I am a hospitalist and respect outpatient internists and family practitioners too much to consider myself as noble as them. But I am an internist and today, a pain management specialist paged me for a consult, I mean, comanagement, I mean, “take care of all the paperwork under the guise of controlling her already under control chronic illnesses”. I digress. When I answered the page, he asked if I was the hospitalist. I said I was and he said, “Oh, well, sorry to be you”. When I told him that I think this patient belonged to another group, he said “Why don’t you just figure that out and then you can call the other person.”. What? Thanks for the disrespect, a-hole. My time is important too. I do have patients that I make medical decisions on, not just paperwork. I care less about the discrepency in pay then I do about the total lack of respect for what I do. Unfortunately, in America, money = respect. I am sick of being “just the hospitalist.” I am the person that saves the specialist’s ass (with the exception of a select few) at 3 am, only to be dismissed in the light of day. We actually “comanage” on patients and the admitting specialist doesn’t even round on them over weekends. Why are they getting paid a lump sum for the H&P, discharge, daily visits, etc. all included in the price of surgery, when we are actually doing all of their paperwork? Why can’t we charge them to be their scut-monkeys? Of course, they bring in the money so they are more valuable to the hospital admin and we will always lose. Just like the high school football team…Sad.
At Internal Medicine 2009, I ran into a former resident (from the 1980s when I was a program director.) I asked him about his career, and he told me of 15 years in private practice. He then left to become a hospitalist. He is finally happy in his 3rd hospitalist job.
I have cautioned frequently in essays that the title does not define the job. I know of outstanding hospitalist jobs, and I know of jobs that represent semi-advanced resident positions.
Hospitalists are mobile, in short supply, and valuable to their hospitals. My advice to the commenter is to re-evaluate your hospitals approach to hospital medicine. The problem may be the hospital’s expectations.
Internists tend to say yes. We become the "least common denominator" for patient care – we get the patients who others "refuse." We are the nice guys and gals.
The best hospitalist programs set clear limits on their responsibilities. As hospital medicine evolves, it needs strong leadership based upon sound principles. I am very interested in Dr. RW’s thoughts about this post, as I know that he has strong feelings about this issue. I am inviting him publicly to post and I will post his comments as a blog entry here. I also invite other hospitalists to weigh in. This is a huge potential problem.
{ 8 comments… read them below or add one }
The recent post by Dr. Centor describes the future of general internal medicine. We are rapidly becoming the scut monkeys of the medical zoo.The job of both the Internist in the ambulatory care setting and the hospital is being reduced to being a hand-maiden for specialists more sought after for their procedural skills. Those skills and the procedures they generate make the hospitals money,thus it is no surprise that the system have created highly skilled coolies to lighten their loads.
The request that Dr Centor resents is replicated several fold in my practice where I am yet one of the remaining “traditionalists”. Here specialists demand that I “co manage” their patients not only in the hospital but also in the skilled nursing facilities as the GPS positioning devices in their expensive automobiles are not programmed to find these locales.In addition the administrative loads imposed by insurers, pharmaceutical benefit managers and others have created situations that have earned the ill will of patients who believe that as i struggle with these administrative burdens and cannot humanly address them in real time that i am providing them with inadequate care.
Administrators have converted us from physicians to”providers” confusing our professional roles with those of faith healers and others.
The lament in the blog is a little late,the train has left the station. In the Obama reforms which attempt to move primary care back to more favorable seats even our professional organizations are afraid of disturbing the status quo and demand that we yet travel in steerage as they refuse to demand reduction in specialist compensation to enhance primary care pay.
This blog was critical of a letter I wrote several years ago pasted below.
ANNALS OF INTERNAL MEDICINE
2 May 2006 | Volume 144 Issue 9 | Page 702
TO THE EDITOR:
A thoughtful editorial (1) bemoans a decline in the number of practicing internists but admits to a paucity of information in literature and among physician workplace researchers to explain its causes. I have previously made comments (2) relevant to this problem. Thirty years of practice as an internist allow me to make further observations.
Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings.
Medical subspecialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist’s only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation.
A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory?
I am interested whether Dr. Centor and Dr. Wachter would address my then concerns in the world Internists work in today?
Have you considered doing a fellowship?
The expectation that the hospitalist figure out if the patient belonged to another group leads to one of my most frequent complaints about the hospital where I practice. I have a primarily office-based practice but also take care of my own patients in the hospital. Quite often they will get admitted for surgery and rather than notifying me of the admission the hospitalists will get called. Most of the time they see my name on the chart and call me. It would be far better for me and my patients, and save the hospitalists from wasting their time, if they would simply notify me when my patients are admitted by someone else.
There have also been a number of times when there have been problems such as patients not receiving necessary medications after sitting in the hospital for a day or two before I find they are in the hospital. I have repeatedly requested that I be notified at time of admission if my name is listed as a patient’s primary care physician, but this is far too difficult for the hospital to manage.
I especially find this annoying when they also talk about the patient centered medical home. Why can’t the hospital manage to “phone home.”
It’s interesting. You can take the higher road and address it with class. As a physician, a professional and a human, I would never treat someone else in this regards. With that said, only you can control how much “abuse” you accept. You set the ground rules and you make sure others know. When my group first started we were being asked to read post central line chest xrays by surgeons who had “already left the building.” Of course, this is not a billable procedure. We were assumed to be house docs at the beck and call of others. We were also being asked to sign oxycontin scripts for docs who had already left the building. We were also being asked to declare death in patients at 3 am that were not on our service. All this went away once the ground rules were established. And very quickly I might add. If you allow yourself to be disrespected, that is your own fault.
I frequently get consulted by subsubspecialty services that consult us for “medical management”.
Medical management of stable medical issues is not a consult, nor does it need daily following by anyone but the surgeon and the daily nursing evaluation. It’s like living outside the hospital. You don’t have a doctor following you around at all times. I kindly review the admitting H&P, write a brief progress note and indicate the stability of the medical problems. And then sign off the care of the patient. As a hospitalist, we are not there to do skut work. If the surgeon wants some one to take midnight calls for a head ache or a sleeping pill they should hire someone to do that for them.
With that said, I always leave the door open to call back any time with acute medical related questions.
I once had a nurse tell me the surgeon wanted me to address surgical pain related issues. I laughed and deferred as “out of my scope of practice.”
You control the ground rules. If you don’t, and you don’t like the ground rules, it’s up to you to either change them or find another position.
In this case I would simply write an order to notify referring physician that patient has other physicians providing his continuity of care. And sign off. I would do his job for him. That creates an enabler, much like feeding the alcoholic his booze.
Regarding the last comment, when I am consulted I always ask who the outpatient doc is. Certain docs always see their own. I always ask that the clerk call the primary for patients who may be seen by their primary and then tell the clerk to call me back once it is known whether I or the primary should see. After seven years this should be automatic. But in some parts of the hospital, it is a daily battle.
DB,
Thank you for posting this. This pushed some of my buttons. Yes, I will write a post on this topic. Very heavy schedule now, so watch for in in a couple of days.
That would only exacerbate a continuing problem, one does not need a fellowship to practice competent medicine and in many specialties the extra years of training add procedural but few clinical skills.
Unfortunately, there may be a change in direction for the specialty physician who may soon have to do the mundane tasks that they foist on primary care physicians as that breed is rapidly becoming extinct. Would specialty training in primary care then become fashionable?????
Happy Hospitalist,
My point is that as a primary care physician who regularly treats my own patients I should automatically be called at the time of admission. There should not be delays until the hospitalist sees the patient and determines that they were called in error, and the hospitalist shouldn’t even be bothered with this.
In our case the hospitalist themselves makes the call. If they left it for the clerk to clarify the call would never get made.
CMS has 80 demonstration projects going on to reengineer health care. The CMS establishment has taken up the process of value based reward. The underpining may be read in Michael Porters book Redefining Health Care in America.
Mr Porter is an economist. By realigning the reward incentives he hopes to improve health care. It is a complex process to capsulize.
In order to keep your interest and get to the point. CMS is leading. ACP seems to be following to fit into this process. It had proposed the medical home. ACP would like the medical home to be the central locus for the realignment of incentives in providing health care according to a value based process.
There is nothing in the value based process I can see which requires a primary care internist. In a value based system pay will go in the direction of value attributed. There will be no sinecure.
By hitching the ACP medical home concept to value based care ACP may be accepting a Trojan horse.
The calculation of economists on the CMS website show that they are going to slice up an internist into minutes of care either directly or as part of a team. what will result will be modest improvement in rewards but so fully calculated and controlled internists will not be granted parity with specialists. In fact I fear the cost of the medical home with all it’s ancillary personnel though justifying under $100 per member per month will cost the independant practitioner as much as he or she gains. The cost of entry will go up to the point physicians will start careers and continue as servants of administrators of group practices.
Some years after the new homes are implemented it will turn into the next coffin nail.
Though verbally advised the amount per member per month will be $40-$80 per member per month and severity adjusted I can not find it in writing at least yet.
To my dismay the severity adjustment will be less that the current(HCC) factor used in Medicare Advantage, as I read the CMS material.
Here is my speculation:
ACP should stop trying to lure more internists into IM with startup bonuses and short term bonuses as the board of governors approved two weeks ago in Philadelphia.
Act on an open reappraisal of the diminished position of the profession.
Put simply, though internists may be doctors for adults we are not and do not have to be doctors for all adults.
Cut down the number of training positions to fit the numbers needed.
Assign so many positions for caring for the very chronically ill in fee for service, and in Medicare Advantage, so many for large groups which will generate high tier medical homes, for hospitalists, and in medically undersereved clinics, etc. then ask how many people bright enough to understand the spectrum of illness will be happy making $100,000 a year in a fee for service setting. Since currently it is not many let the training cadre rightsize.
As to trying to shoehorn the worried well, and commercially insured majority of Americans into a medical home, they don’t want it. Let family practice and it’s nurse practioners thrive on this endeavor.