For those of you who have not yet had a chance to see the heavyweights square off about hospitalist medicine, I would strongly encourage you to do so.
In a recent point-counterpoint, Dr. Mark Williams cogently argues that hospitalists improve the overall efficiency of care without diminishing the quality. Dr. Robert Centor counters that this claim is unproven, although he readily concedes that hospitalists are here to stay. Au contraire, Dr. Williams writes, stating that the evidence is in fact strong. Dr. Centor stays on the offensive. “Dr Williams has written an impassioned advertisement for hospital medicine,” he writes, even as he maintains that the evidence is poor. Internal medicine as a contact sport: I love it!
I’m biased to be sure, but I tend to agree with most of what Dr. Williams has to say. Yet Dr. Centor is not wholly off the mark in suggesting that, “Quality concerns are not driving the growth of hospitalist groups. Rather, this ‘field’ of general internal medicine has grown to meet financial and lifestyle issues.”
Let’s take a look at this claim, starting with the financial side of things. Most people agree that outpatient doctors will make more money if they leave rounding to hospitalists. Many factors go into this equation: payer mix, the hospital-office geography, an individual doctor’s inpatient census. Add $5-a-gallon gas to the equation, and my sense is that most outpatient doctors do better adding patients to their office schedule. At the same time, more than a few hospitalists have gone the inpatient route because the current supply-demand mismatch has us taking in, on average, at least $20K more than our outpatient colleagues.
That said, it was Dr. Centor’s observation about lifestyle that really hit home. The last thing I want to do is deal with the daily hassle of practicing outpatient primary care. It is hard to argue that shift work is not a lifestyle improvement (and I do believe the majority of hospitalists will be working shifts) over being on call every fourth night, with the constant threat of being paged all night long and having a full office waiting in the morning.
But while schedules can be tinkered with, the basics of being an outpatient doc cannot; to me, such a practice sounds like one headache after another. Granted, this is a generalization, one made without having walked in an outpatient doc’s shoes (at least since medical school). Still, between the conversations I’ve had with my outpatient colleagues and what I’ve read about the field today, I gather it can be a pretty tedious gig.
Major culprits that do affect lifestyle are endless forms to complete, constant denials of tests and services, and terrible reimbursement. Whenever I deal with something that my outpatient colleagues must face on a regular basis, I feel great empathy. For example, it seems that I cannot send a patient home with a prescription any more unless I want to talk to the pharmacist about why that medicine is not covered.
To get the medicine covered, I have to call an 800 number and waste at least 10 minutes listening to the sweet stylings of Musak-ed Barry Manilow before I get to futilely plead my case. If I want a CT, I order one; if an outpatient doc wants a CT, he or she spends the day jumping through hoops.
I recently filled out a 10-page disability form, something I can usually avoid as a hospitalist, and I nearly lost it when I read the cover page. The form, which was generated by the great State of New Jersey, offered me all of $20 if I completed the form in my office–and $5 more if I did so in the patient’s home. To correctly prepare the form would have easily taken me an hour!
So, I greatly enjoyed being a spectator to the great hospitalist debate. But it struck me, in the end, as academic. The future of hospitalist medicine is assured, no matter what the direction health care (glacially) takes.
The same cannot be said about the practice of outpatient primary care, however, where shrinking reimbursements and growing hassles may mean a disappearing primary care pool. Yet this is a matter of great urgency and relevancy, and I hope for the sake of our outpatient colleagues, this debate yields a sustainable outcome.