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Demystifying Medicine One Month at a Time

Where have all the young docs gone?

In my new role as one of the directors of an internal medicine training program, I help select new interns out of medical school for the three year training stint of residency.

At the end of residency, many graduates go on to subspecialty fellowships, another two to four year period of intensive training in fields like cardiology, nephrology, critical care etc.

For those that don’t choose a subspecialty, one choice remains: traditional internal medicine (opening or joining a medical practice) versus becoming a hospitalist.

At this point, it’s no contest. Hospitalists earn  more money. North of $200k.  One standard job format involves fourteen hour shifts, seven days on followed by seven days off. Our graduates are unanimously choosing this path.

I fear that young doctors don’t see value in primary care careers. With health care reform set to kick in in 2014, there will be a tremendous shortage of available doctors for newly-insured patients to see.

I’m reposting a story I wrote about one couple’s painful experience learning about what a hospitalist is. In future posts, I plan to explain the competing tensions between the alternate job pathways in internal medicine and examine the health care workforce as a whole.

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A place many internists no longer see.

A few weeks ago I got a call from Frank Wilson (not his real name).

He told me he and his wife were looking for a new doctor and a new hospital.

Mr. and Mrs. Wilson had been with the same doctor for nearly 20 years. The relationship had been warm, and, he explained, “We trusted him to follow us through thick and thin.”

I could sense the hurt in his voice. Why, I wondered, would they give up on a doctor who knew them so well? Among people of my generation, doctors are switched more than toothpaste.

At a time of need, Mrs. Wilson became sick enough to need the hospital. They called their doctor, let’s call him Dr. Gonomore, and he agreed to see her right away.

Mrs. Wilson was short of breath, and would need to be hospitalized, to figure out exactly what was wrong with her and to offer her the most aggressive treatment.

Dr. Gonomore phoned the admitting office at Fancy Hospital across town, where he’s on staff. He also spoke to the team of residents that would accept Mrs. Wilson to tell them about her condition and offer suggestions as to how to care to her.

When Mr. Wilson had his wife at the door ready to leave the office, he casually remarked to Dr. Gonomore, “See you at the hospital.”

Wanting to dispel any false notions, Dr. Gonomore informed the Wilsons that he no longer cared for hospitalized patients.

What really angered Mr. Wilson, more than this feeling of abandonment, was that Dr. Gonomore told them that he’d stopped going to the hospital (other than for meetings) about five years before.

Dr. Gonomore’s practice group, like many other primary care medical practices (both private practices and non-profit-owned), had simply deemed it too inefficient to continue following their patients when they are sent to hospital.

Primary care docs do better financially, on average, seeing more patients in their clinics than they do by taking time out of the office to go and make hospital rounds.

That, coupled with the rise of the hospitalist movement, has changed everything about the way we relate to our patients.

A hospitalist is a doctor who spends most of his or her patient care time caring for hospitalized patients. It does not mean that they don’t see patients in an outpatient (office) setting, but if they choose to, it’s typically only a small part of what they do. Many hospitalists choose not to see patients in an office setting, preferring to spend their clinical time all in the confines of the hospital wards.

Numbers on how many hospitalists continue office practice are hard to come by. However, it’s quite clear that hospitalists are here to stay. From the time the term was coined by Wachter in 1996, the number of doctors choosing to become hospitalists has risen exponentially.

Many in my field expect hospital medicine (“hospitalism?”), like emergency medicine before it, to become it’s own specialty field.

Younger doctors coming out of residency training often choose the ‘certainty’ of shift work in the hospital, leaving their concerns behind at the end of a shift. They can keep using the procedural skills (doing spinal taps, etc.) that they’ve learned during residency–something many office doctors give up due to low volume and little practice.

As an office based primary care doctor, my work comes home with me. There are always phone calls and emails to be returned, and doubts about patients and our shared medical decisions linger around for days until some clarity or progress can be achieved. There is much less of a shift work mentality, given that over time I start to see the same patients (my “panel”) again and again.

“Hospitalism” (my term), the belief that hospitalists provide competent, efficient, slightly lower cost (mostly by achieving shorter length of stay for thier patients in the hospital) care, is here to stay.

Many internal medicine colleagues are happy about the change. Those that want to focus on in-hospital work can do so; those that abhor the hospital (ironic, right?) now can opt out. Still, for those who want a little of both, the middle road exists-but it is trod by fewer and fewer of us.

I was touched by the Wilson’s story. (Happily, Mrs. Wilson was home from the hospital and feeling better.) Mr. Wilson seemed old school, and was looking for an old school doctor that would go to the hospital when he or his wife needed it.

Alas, I couldn’t recommend coming to see me or using our hospital. I suggested starting with smaller private practices, and asking up front if doctors in the practice follow their patients in the hospital.

We in medicine of course assume everybody knows what a hospitalist is, and that people should have the expectation of seeing one.

Mr. Wilson’s story convinced me otherwise.

9 Comments

  1. Dr. Schumann: Did I send my reply or forget to “submit” it? I was looking for a “send” key and couldn’t and may have screwed up. WTJ

  2. WOW. Loved the read. On the other side of the story (as a struggling young doc myself), I believe the system is so enslaved and enamored by super specialization and in a way holds specialists in such high esteem over other PCPs, it is normal for the debt-ridden med student to am for those specialties.

    I would love to have a career in pure, simple, old school Internal Medicine. Looking after people in an Office/OPD or Inpatient basis. But whenever I think it would make me take a rear seat to my super specialized colleagues, I get a little apprehensive.

    Its not JUST us doctors to blame, but the system’s obsession with specialization and a skewed salary/honor system as well.

  3. Dr. Schumann, Loved this story, until I started working in the medical field I had never heard the term hospitalist, how shocked I was to find out that my primary care doctor may not be the person who sees me if I am hospitalized. What a scary thought that someone you have been seeing for years may not be the one taking care of you when you are at a very ill point and need to be hospitalized. One of the first things I did after discovering this term and what it meant was to check with my PCP to make sure he did go to the hospital and exactly what hospitals he had priveleges at. Not that hosptialists are bad it just that if you have this idea that your doctor will see you in his office as well if you should have to be hospitalized and you find out differently it can be shocking. Thank you for your insight on this topic and hopefully more people will become aware of the difference and check with their doctor on his status.

  4. Excellent posting! I never heard of the term “hospitalist” until you informed me. As a breast cancer “survivor,” my relationship with my doctors are of paramount importance to me. I was so lucky to have my PCP visit me at the hospital after I had a DIEP flap procedure. She said to me, “Being in the hospital is rough, but you will have to tap into your inner reserve of courage and get through this.” She held my hand.

    I can’t tell you how much that meant to me as a patient — to have my own PCP visit me and assure me.

  5. In your new role as one of the directors of an internal medicine training program, you may want to consider how we can address the following.

    As an RN for 40 years, it has been my observation that as healthcare has evolved into an ever-more-dominant DISEASE CARE & business model we see more and more individuals entering the profession(s) who should not be there. They are not ‘healers’.

    They come for myriad other reasons including financial, autonomy in time management, prestige etc. etc. The Canadian and European models, while anathema to the Big Pharma controlled US ‘medical industry’, seems to be better focused for patients overall and closer to what Hippocrates viewed as health care.

    Their care givers are in it because they truly want to do just that — give care to those in need. There is less incentive for other types to enter the profession(s).

    I have no doubt that you are aware of these issues as well. They factor into your interest in DYI mediicine more prominantly than you may ever have thought about ! Semper Fi !

  6. Jennifer Hoffman

    December 4, 2011 at 11:17 am

    Keep up the wonderful work, I read posts on this site and I think your blog is really interesting and has got good info.

  7. Hospital medicine has become so complex and we office-based physicians may feel our inpatient skills are not up to par. Our office practices are extremely busy and clincal work in addition to doing and delegating the enormous amount of administrative tasks and emails we answer don’t allow time to practice inpatient medicine optimally.

    I love the hospitalist programs. One group recently came to my office so that we can work seemlessly together, and patients don’t have to be admitted through the ER as they often are.

    I inform my patients of this program and once they understand how it works they feel they will be receiving optimal care.

    I learned I had to be proactive about communicating this information to new patients because one did expect continuous care while an in-patient. Of course, I still do social visits whenever possible.

  8. Interesting story, and I’m not surprised that Mr. Wilson was unhappy. It sounds to me like the change in practice was handled poorly by his physician. But there’s another side to this story. I’m a hospitalist, and like Dr. Schuman, I have my perspective.

    Our hospital system doesn’t mandate the use of hospitalists, but they do require that primary care physicians (PCPs) have more office hours so that patients can be seen when it’s convenient for them – evenings and weekends. Patients really like this because they have easier access to their docs, but this means less time for office-based physicians to go to the hospital.

    Hospitalized patients are sicker these days, and hospitalists can see a patient, review their scans with the radiologists and talk to all the consultants involved to decide on a comprehensive plan. PCPs have a busy office practice to contend with.

    And what happens to patients who get acutely worse during the day or night? Hospitalists go see them in person. PCPs have to manage it over the phone or call in a sub-specialty consultant. Neither of those options involve the the hands-on personal care you are describing.

    Hospitalists will never be able to match PCPs in terms of patient relationships, and that is an issue. However, that just doesn’t outweigh the benefits. In my institution, the hospitalists have a DVT prophylaxis rate > 90%, while the PCPs average around 65-70%. We’ve reduced the rate of blood clots, which can be fatal, but the primaries haven’t. Our rate of readmission for congestive heart failure is about the same as PCPs, but we have the bulk of the sickest patients.

    Hospitalists and PCPs are really on the same team, and playing well together is what’s best for patients in the long run. In the past, internists used to perform more procedures than they do today, because they have had to give those up to specialists who had higher levels of skill and better outcomes. There are parallels with hospitalists, but just as PCPs manage the totality of care in the office, hospitalists do the same in the hospital. When they work together, everyone wins.

  9. I do believe that part of the problem of shortage of physicians is linked to the low number of residents admitted into the residency programs…I know of situations where candidates are having a very hard time finding residency spots and many of them going unmatched due to the very low quotas… PG 1 positions are hardly over 6 spots in most programs and when you compare that to over a thousand qualified applicants during each match season, you can begin to see why the shortage exists and reaching an alarming level…the push should be to increase the number or residency spots for PG 1 positions if we truly want to address this shortage.

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