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Good old days

January 2012

While not quite as far back as the Cretaceous period, there once was a time when the primary care doctor freely roamed the hospital. This was, of course, well before the arrival of the hospitalist. The emergence of the hospitalist and near extinction of primary care docs in the hospital was a complex process; equal parts mutual and, of course, driven by many economic and social drivers. It was an evolution that most would agree resulted in greater job satisfaction for all parties and, to borrow from Darwin, left them all more evolutionarily fit.

So it would be strange if I were to yearn for the “days of old,” given my predilection for all things hospitalist and my unwavering belief in evolution. But a recent experience has left me a bit sentimental. My father, who is otherwise healthy for his age, recently was treated in an ICU for urosepsis (aka “sepsis from a urinary tract infection” to the DRG-conscious hospitalist), compliments of a benign enlarged prostate. Is it a HIPAA violation to discuss your father’s medical condition? So much for my inheritance.

Anyway, back to my point. My father, a professor in a small college town, was overwhelmed by fever and chills and checked himself into the local 40-bed community hospital. As is the case with most college-town hospitals, if you are 18 and inebriated to the point of unconsciousness, you have come to the right place. If practice makes perfect, no hospital in the world is better equipped to treat such overindulgence.

But urosepsis? My first thought was concern especially given that a world-renowned hospital was only an hour’s drive away.

The ER doctor assured me that all was well and that my father’s trip to the ICU was mostly a precaution. He would bolus fluids, antibiotics were on board, and he’d started low-dose dopamine. Had he checked the lactic acid? No!?

OK, enough with my sepsis bundle meddling. Just let me talk to the on-call hospitalist when he gets down to the ER.

There is no hospitalist? No intensivist either?

I debated whether I should be on the next flight out of Philly, but I was assured that he was stable, so I slept on it. Early the next morning, I received a call from my doctor. Or at least the last doctor who ever felt like my very own physician: the family practice doctor I had when I was an adolescent.

“Your Dad’s fine. He’s off dopamine. Probably be here another day or so, but we can move him to the floor. By the way, heard from your dad you have become a doctor. What type?”

“A hospitalist,” I said. “And urosepsis is my specialty. In fact, it is probably one of four diseases that I can actually treat.” Adding a nervous laugh, knowing full well that I wasn’t kidding.

Later that day, I spoke to my dad who said there was no need to fly out. He was feeling much better. And his care had been great. He had known his doctor for 30 years, reminiscing about the days he used to drag me to the office when I protested I was too sick to go to school. Dad told me how at ease it made him to see such a familiar, trusted face.

And I had to wonder what would have happened if I’d insisted he be shipped off to the mega-university center.

There would be many outstanding doctors. And then, there would be many more. A hospitalist of course. An intensivist. Most probably an infectious disease doctor to confirm the obvious antibiotic choice. Perhaps even a nephrology as my Dad was a bit prerenal.

And because my father came in on a Thursday night, he probably would have been admitted by the night hospitalist. Then the day hospitalist in the morning. And if they switched teams on Saturday, as many programs do, he would get another hospitalist for the weekend. Then the subspecialists on call for the dreaded weekend shift would show up in sequence. I suspect sum total my dad would have been lucky if he meet fewer than 15 different docs during his 48 hours in the ICU and two days post-unit before being shown the door. At the community hospital, the only unfamiliar face was the ER doc and eventually a urologist.

Have I just argued for the good old days? Well sort of, maybe, but not really. At the end of the day, the hospitalist movement is what it is, to state the obvious. Our growth is due to many factors, not the least of which is that the old model is no longer able to sustain or replenish itself for the cornucopia of reasons we all know well. Even if it turns out that we are nothing more but well dressed “cost shifters” a la the Annals article of last summer, any urge for the return of the Marcus Welby era is laughable.

It is now extremely rare to hear what had been a common refrain when I started my career over 10 years ago: “I wish my doctors still came to the hospital.”

Quickly (and perhaps a bit defensively), I would expound upon the virtues of a hospitalist. We specialize in hospital medicine, we are always around, we are highly efficient. And then if patients were still awake, I might even lecture them on the history of our ascension. Given that I am a reasonable communicator, most patients would nod in approval. Or perhaps nod as physicians do when they just need to get out to see the next patient.

But perhaps the next time a patient yearns to see a familiar face that they have trusted for years, I will answer differently. Maybe I will simply say, “Yes … wouldn’t that be nice.”