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A vast hospitalist conspiracy?

October 2008

Sometimes finding the inspiration for a blog entry requires significant effort, but other times, not so much. This blog falls into the latter category.

A recent letter to the editor in AMNews was titled “Predominance of hospitalists has quality assurance implications.” The author expressed concern that a medical staff is compromised if it cannot find “noncontracted members sufficiently free of conflicts of interest to serve.” He continued: “… if we further disable local medical staff ability to warrant safety of hospital care, outside interests will fill the void with agendas we all would just as soon avoid.”

Where to begin? Well, to ask the obvious: Just what evil agenda do hospitalists bring to the table? One might envision a vast hospitalist-wing conspiracy to replace the well-known Hallmark holiday “Doctor’s Day” (March 30th–mark your calendars) with the more narrowly defined “Hospitalist’s Day.” I’m sure secret cells are holding meetings even as I write.

But I digress. To suggest that hospital-employed physicians, hospitalist or otherwise, are inherently unable to practice medicine without conflicts of interest that may drive doctors to not provide the most appropriate patient care is, well, pure malarkey.

Conspiracy theories aside, just what are these supposed conflicts of interest? I see hospitalist medicine, directly-employed or otherwise, as a milestone in patient safety. The hospital is our house; we–in the most literal sense–live in that house, and we won’t allow political and financial agendas that may be harmful to patients to complicate that home. Indeed, many would argue that our exponential growth has been fueled in part by just such vigilance.

This letter to the editor appears to assume that first, hospitals brush aside patient care issues in favor of political, financial or resource-utilization agendas, and that second, by populating a medical staff with their own employees, there will no longer be anything to prevent these plans from coming to fruition.

This, of course, assumes that hospitals want to employ physicians in the first place. The average net negative cost to a hospital for employing a physician is now upwards of $100,000. The dynamics of the current health care crisis–namely decreasing reimbursement, the pending implosion of Medicare and the absence of meaningful tort reform–have forced hospitals to incur this cost to ensure that there will be physicians to take care of hospitalized patients. In many areas of the country, the changing health care market suggests that hospitals will have to employ the outpatient primary care providers and other subspecialists as well.

There can be no doubt that the traditional composition of the medical staff is changing as the hospitalist movement becomes the predominant model. On this point, the author is correct although his assumptions regarding the implications of this change are, to my thinking, in error.

The medical hospital staff and the hospital traditionally have been discrete, separate entities. I think it is fair to say that many conflicting agendas did and still do exist because of this fact. AMNews has almost weekly reports on the outcome of legal verdicts between medical staffs and hospitals that usually resolve around issues of sovereignty.

It is also fair to ponder what the overall implication will be for physicians who were once independent in terms of their financial relationship to the hospital. This potential loss of perceived autonomy has no doubt been very alarming to physicians who practiced in a time when the hospital maintained a very different relationship to its medical staff. Yet there is nothing to suggest that this changing composition compromises patient care. It could even be argued that“contracted”physicians may be better positioned to align their efforts with the hospital to move to forward new patient safety initiatives ranging from hand washing campaigns to goal-directed sepsis protocols.

I’ll stop here, not least because I don’t want to read too much into a short letter, particularly one that I could easily have misconstrued if the letter was edited for publication and some statements appear out of context. But I stand by my claim that it is misguided to believe that the care provided by hospital-employed hospitalists is compromised by conflicts of interests. Indeed, I would argue that hospital-employed physicians reduce the potential for putting agendas ahead of patient care.