Yes, it is true they are still out there. They 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 nonmedical 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 CMS 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 (Sorrel King, Helen Haskell and others) 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, MD