What Can the Unmatched Seniors Tell Us?

18 03 2013

Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were.  Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”

It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not.  Obviously, many programs put more positions up for grabs in the Match.  After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why  – some of which I have tried to answer to the best of my ability below.  I welcome your input as well.

  • Are these IMGs?  This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
  • Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday.   Last year,  815 Us seniors went unmatched after the SOAP.
  • Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this.  The 2012 data shows that more unmatched seniors did choose to go into competitive fields.  Last year, the % unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields for example.
  • Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as ‘suicide’ ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.
  • If they had gone into primary care, would they would have matched?  I hear this myth that program directors in primary care fields only take international medical graduates (IMGs) since not enough US medical graduates apply.   This is due to the largely untested assumption that any US Senior would be preferred to an IMG.  However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average US Student.   The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by US grads. Interestingly, many of these spots happen to be primary care driven fields.   Yet, it is still unclear if US Seniors will displace IMGs for spots in IMG oriented residencies.  It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to US students.
  • Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field.  However, we cannot ignore the supply/demand side of this equation.  At a time when there is a shortage of physicians and a call to increase the number of physicians, the US medical school system by responded to this call.   New medical schools have opened.  Existing medical schools have increased their enrollments.  So, there are now more US Seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years.  Given that the supply of matched candidates includes both foreign-born IMGs and US-born IMGs, there are more candidates than spots.  And while many believe IMGs will be the ones that get “squeezed out” in this shortage situation, again this is an untested assumption.  It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities,which are often not geographically desirable by US graduates.

 We are left with a fundamental question:  Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot?   At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies?   Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training.  Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.

There is a potential solution.  The “Training Tomorrow’s Doctors Today Act” by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the “Resident Physician Shortage Reduction Act of 2013” sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years.   Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.

Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.

 –Vineet Arora MD MAPP





Where are the Lollipop Men in Healthcare?

9 04 2012

I recently watched Dr. Atul Gawande on video describe how what American healthcare needs is pit crews and not cowboys.  This sentiment is also memorialized in his thought-provoking writings for the New Yorker.

Interestingly, Dr. Gawande is not the first person I have heard to suggest such a thing.  A colleague named Dr. Ken Catchpole actually studied Formula 1 pit crews and used the information to guide improvements in pediatric anesthesia handoffs.  His observations were astounding and really highlighted how the culture of medicine is different from Formula 1. In Formula 1, pit crews have a ‘fanatical’ approach to training that relies on repitition.   In healthcare, the first time we often do something is “on the fly”.  Moreover, on-the-job training usually means ‘checking the box’ by attending an annual patient safety lecture.   Perhaps the most important was the role of the “lollipop man” in pit crews.   And yes, even thought it’s a funny name, it’s a critical job.   As shown in the video, the Lollipop man is responsible for signaling and coordinating to the driver the major steps of the pit stop.  When it is safe to step on the gas, the Lollipop man will signal to the driver.  Sounds like a thing so perhaps it can be automated.  Wrong.  When Ferrari tried replacing the Lollipop man with a stop light that signaled the driver, the confusion created (does amber mean stop or go?) led to a driver leaving the pit with his gas still connected.  Quickly after this incident, Ferrari announced it would go back to the tried and trusted Lollipop “hu”man.

So, who are the Lollipop men (or women) in healthcare?  Turns out that Dr. Catchpole and his team observed that it was often unclear who was leading the handoff process that they were observing in healthcare.  With team training and system reengineering, Dr. Catchpole’s team was able to reorganize the pediatric handover so there was a Lollipop man (anesthesiologist) at the helm.

While these handoffs represent a critical element of healthcare communication in a focused area, it is symbolic of a larger problem in healthcare – we are still missing “Lollipop men” to coordinate healthcare for patients across multiple sites and specialties.  This is even more critical on the 2-year anniversary of healthcare reform and this month’s match results. At a time when we need to cultivate and train more “Lollipop men” to coordinate care for patients, we have had stable numbers of students who enter primary care fields.   And like the lessons from the Ferrari team, it is doubtful that a computer (even Watson who is now working in medicine apparently) will be able to do the job of a Lollipop man.

So, how can we recruit more Lollipop men?  While it is tempting to blame the rise or fall of various specialties and market forces, it is important to recognize that being this is a difficult job to do when the Lollipop is broken or even nonexistent.  Without the tools to execute the critical coordination that Lollipop men rely on, they cannot do their job.  So, the first order of business to ensure that the Lollipop, or an infrastructure to coordinate care for patients through their race that is their healthcare journey, exists.  As the Supreme Court debates the future of the Accountable Care Act, there is no greater time to highlight the importance of the Lollipop.

–Vineet Arora MD





Advocate to Preserve Residency Funding

30 10 2011

bills,budgeting,businesses,cash,cost cutting,currencies,dollars,savingsSo, you have probably heard about the Supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending.  But, do you know that the chief target is RESIDENCY TRAINING!   That is right.   Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money’s worth.  Of course, this comes at a time when there is a shortage of residency spots given the expansion of US medical schools, and a dire need for physicians, especially in primary care, to meet the needs of healthcare reform.

So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the Supercommittee pleading with them not to cut GME funding.   Now the situation is dire enough that the AAMC advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman.  (And yes, if you live in a Supercommittee state, its even more important for you to do this).

So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action.   For my fellow medical educators out there, you don’t need to be left out.  The American College of Physicians has a very broad (don’t need to be an internist)  easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.

Medical educators have actually started a dialogue about the role of advocacy in medical education.  Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training.  I can think of no other way than advocating for preserving funding for the system by which we train our nation’s future physicians.

Vineet Arora MD

(AAMC email encouraging residents to take action)

***************************************************************

Dear Resident:

I encourage you to take a few minutes to  visit the AAMC Legislative Action Center (http://capwiz.com/aamc/home/), select “Residents”,  and send an electronic letter opposing cuts in Medicare funds that support residency programs.   With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction.  PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg, gmail.com), AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.

Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.

It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns.    You are represented by members of the “Super Committee” that will finalize the deficit reduction plan.

Thank you for your help.

Atul Grover, M.D.
Chief Advocacy Officer
AAMC





The “Social” Side of Hospital Rounds

17 01 2011

This weekend, I just finished another 2 weeks on service – the first 2 weeks of 2011 in fact.  This time, I had also had a shadower, but one of a different kind.  As part of our Institute for Healthcare Improvement (IHI) Open School, we are making an effort to have collaborative learning opportunities for our medicine and health administration program students.   Achieving true interprofessional learning is challenging for schools like ours without a pharmacy or nursing school.    

To jumpstart our collaboration, a team of us traveled to at the Institute of Healthcare Improvement conference.  It was there over dinner that Jeff Kunkel, one of the Social Work students, asked me if a lot of social work issues came up in hospital care rounds.  I laughed momentarily and reassured Jeff there would be lots of social issues and invited him firsthand to witness them on rounds.  Unlike the premeds that I sometimes take on the weekend, I wanted him to come during the week so that he could also attend the multidisciplinary rounds with our case managers and social workers that our attendings go to daily. 

The opportunity presented itself that first Friday – our team was on call so it was a perfect day since we did not have many patients and were able to delve into their problems.   While there are social issues every day, dealing with them becomes exponentially harder over the weekend when you only have social workers on call.  This makes Friday an especially important day to advance care or facilitate any discharges.  While some believe that doctors don’t work on weekends, the truth is that they do.  The problem is that not everyone else works on the weekend making the hospital inefficient over the weekend and nothing gets done.

 I introduced Jeff to our housestaff team as a social work student who was especially interested in the social issues.  For each of the presentations, they started with a one liner to brief our student on the patient’s problem but also described the social issues.  In doing so, the social issues that sometimes plague our rounds (and our residents) all of a sudden became the highlight of rounds.  The patient that leaves AMA, the patient who was homeless, the patient who did not want to go to rehabilitation but was too weak to go home, the patient who was uninsured and could not afford his medications…  the list goes on.

Afterwards, we had an opportunity to debrief.  It was fascinating to hear what Jeff found interesting.   He noted that I sometimes have to ‘talk patients’ into leaving the hospital.  I told him that the sad truth is that patients often expect to stay in the hospital longer than they can and should.  Not only is staying in the hospital dangerous and costly due to hospital-acquired infections and other hazards, hospitalizations are increasingly scrutinized to ensure that each hospital day is ‘medically necessary’ by auditors who are incentivized to penalize.   Given this, managing patient expectations becomes very important and something that the attending often ends up participating in. 

As we think about the increasing pressure to ensure that patients who don’t need hospital care go home, it is equally important to ensure a safe care transition to avoid a preventable readmission.  While optimizing these decisions requires clinical judgment, it cannot be done without thinking through and addressing the social issues.  This makes having a great social worker even more important for the future.  Unfortunately, like many other healthcare fields, there is an impending social work shortage as highlighted by a major capitol briefing held by the National Association of Social Workers.  While many of us tend to focus on the need to train competent physicians and nurses, we must not forget the that we need good social workers too. 

–Vineet Arora MD





Holiday Wish List for Medical Education

24 12 2010

It’s the holidays which means that the students are on vacation and faculty have a little more time to unwind.  Unfortunately, residents are still hard at work but celebrate the holidays in their own way in the hospital as we have discussed before.  I’ll be joining them January 1st but for the moment get to enjoy some time off as well. 

Even though medical schools have closed their doors for 2010 and faculty are getting much needed rest, it is time to reflect on what is needed for medical education in the New Year and beyond.  While it’s been a banner year for healthcare reform, there are still some issues that are looming large for medical education, especially graduate medical education.  It’s important to revisit these issues and especially focus on what the ‘wish list’ as medical education prepares for the ‘twenty-tens’.

  1. Funding to Meet the ACGME 2011 Duty Hour Requirements   With 6 months and counting to the implementation of shorter hours for resident physicians, budgets are getting made now for the new fiscal year.  On top of that list in teaching hospitals is how 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 set at over 1 billion for duty hour compliance, obtaining funding is not easy.  However, securing the appropriate financing for these solutions is critical to ensuring that residents are not doing the same or more work in less time.  Increasing resident work intensity may undermine any potential improvements in patient safety and resident education.   To make matters worse, funding may be harder to obtain than ever since funding for graduate medical education by CMS is under threat of redirection.  
  2. A Curriculum to Teach Doctors to Practice Cost Conscious Medicine  With an unprecedented focus on how to contain costs and ‘ration’ care, we are missing one key piece of the puzzle – how to teach young physicians and physicians-in-training how to do this effectively.   Most faculty physicians do not know the costs of the tests that they order making it necessary to create off-the-shelf curricula in this area.  To make matters worse, cost of laboratory tests can vary by region and hospital, making a standard curriculum challenging to implement.  Nevertheless, overreliance on medical testing has run rampant in teaching hospitals, largely due to the lamented “demise of the physical exam”.  If one way to teach cost-conscious medicine is invest in the low cost physical exam skills, we can all learn from the Stanford 25 that is being resurrected by acclaimed physician author educator Abraham Verghese.   While we improve physical exam skills and hopefully change the incentives, we will still need new tools and tips for how to train the cost conscious doctors we wish to produce.  One possibility is through the use of narratives – A new group called Costs of Care launched an essay contest to and will be periodically posting stories to help raise awareness. 
  3. More Residency Spots – As we’ve discussed, without more spots for all those new medical schools opening their doors, medical school graduates will soon face unprecedented competition during the Match without a corresponding increase in residency positions.  While the assumption is that the International Medical Graduates will be squeezed out at the expense of the US graduates, this is not entirely a given.  More than a few program directors of IMG exclusive residency programs say they will continue to take International Medical Graduates.  Regardless, it’s the US that loses in the end given the projected doctor shortage and the only pathway to licensure is via a US residency.  While CMS is exploring ‘redistributing’ spots to primary care, the general consensus is that more will be needed.
  4. Student Debt Relief  Medical student debt continues to plague US education.  While some programs, such as the National Health Service Corps, have been expanded to help address this issue, it is still important to expand such programs to reach a larger audience of medical students.  One novel way to do this is to pair student debt relief with service, an idea put forth by the Editor of Academic Medicine as this year’s “Question of the Year.”  Many schools responded, including our own, which created the REACH (Repayment for Education to Alumni in Community Health) Program to help.  To achieve a larger scale impact, more programs on a federal and state level are needed.  In the interim, the AAMC “FIRST” initiative is a terrific resource to help students navigate their debt and keeps up to date stats about the situation.
  5. Making Primary Care as a Desired Career  The shortage of primary care physicians will devastate the US as more patients become insured and the population ages.  One of the central models for healthcare reform is the spread of the patient-centered medical home, led by a primary care physician.   While the future roles of nursing is explored and potentially expanded to meet this need, it will not be enough to care for complex patients with multiple disease and medications which require care coordination.  So, if primary care is so important, why are more students not choosing to go into it?  One striking finding in the recently released 2010 survey results of all entering medical students is the number of students who declared they would subspecialize.  12% were already on the “ROAD” (rads, ophtho, anesthesia, derm) while an additional 9% were budding orthopedic surgeons.  Meanwhile, 8% were interested in family medicine.  Although 18% declared an interest in internal medicine, 2/3 of these will ultimately subspecialize too.   So what do entering students already know about these specialties?  Well, the elephant in this room here is the income gap between primary care and specialists.   As long as this disparity exists coupled with the debt discussed above, it is difficult to dissuade career decisions, especially when they are made this early!   No one wants to discuss this since it pits doctor against doctor but the time for this discussion is long overdue.

While it would not be wise to wait up for Santa to deliver on these wishes tonight, keeping our focus on these issues in the New Year will surely help usher in the next decade of medical education.      

–Vineet Arora, MD





Getting Primary Care on the ROAD: Charting a New PATH

24 05 2010

I just returned from ACP Leadership Day where 375 internal medicine physicians and future physicians from all over the country descended on Capitol Hill to advocate for primary care.  Before I left, one of my colleagues asked me what we would have to talk about since healthcare reform already passed and includes some boosts for primary care.   Well, we had plenty to talk about!   While the main goal of healthcare reform was to provide coverage and insurance reform, the ultimate question is will newly insured Americans be able to access care?  Even if they have insurance coverage, they may not be able to see a doctor if there are not enough primary care doctors to see these patients.

Therefore, the focus of our efforts this year was to ensure that we have a primary care workforce to meet the demands of the newly insured.   Because of the long dwell time to train primary care physicians, we need to start now to ensure we have doctors for the future.   One staffer told us that he heard that medical students wanted to go into lucrative specialties to pay back their debt, and I asked if they had ever heard of the “ROAD” (aka Radiology, Ophthalmology, Anesthesiology, Dermatology) which refers to the desired lifestyle and highly reimbursed specialties.  He responded we needed to get primary care back on the ROAD or maybe make it “P-ROAD.”   I don’t think P-ROAD makes a great acronym, but PATH may work better: Primary care = Access To Healthcare.    While healthcare reform law (aka PPACA) includes many boosts to primary care, there are a few key omissions that can easily undermine healthcare reform.  Moreover, the question is now what provisions will be funded and at what level.  To get Primary Care back on the ROAD, we need to create a new PATH that includes fixing every step of the pipeline for physician workforce so future and current doctors can see themselves providing this valuable service.  

  • Medical student:  Debt relief so students can go into primary care  Medical students cannot pursue careers in primary care if they continue to carry an average debt burden of roughly 160,000 dollars upon graduation.  The initial healthcare reform bill included loan repayment programs for those who enter primary care, but this was stricken due to the cost of these provisions.  While the National Health Service Corps is the most widely recognized loan repayment program, it is very competitive and will not fill the primary care shortage alone.  Therefore, expansion of this program or creation of new loan repayment programs are needed.   Medical students are especially adept at making the case for loan repayment – and the health legislative aides that we met with were especially sympathetic to them since they may be able to relate to them (they are also closer in age).
  • Residency:  Expand primary care spots & create new training models  With new medicals schools designed to train primary care physicians, it is unclear if there will be enough residency spots for these newly minted physicians to match into.  As I’ve stated before, the supply of US graduating medical students will overtake the number of residency positions in a few years if there is no increase in residency spots.  Moreover, if residency slots aren’t ‘slated’ for primary care, one can imagine that new graduates will gravitate to the specialties.  There are provisions to reallocate 65% of unused residency positions to primary care, but that still won’t be enough due to the shortfall of primary care physicians.  The ACP recommends 90% of these spots go towards primary care.  In addition to creating slots, residency programs must be given the latitude to design new models to train primary care physicians.   Since funding for residency training is given to hospitals, currently residency programs face significant challenges in getting residents experiences in ambulatory settings.  This may change with healthcare reform legislation that supports the creation of new ‘Teaching Health Centers’ in the community to train primary care physicians, provided that these programs get the funding they need.  
  • Practicing Physicians:  Reward & redesign primary care work  Lastly, entering and staying in primary care will not be possible as long as the income disparity continues to persist.  Moreover, with a pending 21% cut in Medicare physician fees kicking in on June 1st if nothing happens will not help things.  This is why we need to ultimately reform the payment system (for how we ended up here, see this earlier post).  The House has just introduced legislation HR 4213 which would stop the cuts and provide 3.5 years of stable Medicare payments and reward primary care doctors.   Certainly, this will help things in the short term.  However, several of the trainees I spent time with in DC firmly stated that it was not just about the money, but also the hard work associated with primary care.  This point was eloquently illustrated by Dr. Richard Baron in a recent New England Journal  of Medicine article in which the primary care physicians in his practice responded to a telephone call or a lab test an average of 43.2 times a day!  All of this care goes uncompensated in our current system.  As one physician writes, it is time to reward coordination and communication of care.   One possible way to do this is to adopt the new patient-centered medical home, which is a way to redesign practice to promote a team approach (with physicians and other allied health professioanls) supported by technology to deliver primary care to a group of patients.  Another solution was featured in a recent issue of Health Affairs devoted to primary care, which contains an article which poses the provocative question: what would martians think about primary care?  The answer is a more radical redesign to overhaul the entire physician workday to see fewer patients and compensate the uncompensated care such as email and phone calls.

Unfortunately, as one of the other staffers said, “there is a lot of healthcare fatigue on the Hill” so this may take time.   Moreover, the big barrier is cost especially given the high price tags of these bills in a fiscally challenged environment.  While these reforms will cost money in the short term, its important that we highlight that fixing these things later on will cost exponentially more — if it can be fixed at all.   This is why its important that physicians and medical trainees need to make the case now about the importance of these issues to ensure physicians for the future.  

To learn more, sign up to be a Key Contact for the American College of Physicians for breaking updates on these issues.  More information on ACP positions on physician pipeline here

–Vineet Arora, MD

Share





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








Follow

Get every new post delivered to your Inbox.

Join 16,209 other followers

%d bloggers like this: