office and transistion to a concerige practice and I would never go back to the hospital. The hospitalists in our area make rounds a several hospitals and are not inhouse most of the time. The hospitals have developed response teams comprised of RNs and NPs. Before we had residents and interns to do this work but they rebelled and only cover the teaching services that limit the patient load to about 15 patients. So I don’t see how this is an improvement in the quality of care now compared to 20 years ago when the Internest’s office was adjacent to the hospital. Sure you were in the office but it took about 5 minutes to walk over to the hospital in an emergency. Now this model is uncommon and unprofitable but I believe it is still the best way to deliever care to medically complex Medicare patients. This breed is dying out and there is not financial incentive to revive it – at least for now. But we will see this model develop again because how can fragmented care be better than comprehensive care?