Am Fam Physician. 1998;58(2):336-339
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.