Demystifying Medicine One Month at a Time

Tag: hospitalists

Lamentation

I had an article published on the Atlantic’s website.

I’ve been struck over the last few years by how many graduates in my field of internal medicine choose NOT to work as ‘traditional’ internists.

Some good readin’.

Call us what you like:

  • traditional internists
  • general internists
  • primary care internists
  • outpatient internists
  • just plain old internists

You can see we’ve always had a problem with what we’re called. What is an ‘internist’ anyway? No one has any problem understanding what a cardiologist is. It’s right there in the name.

Subspecialties have always been a good career path for Internal Medicine graduates. But those of us that didn’t want to do the additional training (three to four more years) to become certified in a specific body part could always be internists.

But now our graduates are choosing hospital work as the path of least resistance. And for good reasons:

  • Better pay
  • Flexible scheduling
  • No ‘on-call’ (i.e. after hour) duties
  • Feeling better trained for the work

Part of me is jealous that this opportunity did not exist as such when I graduated twelve years ago. Part of me is sad that our trainees don’t want to take the job that I willingly signed up for.

The hospital has excellent systems in place to provide good care for patients. The doctors that work there are part of a well-oiled (well, at least greasy) machine that caters to them as much (if not more) than it does for patients.

Not true in the office world, where there is less support. More of the administrative, financial and organizational burdens fall on the doctors. That isn’t inherently bad, but it’s not what we are trained to do. And by comparison, it makes the practice of outpatient (office) medicine that much harder.

More importantly, there’s the relationship aspect: I chose to work in primary care because my relationship with patients would evolve over decades. I believed (and still do) that by getting to know patients more thoroughly over time, I can provide better, more informed, value-conscious care. The relationship between a hospitalist and a patient lasts days. Then it’s over. For an ER doc, it’s hours or even minutes. I’m not passing judgement; it’s just a different type of thing altogether.

I think about my patients at night. On the weekends. In the shower. Wherever and whenever.

In site-based care, like the hospital or the ER, when your shift is over, you go home. Without your work. [I know, of course doctors in these settings think about their patients when they go home. It’s just the idea of this ‘freedom’ that rankles.]

I could jump ship and become a hospitalist. As I reported in the article, a colleague left her office practice after twenty-three years. Her patients are upset, confused, wistful. Grateful for her care over the many years. Happy for her personally on an intellectual level. But emotionally distraught.

When I started researching the article, I identified with Dr. Fingold (read the article for context). To some degree, I looked at Dr. Wachter as someone who had unleashed a profession-altering (destroying?) force into the world.

By the time I was finished, I realized that things are not that simple. Dr. Wachter took me on a whirlwind tour of the history of hospitalists and their impact in American medicine–and it’s quite a story. He certainly didn’t unleash the disruptive force as much as he understood it, rode it, catalogued it, and helped develop it.

“I invented the term ‘hospitalist’ like Al Gore invented the Internet,” is only one of his well-crafted interview lines.

The work I did for the article is helping me to radically re-think both how we practice and deliver health care, including how we teach it to our future doctors, regardless of where they end up practicing.

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.

_________________________________________________________

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.

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