American College of Physicians: Internal Medicine — Doctors for Adults ®

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LETTERS

Hospitalists

From the July/August 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

I have been working as a hospitalist since 1992. I currently work in a rural 102-bed hospital where three of us manage 85% of the intensive care unit patients; family physicians and surgeons care for the rest. We also provide total inpatient care for seven local physicians and inpatient consulting and critical care services for the rest. We do our own ventilators, pacemakers, swans, echos and endoscopy services and procedures, etc. Consultants in cardiology, gastroenterology, oncology and neurology come in on a scheduled basis.

To be fair, there are some problems. As your article (Internists in the hospital-only, May ACP Observer, p. 1.) pointed out, patients often initially want their own doctor to take care of them. Others want us to take care of them once they leave the hospital. We explain that if we provided that care, we would not have the time to take care of patients when they are in the hospital. This works better than saying we don't want to "steal" patients.

We also emphasize that we work with their primary care doctor. We tell patients that their regular doctor can take care of 90% of their problems. We do provide follow-up care when we place a permanent pacemaker in a patient, but we remind patients that we are caring only for their pacemaker problem, nothing else.

We try to provide continuity of care from the beginning. The person who admits a patient cares for him throughout the hospital stay. At times, we negotiate the patients if one of us likes a particular problem better than the other.

In general, it works well. Patients are accepting hospitalists, and we like it. For the most part, we hate office-based medicine.

Thomas G. Pelz, DO
Prairie Du Chein, Wis.

At Ohio State, we have worked as hospitalists for years. We have only an academic faculty practice here with no private physicians. An outpatient clinic doctor will admit a patient to the hospital to be taken care of by one of the inpatient faculty members. For example, there are two cardiology services with two attendings per service, but more than 20 staff cardiologists who follow outpatients. Each month, however, only four of them follow inpatients with the housestaff and students on service. With a good electronic medical record and hospitalists who are "partners" with their outpatient doctors, the system works wonderfully.

Andrew Thomas, ACP Associate
Columbus, Ohio

I was deeply saddened by the article on hospitalists. As the daughter of a full-time solo practitioner in internal medicine and geriatrics and a practicing internist myself, I see any move to further divide the delivery of care to our patients as an abrogation of our very duty and dedication to the practice of medicine.

It has often been said that medicine is as much an art as a science. Part of healing involves knowing our patients, which includes their lives and the environment in which they live. Only then can we fully customize our therapeutic interventions. I fully acknowledge the role of specialists and their added expertise, but primary care physicians are the coordinators who draw on this extra knowledge as they guide the patient down the path of their medical care.

Turning over our patients' care to a "hospitalist" every time outpatient treatment is not an option is like severing an umbilical cord and delivering the unsuspecting infant to a foster home. Though they may be thoroughly skilled in the latest hospital treatment and in the most efficient way to deliver it, "hospitalists" have no long-lasting physician-patient relationship. Yes, they can employ social workers and other team members to gather information about the patient's environment and life situations, but this is no substitute for physicians who know their patients, and with whom the patient has developed trust and understanding. Medical and other factual information can be passed between covering physicians, but it is not the same as the awareness that the patient's own physician has.

Dedicating our lives to medicine is not easy. There is a constant balancing act between our private lives and our profession. I call out to all dedicated internists who are providing "full services" —both outpatient and inpatient care—to speak out now against this surge to treat patients as units of a job to be portioned out by time and services. We must stand up for our patients who are entitled to comprehensive care with continuity from a physician who knows them as a whole person.

A. Michele Ricard, ACP Member
Berlin, Mass.

As a chief resident looking for a job, I have seen many ads for hospitalists. My concern has to do with the problem of burnout, and what hospitalists will do when they are burned out and want to return to the outpatient arena. Will they have to do a mini-residency to hone their outpatient skills again? Will they be marketable?

Interestingly, I have seen and responded to ads for hospitalists in both the heavily-managed areas of California and in small, fee-for-service communities such as Tyler, Texas, Fayetteville, N.C. and Stuart, Fla. My impression is that the trend is not being driven by economics as much as it is by lifestyle and efficiency. Clearly, having to drive to and from a hospital to see one or two sick patients often at the expense of seeing one's outpatients is inefficient and time consuming.

David M. Feinstein, ACP Member
Phoenix, Ariz.

Editor's note: For more information on the National Association of Inpatient Physicians, call Winthrop Whitcomb, FACP, at 413-748-9321, or John Nelson, FACP, at 352-333-5113.

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