Thursday, May 27, 2010
Debunking five myths of the hospitalist-haters
This post by Vineet Arora, FACP, originally appeared on FutureDocs and cross-posted on MedPage Today's KevinMD.com.
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, MD, 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 two-thirds 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 U.S. 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 two-thirds 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 one-fourth of patients prefer their primary care provider to see them in the hospital, one-fourth 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 two-thirds of primary care providers liked hospitalists, only one-third 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.
This post was cross-posted on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.
Labels: career choices, handoffs, hospital medicine, lifestyle, primary care shortage
posted by KevinMD.com at
11:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert
Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the
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also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
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Berger
Zackary Berger, MD, ACP Member, is a primary care
doctor and general internist in the Division of General Internal
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CasesBlog
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Dimov, MD, ACP Member, is an allergist/immunologist and Assistant
Professor of Medicine and Pediatrics at the University of Chicago,
where he evaluates and treats both pediatric and adult patients.
David
Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally
renowned authority on nutrition, weight management, and the
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Dr.
Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal
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patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid
changes in science, medicine, health and healing in the 21st century.
FutureDocs
Vineet
Arora, MD, FACP, is Associate Program Director for the Internal
Medicine Residency and Assistant Dean of Scholarship & Discovery
at the Pritzker School of Medicine for the University of Chicago. Her
education and research focus is on resident duty hours, patient
handoffs, medical professionalism, and quality of hospital care. She
is also an academic hospitalist.
Glass
Hospital
John H. Schumann, MD, FACP, provides
transparency on the workings of medical practice and the complexities
of hospital care, illuminates the emotional and cognitive aspects of
caregiving and decision-making from the perspective of an active
primary care physician, and offers behind-the-scenes portraits of
hospital sanctums and the people who inhabit them.
Gut
Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist
at the University of North Carolina School of Medicine, and the
Program Director for the GI & Hepatology Fellowship Program. He
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pain.
I'm
dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
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attended medical school at the University of Washington School of
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Kimberly Manning, MD, FACP,
reflects on the personal side of being a doctor in a community
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Neil Mehta, MBBS, MS, FACP,
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White
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Peter A. Lipson, MD, ACP Member, is a
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The blog, which has been around in various forms since 2007, offers
musings on the intersection of science, medicine, and culture.
Other blogs of note:
American
Journal of Medicine
Also known as the Green
Journal, the American Journal of Medicine publishes original clinical
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Correlations
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York University Medical Center's internal medicine residency program.
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The Public Library of Science's open access
materials include a blog.
White
Coat Rants
One of the most popular anonymous blogs
written by an emergency room physician.
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