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

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Letters

From the July/August 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

Hospitalists

ACP-ASIM seems to be taking a position against the hospitalist movement with another article attacking the concept. ("Use of mandatory hospitalists blasted," May ACP-ASIM Observer, p. 1.)

While I agree that mandating the use of hospitalists is a poor strategy, the ultimate goal of separating internal medicine practice into ambulatory care and hospital care makes considerable sense to me.

My concern is that currently about 180,000 people die each year from medical treatment, with about 100,000 of these deaths due to problems with prescription drugs. I suspect that too many of these deaths are due to physician error. In our group practice, new general internists spend most of their time managing office patients. They admit about 50 inpatients per year, and only a few of those cases provide an opportunity for them to maintain their skills in caring for the acutely ill.

When you have under-experienced physicians managing acute myocardial infarctions, acute respiratory failure and other serious illnesses, the potential for disaster is great. Deterioration in cognitive skills is not the only issue; lack of familiarity with constantly improving devices and equipment is also an important problem. For an under-experienced internist in a community hospital with little in-house back up, treating a very sick patient at 3 a.m. can be a frightening experience. Substandard treatment is inevitable.

I believe that the hospitalist movement is an appropriate answer to quality-of-care problems in community hospitals. Although continuity of care and attention to the psychosocial needs of both patients and physicians may be important, the size and scope of iatrogenic disease must take precedence. Those who attack the use of hospitalists should be prepared to offer an alternative solution instead of ignoring the serious underlying problem.

D. Blair Beebe, FACP
Portola Valley, Calif.

I can understand why primary care doctors who are adept at and enjoy hospital care are upset that they may no longer be able to practice in the inpatient setting. However, many primary care physicians will readily admit that they are glad to have hospitalists take care of their patients. It won't be long before studies show conclusively that hospitalists reduce the length of hospitalization and that patients and referring doctors report a high level of satisfaction.

Hospital care has become both complex and labor-intensive. In order to discharge patients as quickly as possible, individuals are subjected to a barrage of tests and consultations. For primary care doctors stationed in offices, it is very difficult to keep on top of a patient's hospital care and ensure that it moves along smoothly and effectively. This is an area that consumes an inordinate amount of physicians' time and energy. Far better that they should dedicate it to their office patients.

I have found that the hospitalists in my community hospital do a satisfactory job, and I have not had any complaints from patients. I still make courtesy rounds when I feel they are warranted. Though I receive no financial compensation for them, I do not consider courtesy rounds a burden, and the time and energy saved by using hospitalists makes them pleasurable.

I believe that hospitalists represent the most significant positive change in our profession in the past 30 years.

Edward J. Volpintesta, FACP
Bethel, Conn.

PAC delay

I read with concern about the delay in establishing a PAC for ACP-ASIM. ("Amid conflicting reports, decision on PAC delayed," March ACP-ASIM Observer, p. 1.)

As a past president of the ASIM, I strongly supported the merger of the two organizations. A major pre-merger anxiety revolved around whether the College's decision-making process would decrease the effectiveness of ASIM's previous public policy initiatives. We found the ASIM PAC to be very useful politically in strengthening the internist voice in Washington. While we never raised big bucks, the PAC helped us to connect at events and become a player.

Most recently, the Board of Governors agreed with this assessment, as did the Health and Public Policy Committee. It appears, however, that a single committee can derail the College's decision-making process. Worse yet, it is a committee likely not familiar with the political process. The Ethics and Human Rights Committee reflects a startlingly insular viewpoint.

Through the political process, this nation has accomplished social goals for 200 years. Involvement, not a retreat to the ivory tower, is needed today more than ever to help beleaguered practicing internists. To capture the value of the merger, we need to come up with rapid responses, not process a decision to death. I find it troublesome that a committee can effectively veto an action taken by the Board of Governors.

The College has many strengths, but effective political action needs to move at lightning speed in today's rapidly changing environment if we are to be of practical use to internists.

Eugene S. Ogrod, FACP
Sacramento, Calif.

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