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From our recent electronic newsletter, The Member Connect:
As a practicing primary care internist, I no longer admit my own patients to the hospital. They are admitted by my very talented hospitalist colleagues, who provide excellent 24/7 care to my patients.
The hospitalist movement began in a 1996 article in the New England Journal of Medicine written by Robert Wachter and Lee Goldman, two UCSF Physicians. Wachter is widely considered the “father of the hospitalist movement.” The idea was to provide “specialist” care for hospitalized patients to improve the quality of care. Today, there are approximately 60,000 hospitalists in the United States. Numbers are hard to come by, but it is estimated that 15% of Internal Medicine Residents pursue a career in hospital medicine. Over 80% of hospitals now have hospitalists. Studies have shown that the use of hospitalists can reduce costs, shorten hospital stays, and improve patient safety and the quality of care.
Most primary care physicians I know no longer admit or care for their patients in the hospital. Although I no longer admit or care for my own patients, my workday hours remain the same now as they were 30 years ago. In the early 1990s, I practiced in Portland, Oregon. We cared for our own patients in the hospital. I would round early in the morning (sometimes starting before 6:00 am if I had patients in multiple hospitals), see patients in the office all day, and occasionally return to the hospital during my lunch hour or after work. I usually got home between 7 and 8 o'clock.
I enjoyed the hospital. I enjoyed the challenges of caring for sick patients. I would run into my specialty colleagues, medical residents, and the RN’s, ward clerks, PT/OT, etc., who participated in the care of my patients. There was a sense of camaraderie. Based on my familiarity with the patients, I was able to provide relevant historical context — both medical and social — that was often helpful as we addressed their acute problems. My patients appreciated seeing a familiar face. I would often have an extremely sick patient with multiple specialists involved, and my patient still wanted my opinion and thoughts on their condition, treatment, and prognosis.
During the early 2000s, I stopped providing care for my patients who had been admitted to the hospital. A major reason for this involved new jobs working at county clinics and county jails in Portland. I spent one more year doing hospital medicine during a locum tenens assignment in a small rural town in New Zealand. As Internists there, we served as the sub-specialist and hospitalist for patients in the community.
I am now an outpatient physician. My workday has not shortened. In fact, paperwork, EHR tasks, coordination, and higher patient volume now make outpatient care more time-consuming and frustrating. I could admit my patients, but the logistics and time involved in doing this are no longer tenable.
What do I miss about not taking care of my own patients in the hospital? -I miss not being able to provide care to my own patients when they are sick and most vulnerable. -I miss the relationships I had with my specialty colleagues and hospital staff. -In all honesty, I don’t feel like a “complete” doctor.
So, what do I do? I visit my own patients in the hospital. My clinic is conveniently located across the street from the hospital, making access easy. I make it very clear to my patients that there is a “hospital team” caring for them. I inform them that the hospital team communicates with me and that I will see them after they are discharged. I try to visit each of my patients at least once (sometimes more) during their hospitalization. When I see patients after their discharge, they always comment and thank me for visiting them.
Obviously, this practice is not feasible for most outpatient doctors as many practice locations are miles from the hospital and would require a substantial time commitment (that is not compensated). These “social visits” also require extra time in an already long day. The other benefit of visiting my patients in the hospital is that I have regular interactions with my specialty (and hospitalist) colleagues in the hallways or the doctors' lounge.
I would argue that the hospital is the social hub of medicine for doctors. Many of us in primary care now practice in “silos,” where we have little or no personal interaction with our specialty colleagues. This is a loss for the profession. In my experience, a personal relationship goes a long way when I call a colleague to discuss or refer a patient. Our relationships with our colleagues are one of the greatest aspects of our profession. Medicine truly is a “team sport.”
I miss the hospital.
Respectfully,
Todd Engstrom, MD, FACP President, Central Coast Medical Association
Executive Committee: Todd Engstrom, MD, President Christopher Quijano, DO, President-Elect Timothy Auran, MD, Treasurer Bradley Knox, MD, Secretary Douglas Murphy, MD, Immediate Past President
Directors: Kevin Casey, MD Justin Chang, MD Julie Fallon, MD Priti Gagneja, MD Samira Kayumi-Rashti, MD Winifred Leung, MD Nicole Stern, MD, MPH Robert Turbow, MD, JD
Sharon Basham, MD Kevin Casey, MD Todd Engstrom, MD Julie Fallon, MD Priti Gagneja, MD Maya Heinert, MD, MBA Samira Kayumi-Rashti, MD Jason Krupp, MD Christopher Lumsdaine, MD Douglas Murphy, MD Christopher Quijano, DO Jane Varner, MD
René Bravo, MD
Jennifer Hone, MD
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