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Tuesday, August 07, 2007

Hospitalist-A deal with the Devil or why bother to learn all that ICU stuff?

D. Rob has a thoughtful piece concerning his group's (IM-PED) experience with the new world of the hospitalist. Dr. Rob is a meds ped physician and in the era pre hospitalist he spent considerable time caring for sick IM patients in the hospital and taking call which on weekend was often a time of no stop work.

Enter the hospitalist. Now his office is more available to patients ( longer hours), his pay per time spent is better, and there is more sleep and family time. This , in a many ways, could be portrayed as a win-win situation for the office based physician who does not do hospital work.

But ,as he explains, everything did not get better. His patients ( the folks he sees now only as outpatients) have their care fragmented and all are not pleased by having a stranger as their doctor at a time when they are sickest and most vulnerable to stress and fear. He laments that typically there is a major informational disconnect between the in and the out patient care.

So it is a trade off. If you follow the money you have to conclude that there is little chance that the hospitalist movement will be reversed. Both the hospitals and the office based physician seem to benefit financially.

If a residency trained internist becomes a "officist" you have to wonder what was the point of the ICU, CCU sick-patient training in the hospital that he endured and that in fact took up the bulk of his training. I suppose you could say he will be more able to recognize who needs to go be temporarily managed by the hospitalist and arguably better at zebra spotting which could be offered as one feature distinguishing the office internist from the FP physician which may well be a distinction without a difference in the eyes of the patient . As best I can tell and as much as I hate to say it in regard the average 10 minute encounter with a blur of a white coat there is little or no difference if the coat is worn by a FP or IM doctor except the former probably does a better job with derm and office type ortho problems.


Dr. Rob said...

I am Med/Peds and am working with FP's in the office. They certainly adjust to the office setting better than those of us trained mainly in the hospital. We probably have more depth to what we do when compared with the FP's, but the breadth of their office knowledge is far more than ours. I certainly don't consider my overall training superior when it comes to caring for adults. The FP's are strong at some things, I am strong at others. Pediatric care, on the other hand, is definitely an area where I feel better trained than the FP.

So I guess the lesson here is: pick your poison. There will be pluses and minuses with any kind of training. The raw material is probably more important than the method of training.


Richard A Schoor MD FACS said...

you made an interesting comment. Patients don't like when they see a stranger in the hospital, instead of the doctor that they have developed a relationship with over time. Well, here is my question. How much do they dislike it, and what value, in terms of money, whether in premiums or direct payments to the physician, do the patients and families give to seeing their own trusted doctor in the bedside when, as you say, they are at their most vulnerable? I suspect they don't dislike it enought o pay for it themselves.

james gaulte said...

They may well not dislike it enough to pay for it.Although,the way things work they may not have that option.I suppose a very well informed patient could prior to the need to go to the hospital strike a deal with the internist to be treated by him in the hospital should the need arise.If the physician agrees,if he still has hospital privileges,etc.