Hospitalist Haters: Can We Bury the Hatchet?

15 04 2010

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

Share

About these ads

Actions

Information

10 responses

15 04 2010
GlassHospital

Great post, FutureDocs! Important to address criticism with data, which you do strikingly well.

Thanks for the mention, though I fear I may have been misconstrued: The goal of my post was to share poor Mr. Wilson’s story, not to bash hospitalists. In relating he and his wife’s sorry tale, I hoped to inform non-medical readers about the prevalence and growth of hospitalists. A bit of anticipatory guidance for the lay reader, if you will.

If there’s a villain in the story, it’s Dr. GoNoMore, the PCP, who failed to effectively communicate to the Wilsons about what they could expect.

I am in that majority cohort of PCPs that prefer hospitalists–though I agree the communication and transitions of care pieces could be greatly improved. After all, I’m a recovering hospitalist myself.

Here’s the link again, for those interested:

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

-GH

18 04 2010
futuredocs

Thanks for the clarification GlassHospital! Your support is appreciated. I wanted to highlight that your patient and the story brought up the question and its a good question since one can imagine patients should be prepared about who will see them in the doctor. I agree we need to do a better job in this area.

15 04 2010
» Seeing hospital medicine clearly db's Medical Rants

[...] My good friend Vinny Arora chimes in today – Hospitalist Haters: Can We Bury the Hatchet? [...]

21 04 2010
What Matters Today Blog Scoop » Seeing hospital medicine clearly

[...] My good friend Vinny Arora chimes in today – Hospitalist Haters: Can We Bury the Hatchet? [...]

9 05 2010
MaryAnn

I think the use of the word “Hate” diminishes the points you are trying to make. Hate is such a strong word, I found it distracted me as my mind searched for a less polarizing term. It’s not as “black and white” as your catchy alliterative title suggests. In a recent “Your Caring Life” column in Caring Today, a magazine for family caregivers, Robert Edelstein quoted Dr. Wachter who coined the term hospitalist, “This can create a level of mistrust; Is my doctor abandoning me? But in many systems it’s been determined that to have this doctor, who’s a partner to your regular doctor, is a good idea.”…..However, as Dr. Wachter points out, “Unlike a primary care physician, you probably won’t be able to choose your hospitalist.” On an emotional level, it is more complicated, than what you write. Also, I might add that in my limited experience interacting with a hospitalist, not all hospitals have implemented an excellent model. My father was admitted to a hospital this past February and for the first four days, he saw a series of different doctors. Finally on day five, a very good hospitalist took over and the attention and standard of care increased. But, my father missed his primary care doctor, truly felt abandoned and did not like the hospitalist. I thought the hospitalist was excellent but my introduction to this model of care has left me wary. It seems less personal, but that is the trend of medicine today, isn’t it?

9 05 2010
futuredocs

Thanks for your thoughtful comments from the patient perspective. My commentary was largely meant to reflect the very real tension between primary care physicians and hospitalists highlighted in recent articles in the Annals of Internal Medicine and that have been discussed at recent medical meetings or emerged in the workplace. Certainly, every doctor is different (primary care or hospitalist) so specific patient experiences will differ. Your observation reminds me that continuity of care is one of the things that patients crave in all of their medical interactions, but is often not achieved since their doctors don’t work 24hours a day. What we need is a team-based system, like Dr. Wachter notes, where patients do feel that all of their doctors (primary care, specialist, hospitalist) are working as a team and are on the same page. For this to happen, we need a system that promotes coordination of care, communication, and better handoffs. I do hope we can get there.

27 05 2010
MaryAnn

Thank you for your thoughtful and kind reply. I totally agree with the points you made about continuity of care and a team approach.

7 06 2010
Cheryl Handy

IMHO the Hospitalist Program Model must be standardized. These physicians may serve a vital role at some hospitals. But, at other hospitals (like Duke University Hospital in Durham NC), the hospitalists ignore Fellows, residents and, most horrifically, the patients’ treating Duke Clinic physicians.

There should be cooperation, coordination and communication. DUH has none of these. As a result, patient safety and continuity of care are compromised.

10 06 2010
Jeff Brown

Acrimony aside, the salient issue here is what’s best for the patient. As you noted, care transitions are a “sticking point” for hospital medicine, largely because of breakdowns in communications to PCPs. (In the survey you cited, only 56% of the PCPs were very or somewhat satisfied with communication with hospitalists.)

The issue of discontinuity of care that can occur after patients are discharged is a serious concern that needs to be addressed. But it’s a subset of a broader problem that receives little attention – the everyday discontinuities (and delays) in care resulting from inefficient communications between inpatient medical teams and other physicians, including PCPs. The Joint Commission has cited communication breakdown as the single greatest contributing factor to sentinel events and delays in care in U.S. hospitals.

Hospitalists are here to stay. And we’ve found that they can peacefully co-exist with PCPs if everyone at the hospital has the clinical communications tools to help each other coordinate care.

24 12 2010
Holiday Wish List for Medical Education « FutureDocs

[...] to make ends meet with residents who work shorter hours.  Residents are low cost labor compared to hospitalists and physician extenders who are their most likely work substitutes.   With the overall price tag [...]

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s




Follow

Get every new post delivered to your Inbox.

Join 16,212 other followers

%d bloggers like this: