Editor's Note: which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Stephen C. Schimpff, MD, a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, and author. This blog is also coauthored by Harry Oken, MD, a practicing primary care physician and professor of medicine. The views expressed in these blogs are those of their respective contributors and do not represent the views of or UBM Medica.
No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician-patient relationship and the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged. At a time when the patient most wants and needs the comfort of a long-time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to create this state of affairs?
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PCPs have seen their overhead costs rise dramatically along with insurer-mandated paperwork and government-mandated electronic health record (EHR) time requirements. This means the PCP must see more and more patients for shorter and shorter periods to cover overhead and still reserve time for the nonclinical requirements. The average visit time is now 15 minutes with only 8 to 10 minutes of face time. It also means that most—but definitely not all—PCPs no longer attend their patients in the hospital, leaving that function to the hospitalist.
Hospitalists are trained in caring for patients in the hospital. Since that is all they do, they become very experienced in dealing with the types of medical issues that require hospitalization. Working full-time in the hospital means that they know how to get things done in that setting and do so fairly efficiently.
The growth of the hospitalist movement over the past 20 years has been truly phenomenal—at 50,000 physicians, it is the largest medical subspecialty (cardiology is next at 22,000), surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000.[i]
Early studies suggest that quality was improved and costs reduced with the advent of hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something difficult for the community-based physician to achieve. With the need to see multiple patients each day in the office to cover overhead, many PCPs willingly ceded hospital care to the hospitalist.
In our experience, hospitalists are a heterogeneous group, many are just out of an internal medicine residency; some are working part-time because of childcare obligations. Many are contemplating a fellowship, but want to catch up on loan obligations. Some hospitalists anticipate at a future point to become PCPs. Still others intend to make a career as a fulltime hospitalist.
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Frequently employed by the hospital, they still must meet productivity standards in order to earn their salary. Often this means caring for a large number of patients, most of them quite ill. Although they are expert in what they do, they do not have the years of interaction with the patient that the PCP has. They did not know the patient before the hospital event and are not likely to know him or her after. Each patient is an individual with his or her unique family, social, economic, and of course, medical background.