Patients leaving primary care physicians who eschew the hospital

29 Jun
2009

Had a great time talking to family physicians at the Alabama Academy of Family Physicians. One conversation with an experienced family physician included the hospitalist phenomenon. He mentioned that a significant percentage of patients left his practice when he stopped making hospital rounds.

Patients are smart. They understand the value of having a physician who knows them well. I wonder how prevalent this sentiment really is.

Most articles about the value of hospital medicine focus on the hospital and the care received there. I am sensing a growing skepticism amongst patients.

I write this as someone who has eschewed the outpatient clinic. Most patients that I see really have no choice. I help care for “unassigned” patients in a community hospital and VA patients (who have never had comprehensive physician care.) My hospital experience is clearly skewed because of the patient population I serve.

But I do believe this is a legitimate concern. I hope that this rant will stimulate some commentary from hospitalists, outpatient physicians and comprehensivists.

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5 Responses to Patients leaving primary care physicians who eschew the hospital

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Web Media Daily – Monday June 29, 2009 | Reinventing Yourself...

June 29th, 2009 at 7:37 am

[...] Patients leaving primary care physicians who eschew the hospital …DB’s Medical Rants [...]

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CancerDoc

June 29th, 2009 at 8:47 am

I was recently consulted on a 89 year old female admitted by our hospitalist service for dyspnea who also, incidentally, had pancytopenia. When I reviewed the labs available to me, this had been going on with in a relatively stable fashion for years. The patient has limited mobility and is at peace with life (actually making the statement “I wish I could just go on a die; I have done my part for this world.”). I did my evaluation, but recommended supportive care. Her family, who had been on vacation when she was hospitalized, called immediately on their return. They knew about the blood issue, but in agreement with the primary did not want anything done “at her age and with all of her other problems.” Therefore, because a primary who knows her was not involved in the care while in the hospital, a unnecessary consult was generated. In general, I see patients on the hospitalist’s service often achieve continuity through all of the specialists that are consulted. We become the continuity because we see them in the hospital.

On the flip side, I was recently talking to one of our internists. He is burned out and finds having to worry about hospitalized patients that are “crumping” inhibiting his ability to focus on the clinic, and if he can’t focus on clinic, he can’t have the through put that he needs to generate a profit. He is considering going the hospitalist route because he feels that he wont’ be working as hard and the compensation will be better. THAT will be a loss to our community. As someone who works both in and out patient services, it IS difficult and feels that no one is receiving the best care when a patient is “crumping” and one is trapped in clinic. I don’t think there is good answer.

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internist

June 29th, 2009 at 6:38 pm

Hospitalists do not care. They are most interested in disposition, that is, discharging the patient from the hospital and lowering the census. They do not advocate for the patient as a primary care doc would do.

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solo dr

June 29th, 2009 at 8:40 pm

Both my local hospitals have hospitalists. Most of the younger doctors and doctors close to retirement use the hospitalist services. The hospitalists are there 24 hours a day, which does help speed up discharges.
What I find is that since each hospitals pays and supports its own hospitalist/multispecialty group, and the hospitalists give the consulations to select specialists who happen to be in the same group. The hospalists take the ER call for inpatients who are without regular primary care doctors, which does save most of us time in rounding.
I still see my inpatients and outpatients. For the 1-2 hours spent rounding in the hospital daily, I can make 5 times or more the amount of money with less liability in the outpatient setting.
I see my patients because I care about them and because I like to know what abnormal tests and medication changes happen during the hospital stay. I have gotten new patients from the ER call where hospitalists see the patients and the discharge summary simply states that cardiac meds were continued and/or the discharge summary is not done 2-3 weeks after the patient is going home on coumadin or other meds that need monitoring. I feel safer seeing my own inpatients and outpatients, even though the inpatient care is not financially rewarding.

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JunkMD

July 1st, 2009 at 9:40 pm

As a former “comprehensivist” recently turned hospitalist, I hear what you are all saying. However, a perfect world does not exist at this time in American medicine. I don’t think anyone can debate the fact that knowing a patient well and caring for that patient as both an outpatient and an inpatient is the best scenario.

Unfortunately, until we address the true problem, which is how we get paid by the government and private insurers, this is the way it is likely going to stay. I routinely hear the comments which tend to insinuate the hospitalists’ selfish motives of more money and a better lifestyle. However, I disagree that the notion of sacrificing my family, my education and basically my life to hold on to an ideology is somehow more noble than providing quality care to inpatients. It is much easier for the “comprehensivist” with 8 partners to make this argument than many of us who are in small practices (and I do realize that many making these arguments are in the smaller practices).

I would go back to a traditional practice in a heartbeat if the pay was equitable and I would be able to make a living, pay overhead and have a somewhat normal lifestyle. But, as the house calls of Marcus Welby’s day have gone by the wayside, unless something changes the way doctors are paid, so will the traditional medical practices (unless of course, they choose retainer medicine).

I would also disagree with the assumption that just because the primary physician is not rounding that there is always fragmented care. As in any situation, your program is only as good as the integrity of the physician delivering the care. I don’t profess to know my inpatients as well as their primary physicians but I make it my job to review every available old record, call the primary physician for information, and upon discharge, make darn sure that the primary physician receives a discharge summary before the patient follows up. If a summary is not possible prior to their visit, a phone call to the doctor is in order. If you take pride in your work, you can have a superior delivery system.

With the way we are paid and the way I had to run patients through my office like cattle, I felt as though the only way to provide quality care (in my particular geographic area as I am one of only a few internists), have a decent lifestyle and also the only way for me to maintain the internal medicine education I have worked so hard to attain, I had to choose inpatient medicine. Maybe it’s because I’m just not that smart, but I have to have time to read and study about my patients in order to keep up.

Let me finish by saying how much I admire the physicians who are committed to practicing traditional medicine. My hat’s off to you!

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