The paper of record has a piece on hospital medicine today. I guess this means that the field has arrived. New Breed of Specialist Steps In for Family Doctor As usual the Times does not distinguish between family medicine and internal medicine. I have learned that the Times understands the difference, but chooses not to make the distinction because "they" do not believe their readership (the most intelligent and sophisticated readership in the world) understands what an internist is.
The article focuses on a few issues. First, they highlight hospitalists doing the hospital care for primary care docs. They do a reasonable job of explaining the economic forces that make this a good deal for primary care docs. Second, they discuss the problems that hospital medicine brings – transitions especially. Finally, they discuss the problems of processes and systems in hospital medicine.
What do they leave out? They seemingly ignore the big growth industry in hospital medicine – concurrent care of many surgical patients. They allude to the issue of unassigned patients.
But the biggest thing that they avoid is the idea that hospital medicine exists primarily because hospitals pay their way. Given our payment structure, hospitalists cannot make a desirable salary purely based on billings. Hospitals understand the value proposition, and pay salaries that make the job financially competitive.
Of course, even the Times cannot write a nuanced article about either primary care or hospital medicine. Since I have spent much time working in both fields, I can see the omissions and flaws in their articles.
If they must simplify this issue, then what happens in their other articles. And TV "journalism" is even less compete.
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Also left out is any reference to the qualifications and experience of these hospitalists. My husband became ill last year and was admitted through the emergency room of a “high quality” hospital. He was left in the care of hospitalists, who seemed to be completely clueless as to how to diagnose and treat anything more complicated than the most obvious of ailments. They were young, inexperienced “technicians” who have simplistic, preconceived notions and fail to listen adequately. “Continuity of care” was a joke. This was a very scary education about the state of hospital care today. I do not want doctors diagnosing and treating me who are happy to spend 60% of their time doing paperwork and designing systems. And where in the article is any discussion of the “downside” of this system?
I also agree with your assessment of the Times’ patronizing and dumbed-down coverage. I have been observing this trend with distress as they continue to sink to new lows. Their skewed and frequently buried coverage of climate change is a case in point, which any person with the vaguest scientific literacy will realize. They’re just caving in to the prevailing trends in our culture – the sound bite, shallow content, tricked-out graphics. They need to realize they do indeed have an educated, sophisticated readership who may already have started looking for a replacement for the Times. A rising tide lifts all boats, and if the Times were to maintain their previous level of fearless reporting of the truth, and perceptive, thoughtful commentary, they would be taking a step to stem the tide of dumbness that increasingly pervades American society.
I have learned that the Times (the most intelligent and sophisticated readership in the world)
Reference for this?
I can’t complain. Helped my parents figure out what the heck I do for a living…
My sentiments exactly! This is only possible due to current payment structure which in my biased primary care view is flawed. Medicare RBRVS rates for low level visits ( colds, rashes, uncomplicated chronic medical problems) are about $280/hour while visits for complex patients that require lots of time and care coordination are about half that or less! That is upside down and the wrong incentive. What does this mean in reality? I don’t accept new Medicare patients – I haven’t for more than 6 years. My kids need a college education, I need to fund my own retirement, I have 25 years left on a 30 year mortgage. I can respond to your economic incentives!
I would like to see a study of hospitalist care vs. Full service concierge internal medicine with practice limited to 600. I suspect the latter would be much cheaper due to fewer hospitalizations. But hospitals don’t get paid if people stay OUT of the hospital. Just if they can push them out quickly after they have collected their DRG. I know Wachter and Flanders and the like are tingly all over with this article and the success of the hospitalist movement. To me it indicates a destruction of primary care through perverse economic incentives. Is it the reality now? Absolutely. Is it based on pure science, truth, ethics, patient and physician preferences? Hardly. Just economics. Change the payment structure, good docs compete for complex patients, have time to keep them out of the hospital, costs go down, hospitalists go away.
BTW, where do I apply for that $190K job where you spend half your time pushing paper and the rest sitting around in the ward while the residents do the work waiting for the nurses to call you for a laxitive order because you are so available? Sounds like free money to me!
I still see my own inpatients, often rounding at 6 am and often having to return at 6 pm for updates. The payment system does not reward my efforts. Unlike the article, I do return phone calls to family members of my hospitalized patients, and the family usually likes hearing from a doctor who is familiar with the patient’s care.
The other day one of my patietns was accidentally admitted to a hospitalist and had an ABI repeated for no good reason.
The local hospitalist groups at my two hospitals are both owned by the hospitals. Majically their referrals go to the hospital-owned specialists. Inpatient stays may shortened, but the outpatient studies and 4-5 specialists per patient when I could manage teh patient myself or with just 1 specialist are costing the system more money.
The article also points out a common problem: outpatient follow up. If I see an on call patient assigned to me from the ER who was an inpatient seeing a hospitalist, as I am on call only for my own patients, nothing but a med list and diagnosis list will make it to my office for at least 2 weeks, until the discharge summary is done. Many of the patient never follow up. Continuity of care is an issue under the current system.
Reimbursement is poor for primary care inpatients. Instead of seeing 2-4 patients in the hospital acroos 1 hour or more and with the risk of middle of the night calls from the nurses, I could spend the same time in the office and make 40% more with less liability and less work.
I still see my inpatients because my patients like the familiar face and the doctor who can review the outpatient chart on weekends to preven unecessary tests.
**Hospitals** own and subsidize the salaries of hospitalisits. Everything else is just commentary.
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