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Another one bites the dust

July 2010

Another house doctor program, that it. Perhaps my most lasting legacy will be aiding and abetting the demise of two house doctor programs, and I could do worse. While house doctors are not quite anathema to the hospitalist movement, they did cause measureable harm to our specialty and did little to facilitate good medical care.

I should be clear; many of these doctors were excellent clinicians. However, the crème of the crop do not typically choose to work as non-autonomous doctors who are treated as second class citizens by the medical staff. At best, they can be described as inglorious residents, albeit for better pay.

But first a primer on both house doctors and the region of the country in which they were indigenous. House doc programs were set up to make the life of the primary doctor easier. Yes–there was a time when this was a hospital concern.

These docs were mainly charged with doing history and physicals at all hours for the attending of record. They also served an important role in stabilizing patients at night when the vast majority of doctors were asleep and wanted to stay that way. Simply put, these programs allowed primary doctors admit patients without many of the headaches inherent in having a sick patient in the hospital. This was especially important to the primary docs, given the fact that many subspecialists were becoming less interested in non-procedural work in the hospital. No longer could you count on the cardiologist to admit your chest pain patient on the weekend or the gastroenterologist to admit a GI bleeder any day of the week.

These programs were wholly subsidized by the hospital, and often that subsidy ran into the millions of dollars because many house doctor programs did not bill for their work. It was OK to do the H&P, but it was not OK to bill for it. Because the goal was to cater to the primary doctors, there was no way that the hospital was going to be able to capture revenue at the same time.

Why would a hospital offload responsibility from an attending doctor and other specialists at such a cost? Simple: It was a good business strategy if you were situated in an area where everyone was competing for the primary’s patients. Ten years ago in the Philadelphia area, internists, family physicians and subspecialists like pulmonologists were still serving as attendings. However, the dual life of office and hospital practice was beginning its inexorable slide into the abyss for all of the usual reasons that drove hospitalists to become the standard of practice.

I got my first taste of house doctor medicine in 2004 when contemplating moving from the Midwest (where house doctors did not exist) to the Philadelphia area (where they existed in every hospital that did not have medical residents). For me, the house doctor phenomenon wholly explains why there were so few hospitalist programs in this region at that time, compared to the rest of the country.

And as an aside, it also explains why the few programs that were here paid so poorly. One program that shall remain unnamed offered me 90K to start. Stunned, I replied: “Oh no, I am actually looking for time work.” Fortunately for me, I found a health care system that was ready to make the jump from house doctors to hospitalists.

Even though the proverbial hospitalist cat was well out of the bag by 2005, it still took some courage and foresight by hospital leadership straddled with house docs to take the hospitalist plunge. Any system that allowed attendings to practice remotely was doomed to fail.

After all, the truism that the doctor got paid and the hospital got paid was no longer so true. Doctors were still getting reimbursed, but we all know that the hospital was now on the hook for the bill when insurers determined, often reasonably, that there was no reason for Mrs. Jones to still be in the hospital.

And make no mistake about it: Many primary doctors were none too happy about the exodus of house doctors, and to be honest, who could blame them? Yet another take away for primary care doctors who still wanted to work inside the hospital’s walls. And to add salt to the wound, “Oh by the way, do you mind letting the new hospitalists take care of your patients, now that the house doctors have departed?” Needless to say, it was a time of interesting politics. But like most of you who have practiced more than five years know, there were simply too many factors in play by this time to slow hospitalist growth, regardless of the existing hospital culture.

So at my current hospital, another house doctor program is now gone and likely soon to be forgotten. We have added more hospitalists to make up for their absence. While we did shift much of the service provided by the house doctors (such as pain meds, sleepers, and H&Ps) back to the attending where it belongs, we will still always provide care for unstable patients when their doctor is not around.

Perhaps when Dr. Nelson or Dr. Wachter writes the official biography of the hospitalist movement, the house doctor footnote will be mentioned in the chapter entitled “Speed bumps on the road to supremacy.” I’ll remain more than a little pleased that I played no small role in sun-setting this ill conceived practice of medicine. Nothing personal, it’s just that I have no doubt that hospitalist medicine is such better care.