Profession

Hospitalist, generalist: How they balance care

What obligations do primary care physicians and hospitalists have?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Nov. 3, 2008.

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To assure the best care for a patient who requires hospitalization today, the primary care physician and the hospitalist must work together. Sometimes the system seems to conspire against that.

Reply: As I approach the closing stages of my career, I may be looking at the ethics of the primary care-hospitalist debate through jaundiced eyes. I started my posttraining community practice in rural northern Canada. The town of 25,000 people relied on 10 general practitioners, one general surgeon, an obstetrician and a part-time internist.

I probably learned as much about the practical application of the art and science of medicine in that one year as I had learned in all my training. As generalists, we cared for most of the patients' needs. We admitted patients to the 35-bed hospital, administered anesthesia, assisted in surgery and delivered the majority of babies in the hospital.

When I relocated to Southern California in 1975, I chose to join a group of family physicians who provided similar services. This choice of career filled my life -- from the joy of a newborn and the thrill of surgical intervention to the humility of helplessness with the death of any patient.

In my third decade of medical service, our physical ability to continue this level of intensity in our practice waned. Our group integrated into a large multispecialty organization. Gradually, we evolved into an office-based practice, and hospitalists managed our inpatients, with consultations with other specialists.

The economics of medical practice partly dictated this change. Put simply, it became financially inefficient for primary care physicians to attend patients in a hospital. The ethical commitment to maintain the patient-physician continuity of care from outpatient to inpatient fell victim to a bottom-line mentality.

The advent of diagnosis-related groups as the basis for reimbursement forced hospital administrations to attempt to reduce lengths of stay. A physician dedicated to inpatient care seemed the ideal means for accomplishing the goal of DRG solvency. The financial alignment of outpatient efficiency and inpatient control of hospital utilization heralded the end of continuity of care.

"Maintaining clinical competence" euphemistically became the mantra for supporters of the hospitalist movement, with its implication that primary care physicians could not maintain the skills needed to manage inpatients.

True, as the acuity of illness increased, so did the complexity of management, but the need for patients to see physicians familiar with them also increased. The sense of confidence and comfort in seeing "my doctor" remains an immeasurable but undeniably true phenomenon.

This abandonment of the emotional comfort of patients during a fearful, painful and often life-threatening experience poses an ethical dilemma for me. The powerful experience of assisting patients through a difficult inpatient stay and subsequent recovery or demise remains an essential part of the life of a complete physician.

The increased division of medical care presents an ethical dilemma: To whom does the patient turn for integration of medical opinion?

Consultation with specialists and subspecialists for particular problems or conditions remains essential for quality of care, but one physician needs to coordinate and monitor the evolution of care throughout the inpatient experience.

The removal of the hospital experience limits the outpatient physician's ability to comprehend the effect of that experience in caring for and assisting the person.

I also believe that the now outpatient-only physicians can lose touch with the experience of truly sick people. In fact, it is not that primary care physicians lacked the competence to care for patients in the hospital, but that the lack of inpatient experience now begins to limit clinical competence. The truly sick person in the clinic may go unrecognized by an outpatient physician with limited inpatient experience.

The geriatric population increases this ethical dilemma.

As a patient's physical faculties deteriorate, the need for coordination of care increases. In spite of newer evaluation and management codes that provide reimbursement for some patient management activities, performing almost any procedure on an elderly patient pays more than does visiting and coordinating care for your hospitalized patient.

The financial reimbursement for a simple procedure, such as the removal of a facial skin cancer for example, exceeds that for an acutely toxic geriatric hospital patient, whose care takes much more intellectual time and clinical management.

Without a coordinated, physician-managed medical evaluation of the desires and needs of the geriatric patient, this hospitalized individual sustains numerous investigations and procedures of questionable long-term value. The uncoordinated transfer of care from office-based physician to hospitalist increases the probability of more questionable interventions. Current practice borders on patient abandonment for financial efficiency.

The solution to an improved transition of care rests on rewarding the primary attending physician for visiting and monitoring the patient in the hospital -- with a hospitalist overseeing the moment-to-moment care, followed by the attending physician participating in the discharge planning and follow-up. Having both physicians experience the inpatient care enhances the value of the encounter to the physicians and benefits the patient.

Lytton W. Smith, MD, family medicine/geriatric medicine, Yorba Linda, Calif.; assistant professor of family medicine, University of California, Irvine

Reply: The relationship between hospitalists and primary care physicians is grounded in the shared commitment to seek the best health care for their patients.

The rapid and sustained growth of the hospitalist movement suggests that collaborative management of patients is the de facto model of the clinical encounter for the foreseeable future. That reality has renewed attention to the patient-physician relationship in this changing, often disorienting, health care environment, attention that partly stems from concerns that the use of hospitalists introduces discontinuity in the patient-physician relationship each time a patient is admitted to the hospital.

The rise of hospitalists can be seen as part of the trend toward subspecialization, which inevitably multiplies the number of caregivers involved in even routine medical encounters. As a result of such trends, a contemporary patient's relationship with his or her doctor is more accurately described as a relationship with his or her team of doctors.

And in this context, the doctor-doctor relationship can have as much or more impact on patient care as the doctor-patient relationship.

In an ideal world, the hospitalist and primary care physician negotiate a robust form of professional courtesy that reflects a mutually accepted partnership characterized by frequent, timely and accurate communication that ensures good coordination of care. This partnership requires that team members assist one another in the care of patients.

One of the most challenging and critical aspects of being a good hospitalist arises from the need to quickly form a therapeutic relationship with patients.

Hospitalists must establish trust and learn the nuances of a patient's particular needs during a very brief encounter. The most skilled hospitalist occasionally needs help in accomplishing this. There will always be clinical situations that benefit from the involvement of a primary care physician who is already intimately familiar with a patient.

In our experience, the very presence of the primary care physician at the bedside often reassures a nervous patient. Primary physicians can be vital members of the team when they participate in complex discussions such as those about long-term placement and end-of-life care.

In other situations, hospitalists may find themselves caring for disenfranchised patients who lack primary care physicians.

Hospitalists often end up serving as "pseudo-primary care physicians" for patients who would otherwise not receive consistent outpatient follow-up. In our program, for example, hospitalists have been known to manage a patient's diabetic regimen past hospital discharge, ensuring safety until a primary care appointment can be made.

These examples highlight the ways in which primary care physicians and hospitalists can act beyond the artificial boundaries of their job descriptions. By grounding their partnership in the shared commitment to the patient's welfare, and by always communicating well with one another, hospitalists and primary care physicians keep collaborative care firmly centered on patients.

Although hospitalists have been employed in the U.S. for more than a decade, there is still a perception that hospital medicine is novel. This perception exists, at least in part, because the problems of folding a new medical subspecialty into the health care system have not all been solved. There is still much work to do in modernizing reimbursement rules, improving transitions of care and adopting new information technologies.

Updating the U.S. health care infrastructure will be integral to cultivating a working partnership between hospitalists and primary physicians. And while modern health care seeks to ensure that physicians are competent and cooperative, compassion for patients remains the immutable hallmark of physicians who deliver excellent care.

Hospitalists and primary care physicians have the opportunity to build a positive professional ethos that affirms the durable commitment to patients despite the uncertainties of our ever-shifting medical environment. Physicians' professional obligations to each other flow from the central commitment to the patient's health. With humility, flexibility and courtesy for each other, hospitalists and primary care physicians can fulfill the promise of team-based care by strengthening their shared relationships with patients.

Keiki Hinami, MD, Section of Hospital Medicine, University of Chicago

John D. Yoon, MD, Section of Hospital Medicine, University of Chicago

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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