Per your first point. My wife and I both have graduate degrees, as do most of our male and female friends. We are always shocked at social gatherings at the hard business attitude of doctors.

Doctors quickly move off into a corner and get in heated debates on how to code to acheive a $5.00 increase in per patient visits. They attack my business professor friends for business ideas and justifications dealing with their practices.

When I go to a doctor and am subject to tacky sales pitches or watch data being spun to produce income I am appaled. When you are told you need an invasive test “just to be sure” when there is no data you become very skeptical of all doctors.

I see no joy or sense of satisfaction in the doctors I meet. Only a gritty desire to earn more money and a sense of victimhood.

Db…you make some good points, but it must be pointed out that the hospitalist movement started from primary care outpatient doc’s who were burnt out from the factory pace of the outpatient setting.

There would be no Hospitalists if the environment in primary care was more tolerable for the practitioner.

Hopsitalists did not start out as an academic movement by Internists/ or FP’s. The SHM resulted from the obvious flight of internists from primary care and the evolving needs of this group of doc’s to rally under one banner.

Despite the faults of hospitalists, they will prosper. As most hospitalists can tell you, hospitalists can stop working after 45-50 hours/week…but when they were oupatient doc’s 65-70 hour work weeks were the norm. Women are now equally represented in the profession. They do wan’t to have at least some home life. In oupatient care, the odds of being home are stacked against you. Hence, Hospitalists flourish.

as for nostalgia of the good old days and your questions of “since when did medicine become a job”, incomes for most primary care physicians were at all time highs from 1969-1990,

The past 15 years has seen a rapid decline in income for primary care physicians yet costs of training in real inflation adjusted dollars has gone up 5 fold. I do not think primary care doc’s were giving away their relatively high incomes then. I would guess that most are living on comfortable retirement funds generated by the good incomes of that era.

docs who chose primary care 20-30 years ago saw primary care as a way to work in a esteemed career AND make a good income as well.
THIS is the reason why medical school applications were at all times highs in the 1970’s. College students recognized medicine as job security and as a rewarding profession. Likewise students have always recognized the societal good of the teaching profession, but due to the low income thers has never been a competition for teachers in training.

Again, I suspect it was because the income in teaching was far less than that could be earned in medicine.

Perhaps things were different 40 years ago, but everything in the good old USA is far different today than 40 + years ago. I do agree that our society emphasizes greed, hedonism, self rights above the need to be virtous and work for the common good. (Teaching is the most important profession but pays the least)

No doubt that as primary care is devalued by insurance companies and society, college students will continue go to medical school knowing that primary care cannot pay off the enourmous debt incurred from medical training.
(Also, medical school is now very easy to enter as college students choose other careers where the economic rewards match the finacial, time, and personal investment.)

we all are complicit in this mess. We all value our money more than the common good. We have no shame buying products made by third world countries where child labor and inhumane condtions predominate, as long as it well save us our precious money. We all moan about the massive loss of doc’s doing primary care, but spend our money on cable TV, access to OPRAH, broadband, cell phones and other toys. We spend more time watching the TV than helping our neigboor. We spend more in incarceration than prevention. We are this mess.

Hi,

I’m a PCP or GP in the UK. I have just picked up on this debate from MOOFs blog, where I have just posted:

It’s Sunday afternoon, and I have time, and I have been following your comments around. I guess a hospitalist is just a hospital doctor.

You said:

“I feel strongly enough about this subject that I will simply not see a PCP again … since when I need him most, I now know I’m going to end up with a stranger anyway. Over the last year or more, I’ve discovered that I’m not the only one who feels that way. Most of us haven’t said anything to our physicians, we’ve just stopped seeing them.”

Initial reaction from a PCP like me is one of sadness… but I see the point. In the UK the PCP is a gatekeeper and is not involved in hospital mangament. And frankly, we do not have the expertese to do hip replacemnts or mangae complex internal medicine cardiac problems.

BUT what happens to someone who gets a terminal illness? My own strong belief is that they are going to be better at home with family and friends and being managed by the PCP at home. Of course, GPs in the USA do not do home visits very often (or do they? they cerainly did NOT when I was doing family practice in Chicago) so what happens? How do you get medical support?

+++++++++

I am keen to follow this debate through. In the UK the GP/PCP has a gatekeeper role. ALL patients have a GP (virtually whether or not they wish) because the way the system is set up you cannot really access secondary care without going through primary care.

The goverment over here is currently putting a huge amount of resources into primary care with the objective of reducing the costs of secondary care. It remains to be seen whether or not it will work.

Given that as I understand it AMericans can access , for sake of argument, an internist or paediatricain directly, some of these guys must be going bonkers dealing with utterly trivial illness. Or is this not the case?

John

I could not possibly read all the posts before commenting on this, DB, so I apologize for any conceits that sound original but aren’t.

For pediatricians, there are two sides to the hospitalist movement.

Pro: Pediatrics today is all about lifestyle. Hospitalists will admit patients, stay up late and wake up early for you.

Con: Man, is this ever money out of our pockets! In the era of shrinking reimbursements, hospital-related charges are a significant portion of my income.

It’s important for you to know that absolutely do not admit patients who do not meet admission criteria. I have at most one admission per month, and this is often a patient who goes to the ED without calling me and gets admitted (often without aforementioned admission criteria met).

best,

Flea

I’m not adverse to having a hospitalist take care of me if I were in the hospital, but I would hope they would communicate well with my family doctor. Do hospitalists have to write reports, just like specialists do, that are addressed to a person’s primary care doctor?

I would also hope that when a patient is discharged from the hospital in these instances, that they get paperwork to go along with any discharge instructions – copies of the last bloodwork, last radiology reports, a copy of the last day’s chart etc, plus in writing (even if it’s on handwritten) why they are being discharged and when they need to see their family doctor again. I don’t think it would work well if a patient is simply told, “YOu’re being discharged because you’re not sick enough to be in the hospital anymore. Go back to your family doctor.”

As the mirror image of MOOFs comments – I am a primary care family physician in private practice – I can attest the the fact that I have lost patients due to the fact that I do not admit my own. Of course, neither does anyone else around here, but the patients have to find that our for themselves.

Also, though, the hospitalist movement has contributed to the shrinkage of the PCP scope of practice. 95% of my day is blood pressure, diabetes, cough-and-cold, and musculoskeletal pain. Which is partly why, after 7 years in practice I’m leaving.