Home Blog Have you hugged a subspecialist today?

Have you hugged a subspecialist today?

October 2010

I recently went on the road to visit many of my referring primary doctors, a trip that was long overdue. In the hospital, I get the general sense, via lightening quick patient updates during the heat of the day, that the physicians have been happy with our service. But I still found it invaluable to block off a half hour to discuss how they perceive our level of care and responsiveness.

I came away with two take-home points: One, there is no such thing as too much communication. And two, there is no faster way to secure the heart of the primary doctor than an on-time, comprehensive discharge summary.

After ensuring that our hospitalist program was delivering the expected level of service, our conversations would often digress. Doctors would often reminisce about “way back then,” when they used to still come to the hospital. Although I will never be confused with Studs Terkel, best known for his Pulitzer Prize winning oral history “The Good War,” here’s an account of what I heard.

Primary care’s exodus from hospitals has been well documented. Sicker, more complex patients were being admitted. Hospitals began to demand that these extremely ill patients be triaged more efficiently into and out of the hospital with ever-increasing speed.

Primary care physicians could easily offset stagnating reimbursement for inpatient cognitive care by avoiding the hospital and squeezing in some extra office visits. Aging physicians grew tired of the grueling lifestyle that was the hallmark of the traditional internist. Young physicians considered full-time employment a 9-to-5 job, with no nights and weekends, and they never considered working as their forebears did.

But the narrative that really best explains the exodus of primary care doctors from the hospital revolves around respect, or the lack thereof. Let me explain.

First, the driver for inpatient care evolved away from generalists and migrated to specialists. Initially, specialists marked this transition with deference to the attendings, and made no important clinical decisions without their knowledge or input. But this quickly devolved to the point that specialists began making most decisions in a vacuum. Soon, primaries would arrive in the morning to find that the cardiology consult had metastasized into a pulmonary consult, ID consult and renal consult, all unbeknownst to them.

Given these changes, many primary care doctors started to offload some attending responsibilities. Why not let cardiology admit chest pain and the surgeons admit anything that smelled surgical? In some places, this arrangement worked for a while. But two things happened: Specialists realized that admitting patients was too much work and too little profit. And hospitalists started to appear on the scene. Unlike just about everyone else in the hospital, we were willing to admit just about anything.

Those two factors together were the proverbial straw that broke the camel’s back. As one doctor told me, “It was 2 a.m., and suddenly without any prior discussion, the orthopod wanted me to admit the hip fracture patient I haven’t seen in the office in two years. The next day, cardiology wanted me to admit chest pain again, but was happy to do the stress or intervention. Then the pulmonary group no longer wanted to be the attending in the ICU. Enough was enough. Let the hospitalists deal with it!”

Yes, the primaries told me, they have enjoyed a better lifestyle since they left. Financially, it’s been cost neutral at best and many miss the intellectual challenge of treating complex hospitalized patients. But make no mistake: What drove some out was their changing relationship with the subspecialists.

I’ve recently heard a lot of discussion about “subspecialty dumping,” “mission creep” and “scut work.” Where exactly should we draw the line in the sand in terms of what we are willing to admit?

While I completely agree that there are limits, we would be foolish as a specialty to forget that what drove the primary doctors out of the hospital corresponded directly to our exponential growth. Maybe we don’t need to go so far as to hug a subspecialist today, but a thorough understanding of the past will hopefully help us shape a sustainable future.