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Hospitalists and the Family Physician

BRUCE BAGLEY, M.D.
Chair, Task Force on Hospitalists
American Academy of Family Physicians

Market-based health care reform has changed the face of medical practice. One change has been the emergence of inpatient admitting teams, now referred to as "hospitalists." The hospitalist function is nothing new, but now that a small group of physicians has decided that they should limit their practice to the hospital, everyone is talking about hospitalists. The first meeting of the National Association of Inpatient Physicians was held last year. This group seeks members who have chosen to spend at least 25 percent of their practice time doing inpatient care, and it is interested in recruiting general internists, family physicians and pediatricians. Some among them see the natural progression of hospital care going from each individual physician caring for his or her own patients in the hospital to the model in which all hospitalized patients are cared for by a team of inpatient specialists.

As a matter of fact, the hospitalist movement may stem from the way family physicians and internists have chosen to practice medicine. As physicians moved from primarily solo practices into group practices, they were able to achieve a sharing of responsibilities and expenses. The opportunity for reasonable vacation and family time created a pressure to form group practices. Most family practice groups quickly realized that it was much more efficient to send one physician to the hospital each day to see all of the patients for the group. The other physicians stayed at the office, reducing the time spent in commuting and eliminating the prospect of starting morning office hours late. Most groups rotated the hospital duty. It made sense, and there was good communication between the family physician at the hospital and the partners back at the office. Family practice groups have used this model for decades, and it persists as the predominant mode for hospital practice in groups. There was no need to call the hospital physician a hospitalist--it was just part of being a good family physician.

There are some issues regarding family practice that give reason for concern. Will family physicians who give up their hospital practice lose the opportunity for professional interaction with their subspecialist colleagues? Will family physicians be excluded by managed care organizations or hospitals that have hired a full-time staff to care for the patients in the hospital? Will residency programs develop tracks with little or no inpatient experience for those who choose to practice only outpatient medicine? Will the loss of continuity of care reduce the quality of that care or increase the cost?

The large majority of family physicians who do not see patients in the hospital have made that choice voluntarily. Whether because of lifestyle considerations or personal concern about keeping up with the latest medications or procedures, they have decided not to see patients in the hospital or have chosen to work for a system that does not require hospital rounds of all family physicians. The real concern, of course, is that family physicians will be excluded against their will by a managed care organization or a hospital system that has hired someone to provide full-time inpatient services.

Most residency training is hospital-based, with a significant amount of the three years devoted to inpatient care. Family practice residents should continue to receive a significant amount of their training in the inpatient setting even if they choose not to include hospital care in their practice. Skill in caring for sick hospital patients gives a physician a better understanding of the disease process and allows for better treatment of those patients who are not as ill. Managed care has caused a shift of treatment from the hospital to home and office care. All physicians are caring for sicker patients without the benefit of the hospital surroundings. Training in the inpatient setting is essential.

Probably, the one thing that naturally bothers most family physicians about hospitalist care is the breakdown in continuity of care. Continuing, comprehensive and personal care is the cornerstone of the specialty of family practice. Whatever reason we have for not following our patients in the hospital, it is our responsibility to be in close communication with the physician who is providing that care. We must relate the prehospital course, comorbidities, family and psychosocial factors that will enhance the patient's care in the hospital. The transfer back to the family physician in the office is just as important in order to ensure proper follow-up and reduce hospital stays.

There is no question that the optimal care for hospitalized patients should be accomplished by a skilled family physician who knows the patient and the family. When this is not possible, we still have the responsibility of ensuring a smooth transition from the office setting to inpatient care and then back to home and follow-up care. Family physicians will continue to give hospital care as long as we also provide competent, cost-effective, compassionate care to the patients and families we serve.

As a specialty, we should fight the involuntary removal of hospital responsibility with the same vigor and persistence we have used in the hospital privilege battle. Family physicians who have the training, experience and current competence should not be excluded from caring for hospitalized patients.

Hospitalist Concept: Another Dangerous Trend

ROBERT G. BROWN, M.D.
McLennan County Family Practice Residency Program
Waco, Texas

The fact that increasing numbers of family physicians are limiting themselves to an office practice is alarming. There always has been a small minority of family physicians who chose to practice in the "Doc in the Box" environment, but with the advent of the "hospitalist" concept, it is apparent that more and more family physicians who formerly had traditional practices now are opting out of caring for their patients when they require hospitalization.

Our specialty was built on the concept of a caring generalist physician who was knowledgeable about a breadth of medical problems, one who could handle the vast majority of a patient's needs and who always would advocate for the patient even when the patient's condition required the help of subspecialists. We touted ourselves as the "cradle to grave" physicians or even the "womb to tomb" physicians if we practiced obstetrics. In my years of private practice, before I started teaching at the residency program in which I had trained, I had a busy office practice, took care of my patients in the hospital, delivered babies, saw my patients in the emergency department or met them at the office when trouble befell them at night or on weekends, made house calls when needed, cared for patients in nursing homes--basically I committed to taking care of my patients, and the patients of the physicians with whom I shared calls, whenever and wherever they needed care.

That was the idea. That was what attracted many physicians such as myself to family practice in the first place--the challenge, the variety, the involvement in the lives of patients at every stage. I have maintained a limited practice of several hundred patients even while I have been a full-time teacher for the past 14 years, and I still give those patients that kind of care. It is what they expect from me.

As members of a specialty, family physicians have fought hard for the recognition and respect that we now enjoy. I hate to see that thrown away. Most family physicians do not practice obstetrics, and I can accept that. However, increasing numbers of family physicians will not admit patients to nursing homes. Many will not see Medicare patients ("It's not cost effective for what the government pays," they might say), and they actually turn away patients whom they have treated for years once these patients turn 65. Rarely will family physicians now go to the emergency department when their patients are there. ("After all, we have full-time emergency physicians right there to see them," is the thinking.) In addition, many family physicians now want hospitals to hire "inpatient managers" to care for their patients when they are admitted to the hospital. Again, they cite cost-effectiveness or the waning of their competency in procedural skills or some other rationalization for why it is better for the patients if they stay in their offices and leave the hospital care to the hospitalists. I am afraid the patients will not buy these excuses much longer. Do we really think patients are so naive that they cannot tell the difference between what is best for them and what is convenient for us?

Maybe the "leaders" of family medicine are at fault. Rather than being content with training generalists, they have promoted the oxymoronic concept of "specialization" within family practice by developing fellowships and other routes by which we could obtain "certificates of added qualification" in sports medicine and geriatrics. Maybe we are victims of our own financial success, now getting paid enough for office work that we do not have to go to emergency departments, nursing homes or hospitals to make a good living. Maybe it is the new system of health care delivery that distances family physicians from their patients. (A physician might think, "They're not really my patients, after all, they are patients of the 'Really Big Health Plan,' and I'm just one of the providers for that plan.") Maybe it is just that too many of us have become lazy.

Whatever the reasons, it is worrisome to me that some family physicians are turning their backs on the tradition of continuity of care, the cornerstone on which our specialty was built just over a quarter of a century ago. Cradle to grave? Sure. As long as it happens from 9 a.m. to 5 p.m., and the patient can come to the office.

Prostate Cancer Screening

MATTHEW N. WITTE, M.D.
RONALD A. MORTON, JR., MDBaylor College of Medicine
Houston, Texas

Because of heightened awareness and media attention directed at high-profile celebrity cases, prostate cancer is one of the most commonly discussed diseases in both the scientific and lay literature. Moreover, debates regarding the diagnosis and treatment of this common malignancy have generated heated discussions and have polarized both urologists and family practitioners. Nowhere is this more evident than the current controversy regarding prostate cancer screening. Since the test for serum levels of prostate-specific antigen (PSA) became widely available, prostate cancer screening is practiced both on a yearly basis (associated with Prostate Cancer Awareness Week) and throughout the year at select institutions.

See Article in this issue.

In this issue of American Family Physician, LeFevre presents a case against support of widespread prostate cancer screening.¹ The pillars of this argument are: (1) that the natural history of prostate cancer is not well understood; and (2) that treatment of asymptomatic prostate cancer has not been shown to alter the natural history of the disease. With the current increase in data relating to these two critical issues, these conclusions warrant further consideration.

A series of Scandinavian studies on the conservative management of prostate cancer have provided conflicting results. However, the majority of patients in these studies who did not stand to benefit from radical prostatectomy were older than 70 years and had low-grade and low-stage disease. Furthermore, under current standards of care, these patients would not be surgical candidates in the United States.^2,3 Two recent studies have explored the long-term results of conservative treatment of clinically localized prostate cancer.

Significantly, Chodak and colleagues⁴ documented that men with moderately and poorly differentiated tumors had a 42 percent and a 74 percent risk, respectively, of developing metastatic disease within 10 years. Perhaps more importantly, Albertsen and associates⁵ showed that even men 70 and 75 years old would realize a significant benefit, in terms of quality life years, from surgical treatment of moderately and poorly differentiated prostate cancer. Albertsen's study also shows that men with low-grade and low-stage disease may derive little benefit from aggressive treatment, but make up a small proportion of patients with clinically evident prostate cancer. While I believe that patients with low-grade disease are the best candidates for cure, modern decision analysis demonstrates that patients with moderate or poorly differentiated disease actually have the most to gain from aggressive therapy.^6,7

Prostate cancer is a heterogeneous disease, and many men have clinically insignificant cancers that do not merit treatment. However, these insignificant tumors have been identified during autopsy studies, and their relevance to prostate cancers diagnosed during screening studies is uncertain. In addition to autopsy studies, clinically insignificant prostate cancer has been demonstrated in approximately 25 percent of cystoprostatectomy specimens in which the prostate was clinically benign.

To estimate the potential for diagnosing clinically insignificant prostate cancer during screening, Ohori and associates⁸ compared the pathologic features of clinical stage T1C prostate cancers to clinical stage T2A and B cancers and to cancers identified at the time of cystoprostatectomy. The results of this study show that the pathologic spectrum of T1C cancers much more closely resembles the pathology of T2 disease than that of prostate cancer seen at the time of cystoprostatectomy.⁸

In the Baylor College of Medicine radical prostatectomy series, it has been consistently noted that less than 10 percent of radical prostatectomies are performed in men with clinically insignificant disease. Furthermore, in a review of the literature, Brendler⁹ found that clinically insignificant prostate cancer accounted for 17 percent or fewer of all cases diagnosed in early detection programs. While the diagnosis of a large number of clinically insignificant prostate cancers is a theoretical consequence of PSA screening, in practice this does not appear to be the case.

If one accepts that the natural history of prostate cancer diagnosed in early detection programs warrants treatment, then the efficacy of treatments for clinically localized prostate cancer must be demonstrated. There is mounting evidence that radical prostatectomy is efficacious in the treatment of clinically localized prostate cancer. Long-term, disease-free survival has been shown in patients with clinical stage T2 prostate cancer.¹⁰ Moreover, men with nonmetastatic, poorly differentiated disease who are treated with radical prostatectomy have significantly improved long-term survival when compared with men who receive nonoperative therapy.^11,12 Importantly, between 1991 and 1995, the age-adjusted prostate cancer mortality rate decreased by 6.3 percent overall and by 7.4 percent in men less than 75 years.¹³ Not coincidently, this reduction in prostate cancer mortality coincides with increased deployment of early detection and aggressive treatment of clinically localized disease.

Some experts believe that early detection and aggressive treatment of clinically localized prostate cancer are promising strategies to reduce mortality associated with this disease.¹⁴ Although unequivocal evidence supporting this hypothesis is lacking, there are ongoing trials that address the diagnostic and treatment dilemmas associated with prostate cancer screening. Once these trials are completed, we will have the prospective data necessary to make firm recommendations regarding both prostate cancer screening and radical prostatectomy.

Dr. Bagley is a family physician in Albany, N.Y., and is a member of the AAFP Board of Directors. He is chair of the AAFP Task Force on Hospitalists.Dr. Brown was director of the McLennan County Family Practice Residency Program from 1993 to 1997. He resigned as director to have more time for teaching and seeing patients.Dr. Witte is a senior resident in urology at Baylor College of Medicine.

Dr. Morton is assistant professor in the Department of Urology and Cell Biology at Baylor College of Medicine. He is also the director of the laboratory at Baylor Prostate Center and chief of urology at Houston Veterans Affairs Medical Center.

REFERENCES

1. LeFevre ML. Prostate cancer screening: more harm than good? Am Fam Physician 1998;58:432-8.
2. Johansson JE, Holmberg L, Johansson S, Bergstrom R, Adami HO. Fifteen-year survival in prostate cancer. A prospective, popoulation-based study in Sweden [published erratum appears in JAMA 1997;16:278:206]. JAMA 1997;277:467-71.
3. Hugosson J, Aus G, Bergdahl C, Bergdahl S. Prostate cancer mortality in patients surviving more than 10 years after diagnosis. J Urol 1995;154: 2115-7.
4. Chodak GW, Thisted RA, Gerber GS, Johansson JE, Adolfsson J, Jones GW, et al. Results of conservative management of clinically localized prostate cancer. N Engl J Med 1994;330:242-8.
5. Albertsen PC, Fryback DG, Storer BE, Kolon TF, Fine J. Long-term survival among men with conservatively treated localized prostate cancer. JAMA 1995;274:626-31.
6. Cowen ME, Kattan MW, Miles BJ. Survival and conservative treatment for localized prostate cancer. JAMA 1996;275:31-2.
7. Miles BJ, Kattan MW. Computer modeling of prostate cancer treatment. A paradigm for oncologic management? Surg Oncol Clin N Am 1995; 4:361-72.
8. Ohori M, Wheeler TM, Dunn JK, Stamey TA, Scardino PT. The pathological features and prognosis of prostate cancer detectable with current diagnostic tests. J Urol 1994;152:1714-20.
9. Brendler CB. Characteristics of prostate cancer found with early detection regimens. Urology 1995:46(3 Suppl A):71-6.
10. Partin AW, Pound CR, Clemens JQ, Epstein JI, Walsh PC. Serum PSA after anatomic radical prostatectomy. The Johns Hopkins experience after 10 years. Urol Clin North Am 1993;20:713-25.
11. Ohori M, Goad JR, Wheeler TM, Eastham JA, Thompson TC, Scardino PT. Can radical prostatectomy alter the progression of poorly differentiated prostate cancer? J Urol 1994;152:1843-9.
12. Partin AW, Lee BR, Carmichael M, Walsh PC, Epstein JI. Radical prostatectomy for high grade disease: a reevaluation 1994. J Urol 1994;151:1583-6.
13. Hoeksema MJ, Law C. Cancer mortality rates fall: a turning point for the nation [news] [erratum appears in J Natl Cancer Inst 1996;89:16]. J Natl Cancer Inst 1996:88:1706-7.
14. Parkes CA. An epidemiologist's viewpoint on screening. Cancer Surv 1995;23:127-40.

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