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.