Demystifying Medicine One Month at a Time

Tag: Primary Care Shortage

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.

Help Wanted: DIY Medicine

Taking medical care to the self level.

First there were contractors. Then came Home Depot.

Once we had accountants. Along came TurboTax.

Stockbrokers? E-trade.

Printers? Soon we had Kinkos, er, FedEx.

Even venerable old lawyers are being outsourced and replaced by do-it-yourself manuals and online services.

Which brings me to my profession. Medicine.

I’m researching a new frontier in health care: do-it-yourself medicine. As more information is available online, patients are empowered like never before.

The rise of the e-patient movement is one such example. But now, with direct-to-consumer lab testing and radiology, people are able to access medical services and consume them like any other commodity.

I’m interested in learning about people that obtain these services without the consultation of a medical professional.

Caveat: a lot has been written about cyberchondria, google-itis, and patients advocating for themselves and their loved ones with their doctors.

I’m looking for people out there that self-diagnose and treat but make every effort to steer clear of the medical establishment.

Are you such a person? Do you know one?

All information and stories will be held in strictest confidence. We’re trying to gauge the prevalence of this phenomenon in the world.

Comment on the blog or send tips/inquiries to GlassHospital [at] gmail [dot] com.

Un-Maligning the ER

One last post on the ER….for awhile.

As I mentioned in an earlier post, the ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services (the big exception here is elective surgery–patients having elective operations don’t need to be triaged) have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions:

1. What’s the nature of the illness?

Are we dealing with the heart, the brain, or an abdominal organ?  Is the cause an infection, a blockage, or a blood clot?

2. Based on #1, where will the patient best be situated?

Will the patient need intensive care, or will the “regular” floor be sufficient to attend to the issues at hand?  Should the patient be admitted to a surgical team or a medical (non-surgical) team? Continue reading

The Mystic Portal Awaits

And waits, and waits, and waits……

The ER is the portal of admission to the hospital for what we might call undifferentiated illness.  Shortness of breath.  Chest pain.  Fevers with localizing symptoms (like pneumonia, appendicitis, or gall bladder infections).  “Changes in mental status”–confusion, delirium, or dementia, caused by Alzheimer’s, strokes, and many other diagnoses.  Of course, other emergencies are usually well taken care of in the ER: fractures, lacerations, bleeding, etc.

Why do we have to wait so long to get seen and treated in the Emergency Room?

Well, crowding is one problem.  You’ve heard endless commentary about ER crowding.  Too many people using the ER for non-emergency issues: colds, sprains, back pain–all things that could be better treated in the office or over the phone. Too much difficulty getting seen by your primary care physician.  There are simply more people waiting to be seen than can be accommodated in a “reasonable” time frame.  [Of course, this all depends who is defining ‘reasonable.’]

The ER is a victim of its own success.  The ER “brand” if you will, is sexy.  Start with those TV dramas that glorify the gritty heroes who work on the front lines.   Then, the simple message of an ER’s mission:  “We’re always open, and we can’t turn you away.”  For people who don’t have insurance, or who are frustrated by lack of access to their (or any!) doctor’s office, the idea that the light is always on makes the ER an attractive beacon.

Continue reading

Emergency! (Well, it is to me!)

Everyone knows about the crowding problem in Emergency Rooms (ERs).

Too many people show up to be seen by medical professionals at similar times. This creates bottleneck: more customers than gurneys on which to park them; many more patients than doctors and nurses (and PAs–physician assistants–a growing cadre of medical professionals in the U.S.)

ERs are the beneficiaries (a mixed blessing, to be sure) of a clear and simple message: “We’re always open. You can always be seen, regardless of ability to pay.” The bargain is that you have to be willing to wait. For thousands of people, perhaps millions, it’s a reasonable bargain. At least when they enter it is. Sometimes the waits are interminable.

Many people wind up leaving without being seen, unsatisfied by sitting so long. On the one hand, ER management wants to send the message: if you’re low priority (your issue is not a true emergency), you’re going to wait. And wait.

And wait. Continue reading

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