Is outpatient internal medicine dead?


Category : Medical Rants


Medscape has a provocative discussion occuring – More Physicians Abandon Hospital In-Patient Care.  A few excerpts:

Primary Care Internal Medicine is DEAD – at the hands of Medicare and the Insurance monopoly – the body is still twitching but it’s dead. By the time our leadership both political & medical, realize this it will already be too late. Then, as the house of cards built upon that moribund foundation collapses, I will watch with a morbid glee and hope something better can be built from the ruins.


I currently am in internal medicine private practice and see my patients in the hospital and in the office. I plan on changing to either pure hospitalist or pure office soon (still on the fence as to which one) because my group cannot afford the time lost going back and forth. I do feel the patient and myself both lose out, because the old system was more intimate and individualized. I also feel I will lose out intellectually in whatever sphere I give up. The current liability risks, overhead, and increasing time demands fulfilling insurer’s wants make it impossible to provide service any more. The new way is neither better or worse medically, just different.


In the "old" days practicing in a community hospital you knew the specialist who you could refer the patient to. He or she was somebody you knew. They were people who cared about patient referrals and patient care. This specialist knew you as well and had immediate contact with you after seeing the patient. There was continuity of patient care. Exchange between the referral physician and you was always there. Your patient relied on the primary care doctor and not necessarily on the specialist since you were their "doctor". I feel sorry for the young doctors today but more especially for the patients who have "missed out" on the essence of real medical caring.

The entire thread (now 17 pages) has many great quotes.  These physicians express clearly the economic and life style issues which contribute to the rise in hospital medicine.

As one who loves hospital medicine, I worry about the long term impact on outpatient physicians.  Without hospital rounds they become increasingly isolated.  When the care for their own hospitalized patients, they interact with the medical community.  The dissociation that we now see will likely have negative externalities.

We have evolved quickly to a hospitalist system because of economic and lifestyle issue.  Dedicated hospitalists become comfortable with the hospital and the relevant systems.  But what happens to health care overall?  How does this impact those physicians who never come to the hospital?

I do not have a solution, but I do worry about our current evolution.  We need more "combo" types – those who are comfortable and competent in both inpatient and outpatient medicine.

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Comments (7)

Thank you DB. I thought I must be crazy to continue to be one of the few that does both office and hospital. Despite all the studies, I find hospitalist care lacking, particularly in knowledge of the patients history. I wonder if anyone has ever done a study on how many duplicate ECHOs or MRIs are done unnecessarily by hospitalists, because they were just done by the PCP. I’ll bet if that info were added to the mix, the $400 difference in cost cited by Lindenour would go away.

Exactly, I am very much particular about this. Patients care and history should be maintained in a way to cure disease, but it happens rarely. Solution to this problem is medicine where we have every facility to patient.

I think this is a wider problem than realised. The doctor patient relation is not the same. In fact I agree with the famous quote “distancing began when Laennec rolled a few inches of cardboard as a stethoscope”. I think like everything medicine is trying to follow an ‘assembly line model’ similar to industries, with one doctor specialising in one organ system or in one setting like outpatiient or hospital. But what is often not realised is that patients are different than cars,hospitals different than factories and medicine should not become a business.

Medicine is and should become a business. The problem is that we’ve forgotten who the customer is. Too many of us have drunk the insurance Kool-Aid. I work for my patients. They very much value my care for them in the hospital, so I’ll always continue to see them there. Under the insurance model this is inefficient; under my model this is excellent customer service. It’s good medicine too.

It is one of the most burning problems nearly all over the world, leaving out developing countries.
The ambulant doctor and the “hospital machine” don´t fit together – neither in medical nor in financial terms.
But indeed there is a way in between, which would help everyone: Professional doctor´s centers, assembling a couple (lets say around 10-20 doctors) in a professionally set-up location. We have a few here (in Germany), and tehy are great. In terms of care (more professional), in efficacy (common costs are shared, low overhead) andfor the doctors – they have evrything in-house and can share the bureaucratic burden

For some reason it seems to me that doctors love the doomsday prophecy: “Outpatient IM is dead! Film at 11”.

There will always be new trends affecting healthcare economics. These trends affect the broad healthcare market just like the trends that affect the stock market.

Just like individual stocks within the stock market, there will always be practices that beat the averages and buck the trends. The owners and physicians in those practices will NOT focus on the ambient bad news.

They WILL focus on delivering exceptional care in a systemized way, building a championship team, creating a unique patient care experience and increasing retention and referrals in their practice. And by the way, all of these business skills are learnable and scaleable – anyone can use them.

[The problem is we don’t know these skills and we don’t think like business people. We tend to think more like employees… even if we own our own practices. It’s not really our fault, we’re thrust into running a small business with no training for it.]

I chide my clients to balance their focus between practice building and providing outstanding patient care and to ignore the evening news!

David Zahaluk, MD

Dr. Z is full of bull. I’ve been in practice for 20 years and I have a championship team. Economically, I have never seen things this bad. Our reimbursement is stagnant or falling yet all other costs and overhead continues to rise. Internal medicine is not a viable business in today’s environment.

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