As readers know, I have done only inpatient medicine (albeit as a teaching attending) for the past 8 years. I previously had an outpatient practice for approximately 20 years at 2 sites, ranging between 20% adn 40% of my week.
Hospital medicine has exploded over the past 10 years. We have a new specification – the hospitalist – and a new aggressive organization – SHM (the Society of Hospital Medicine). We know from history that all changes create externalities. Two conversations over the past week have crystallized these externalities to me.
At dinner the other night with non-medical friends, the conversation turned to finding an internist. One person planned to change internists because the long time comprehesivist, now was giving up hospital rounding and turning patients over to hospitalists. This internist has made a lifestyle and financial choice, but left behind is a patient who wants her internist to care for her as both an outpatient and inpatient. She does not want someone she does not know becoming her internist in the hospital.
During the conversation I tried to explain why this was occuring. Of course, I totally failed in explaining the incomprehensible economics of internal medicine. We were drinking wine and having great food and company, so we switched the conversation to an easier subject – politics.
Last week at the Alabama ACP meeting a colleague told me that he was ending his outpatient practice to become a full time hospitalist. His hospital had a great need. He lives in a modest sized city/town. Being a comprehensivist was too draining. He always has enjoyed inpatient medicine; he weighed the pros and cons and decided that hospital medicine was the intelligent choice.
I understand my friend’s angst and my colleagues’ decision. Should we blame these anecdotes on the aggressiveness of the hospitalist movement? I do believe that at times the movement has been too aggressive in selling the movement. I do believe that the enthusiasts have spurred rapid growth without considering the impact of hospital medicine’s growth. However, the growth may really be an outcome determined by the inane payment system that the government has foisted on internists (and family physicians.) Hospitalists cannot make more money than outpatient physicians, but they do, because hospitals subsidize their salaries. Hospitalists provide desired services, and thus the economics work outside of our payment system.
I know all the arguments that hospitalists really save hospitals money, and I believe those arguments. I also know that outpatient physicians make money for hospitals, and yet these warriors are rarely subsidized.
Patients want comprehensivists. They want one physician to see in the office and in the hospital. We hope that the PCMH restores that dying breed.
Physicians want fair compensation and reasonable lifestyle. Most of us have made a major dedication to patient care. We extend our education to our late 20s or early 30s. My first real paying job started when I was 32. We postpone gratification and adolescence.
If I were finishing internal medicine residency training, I would become a hospitalist. I love hospital medicine, and always have. I liked outpatient medicine, but not as much as hospital medicine.
We can pose a question though. What represents the best care for our patients? Have we abandoned our contract with patients when we abandon comprehensive care?
I would argue that CMS (through the RUC) and the insurers have abandoned us. In rereading the important Annals Perspective – The Demise of Primary Care: A Diatribe from the Trenches – I think that it does not need to be such. We have never adequately communicated the case for internal medicine. I recall a rant from 2007 – Thinking versus doing. At that time I quoted from a 2006 rant:
We live in a society that has a love hate relationship with thinking. Geeks are chic, but usually at a distance. We rarely show intellectuals the respect they deserve.
We all want the benefits if great thinking, but I fear that most in our society do not really respect the thinkers. We clearly respect the doers.
Perhaps that is why fees for surgery and procedures exceed fees for thinking. Cognition makes one a nerd.
Perhaps I am too jaded this morning. Perhaps my analysis is flawed. I have been thinking, and it is hard work. I am trying to reconcile the illogic of reimbursement. Could the imbalances come from an underlying prejudice against intellectuals?
Houston (and New York and Los Angeles and Huntsville and Dayton), we have a problem.
