Friday, June 11, 2010
Take two aspirin but don't call me when you really need me
This post by John H. Schumann, FACP, originally appeared at GlassHospital.
A few weeks ago I got a call from Frank Wilson (not his real name). He told me he and his wife were looking for a new doctor and a new hospital. Mr. and Mrs. Wilson had been with the same doctor for nearly 20 years. The relationship had been warm, and, he explained, "We trusted him to follow us through thick and thin."
I could sense the hurt in his voice. Why, I wondered, would they give up on a doctor who knew them so well? Among people of my generation, doctors are switched more than toothpaste.
(Click "more" button below to continue reading.)
At a time of need, Mrs. Wilson became sick enough to need the hospital. They called their doctor, let's call him Dr. Gonomore, and he agreed to see her right away. Mrs. Wilson was short of breath, and would need to be hospitalized, to figure out exactly what was wrong with her and to offer her the most aggressive treatment.
Dr. Gonomore phoned the admitting office at Fancy Hospital across town, where he's on staff. He also spoke to the team of residents that would accept Mrs. Wilson to tell them about her condition and offer suggestions as to how to care to her.
When Mr. Wilson had his wife at the door ready to leave the office, he casually remarked to Dr. Gonomore, "See you at the hospital."
Wanting to dispel any false notions, Dr. Gonomore informed the Wilsons that he no longer cared for hospitalized patients. What really angered Mr. Wilson, more than this feeling of abandonment, was that Dr. Gonomore told them that he'd stopped going to the hospital (other than for meetings) about five years before.
Dr. Gonomore's practice group, like many other primary care medical practices (both private practices and non-profit-owned), had simply deemed it too inefficient to continue following their patients when they are sent to hospital. Primary care docs do better financially, on average, seeing more patients in their clinics than they do by taking time out of the office to go and make hospital rounds. That, coupled with the rise of the hospitalist movement, has changed everything about the way we relate to our patients.
A hospitalist may sometimes see patients in an outpatient setting, but if they choose to, it's typically only a small part of what they do. Many hospitalists choose not to see patients in an office setting, preferring to spend their clinical time all in the confines of the hospital wards.
Numbers on how many hospitalists continue office practice are hard to come by. However, it's quite clear that hospitalists are here to stay. Younger doctors coming out of residency training often choose the 'certainty' of shift work in the hospital, leaving their concerns behind at the end of a shift. They can keep using the procedural skills (doing spinal taps, etc.) that they've learned during residency--something many office doctors give up due to low volume and little practice.
As an office-based primary care doctor, my work comes home with me. There are always phone calls and e-mails to be returned, and doubts about patients and our shared medical decisions linger around for days until some clarity or progress can be achieved. There is much less of a shift work mentality, given that over time I start to see the same patients (my "panel") again and again.
"Hospitalism" (my term), the belief that hospitalists provide competent, efficient, slightly lower cost (mostly by achieving shorter length of stay for their patients in the hospital) care, is here to stay.
Many internal medicine colleagues are happy about the change. Those that want to focus on in-hospital work can do so; those that abhor the hospital (ironic, right?) now can opt out. Still, for those who want a little of both, the middle road exists, but it is trod by fewer and fewer of us.
Who likes hospitals, anyway?
I work at an academic hospital that has used "hospitalists" for almost seven decades before the term was even coined. Back then, it was called a "ward" system--one or more attendings were assigned to a ward, and they took care of all comers. Whether they would later follow up with those doctors (usually not) did not matter. The attending was there to teach the residents and students medicine--how to take care of patients in the hospital.
There's no bucking that tradition. I'm an outpatient doc more than 80% of the time. But in March, and parts of June and October, I migrate into the hospital to take my turn on the wards.
Now I do it alongside the hospitalists. But there simply aren't enough of them to cover all of our inpatients. So my colleagues and I still get our annual turns.
But under this system, unless there's a rare coincidence, I don't follow my own patients when they are hospitalized. When I'm notified (surprisingly, this does not happen automatically), I make a point of visiting, since I know a familiar face and the appearance of coordination between me and the hospital team builds confidence for a patient and family.
I was touched by the Wilsons' story. (Happily, Mrs. Wilson was home from the hospital and feeling better at that point.) Mr. Wilson seemed old school, and was looking for an old school doctor that would go to the hospital when he or his wife needed it.
Alas, I couldn't recommend coming to see me or using our hospital. I suggested starting with smaller private practices, and asking up front if doctors in the practice follow their patients in the hospital.
We in medicine of course assume everybody knows what a hospitalist is, and that people should have the expectation of seeing one.
Mr. Wilson's story convinced me otherwise.
John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, 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 that inhabit them.
Labels: career choices, Glass Hospital, guest post, handoffs, hospital medicine
posted by John Schumann, M.D. at
10:30 AM
Contact ACP Hospitalist
Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.
Previous Posts
- An admission that inpatient care is needed
- More details that no one read.
- Talking about readmissions
- Life at Grady: Innocence Lost
- Medical slang: Zombie Case
- Medical news of the obvious
- We had freedom fries...and now, freedom donuts?
- Increased medical errors in July
- It pays to read the small print.
- PHA sues over restrictions on doc-owned hospitals
Blog log
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 University of California, Los Angeles School of
Medicine, where he 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.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
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
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
hospitalist with an interest in basic and clinical science and
education, with interests in noninvasive monitoring and diagnostic
testing using novel bedside imaging modalities, diagnostic
reasoning, medical informatics, new medical education modalities,
pre-code/code management, palliative care, patient-physician
communication, quality improvement, and quantitative biomedical
imaging.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical
Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education,
ethics in medicine, health care news and culture. Her views on
medicine are informed by her past experiences in caring for
patients, as a researcher in cancer immunology, and as a patient
who's had breast cancer.
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.
Other blogs of note:
American
Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
db's Medical
Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS
Blog
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.
0 Comments:
Post a Comment
Subscribe to Post Comments [Atom]
<< Home