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Am Fam Physician. 1999;59(6):1406-1412

to the editor: I am writing with regard to the editorials on hospitalists that recently appeared in American Family Physician.1,2 While I found Dr. Bagley's editorial1 to be a good discussion of the many issues involved, I was offended by Dr. Brown's editorial.2

I am a family physician who provides only outpatient care. I have been in this practice setting for 5 years. Before that, I provided full-spectrum family medicine care, including intensive care, obstetrics and residency teaching.

I agree with Dr. Bagley that the use of hospitalists should be a choice. Family practice is a specialty in which many different practice settings exist, and we should all be supportive of each other. Family physicians should not be limited by privilege requirements that are set by subspecialties, but neither should we impose on each other the idea of an “appropriate” practice setting. We are all family physicians whether we practice obstetrics or not, perform only outpatient care, work in urgent care, or have a more traditional practice.

Dr. Brown implies that a doctor who provides only outpatient care is not being a “good” doctor. I disagree wholeheartedly. Many physicians, myself included, have realized that to be good physicians, they must be happy with themselves. Many family physicians find that if they spend all of their time on medicine, they “burn out” and can no longer provide good care. Many of us who do not work in hospitals provide excellent care because we limit our practices.

In summary, this is an important time for family practice. We should not criticize each other for the type of practice we choose. Rather, we should stand together to be sure we can all have the types of practices we want.

to the editor: In his editorial on the hospitalist trend,1 Dr. Brown ignores the sobering statistics on physician suicide, divorce and substance abuse. Another observer might just as easily conclude that the trend represents a well-intentioned effort to repair a seriously flawed system of medical training and care.

One of the appeals of family practice is that it is a field broad enough to accommodate myriad different interests and practice styles. It is difficult enough to contend with our subspecialist colleagues, against whom we all too often must defend our right to perform certain procedures. Now we have to defend ourselves against colleagues in our own field who want to force us into roles we don't choose.

If a particular family physician provides hospital services, obstetric services, cardiac stress testing, colposcopy, upper and lower endoscopy and nasolaryngoscopy in addition to his or her usual office-based service, the continuity of the patient's care is certainly enhanced, but I disagree that this then entitles him or her to criticize colleagues who choose not to provide one or more of these services.

in reply: Clearly the use of hospitalists will remain a choice, and I did not argue against that. I did, however, intend to warn family physicians about what to expect if too many of us choose not to see patients in hospitals, emergency rooms, nursing homes or anywhere else besides our offices. We should expect resentment from our patients and their families. Our specialty has been sold to them as one of comprehensive and continuous care. If too many of us opt out of that commitment, what can we expect other than patients who feel betrayed?

I did not say that doctors who practice only in an office are bad doctors. But, I do believe that they will not be as good as they might be if they had remained active in a hospital setting. In his own editorial, Dr. Bagley stated that “skill in caring for sick hospital patients . . . allows for better treatment of those patients who are not as ill.”1 Clearly, if we choose not to practice in a hospital, our skill in that arena, and thus our skill in general, will wane quickly.

I also did not say anything about family physicians performing any sorts of procedures—stress testing, colposcopy, endoscopy and the like. Of course these are matters of personal interest, competence and motivation. Whether or not family physicians perform a particular procedure is a different issue from their willingness to remain involved in the care of a long-time patient who is admitted to a hospital or a nursing home.

My greatest disappointment is that the move toward “hospitalists” is based on the market and/or convenience rather than on our patients. Again, Dr. Bagley acknowledges “that the optimal care for hospitalized patients should be accomplished by a skilled family physician who knows the patient and the family.” He adds, “When this is not possible . . .”1 Well when, exactly, is this not possible?

I suppose that in answering this question, every family physician must take stock of his or her own principles and commitment to our profession. I want family physicians to be good mothers and fathers, good husbands and wives. No family should suffer because of a physician/parent's “devotion to medicine.” We deserve time to maintain our closest friendships and to sustain a hobby or two. Few of us have the devotion of an Albert Schweitzer, who inscribed on the light outside his jungle hospital, “Here, at whatever hour you come, you will find light and help and human kindness.” But, most of us can set the bar a little higher than we have it now, and we can do it without compromising the things outside of medicine that make us whole. How high should we set it? Perhaps the most practical guideline was set forth by a physician from a generation past, Dr. Robert Loeb: “The patient should be managed the way the doctor or a member of his family would wish to be treated if he were that patient in that bed at that time.”2

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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