Medicolegal Issues

Mixed Messages Called Out


I am a hospitalist outsider. A traditional internist, I cared for my patients in and out of the hospital, provided ICU and unassigned ED call, and later transitioned to hospital-only work. Our group developed a hospitalist program and has, hopefully, run an above-average system growing with our community. Even performing full-time hospital work, it took me a year to get over being referred to as a “hospitalist.” It seemed a confining label.

I also feel like an outsider while reading hospitalist literature’s divergent messages to hospitalists. On one hand, I hear great things about how hospitalists will revolutionize healthcare, spearheading improvements in safety, efficiency, and satisfaction, and filling administrative roles. I then see articles about negotiating out of working nights and weekends, about how the productivity of hospitalists remains stagnant but subsidy demands increase, and about how to limit caseloads. I see articles about hospitalist groups becoming privately held corporations, sending revenue that physicians generate (and hospitals subsidize) into the pockets of private investors.

There are two growing hospitalist camps. The first is filled with strategic thinkers driven to fix inefficient hospital care and save each of those 100,000 Institute of Medicine lives. These are the chief residents of yesterday, academically oriented problem solvers with IT savvy and a propensity for coffee-fueled all-nighters. You know them within your hospitalist groups and medical staffs.

The second camp consists of the lifestyle hospitalists; those for whom salary and 16 shifts a month are the goals that supersede professional loyalty to any particular group. These are the physicians who can help meet various metrics but want nothing to do with designing them.

These two groups read the literature with different eyes and career aspirations. As this division spreads, I strain to hear a drowning voice regarding another physician role: our responsibility to our patients. Drowning because both camps are swimming away from the patient, one toward a desk job, the other to a defined shift schedule.

Caring for patients is why we are in medicine in the first place. Most hospitalists came from primary care residencies, so the rewards of lifestyle and money must have been less important than direct patient contact. Primary care graduates entered traditional practices, promptly encountering the headaches of running a practice. Then suddenly a plum job with higher compensation and limited work hours was born, and, unsurprisingly, the primary care fields lost physicians to the hospitalist movement.

For new hospitalists exiting residency, there is no institutional knowledge of the old ways, and while they are not perfect, there are some noble qualities. Dedication to the profession is one, as is an enduring responsibility to one’s patient. Medicine required an occasional need to interrupt personal interests to help a sick human being—a patient—through a difficult time. For those physicians with traditional experience, can you recall articles suggesting negotiating for no nights and weekends? I’m not sure who we expect to provide this care to our patients if we can negotiate out of working.

There are certainly drawbacks to the traditional system: strained family relationships, substance abuse, and poor work-life balance—but don’t throw the baby out with the bathwater. These values elevated medicine to the position it holds today: a respected and well-compensated profession. I fear this young hospitalist specialty may not live up to its hype or responsibilities if hospitalists are motivated to focus on their “job” rather that their duties as the “doctor.” So what to do?

I think this can be a specialty that identifies members as physicians first and hospitalists second through the expectations of our peers in our own groups, medical staffs, and physician societies. We need to grow our groups with physicians dedicated not just to their partners, but the physician community at large; with those who want to improve care not just by meeting myocardial infarction guidelines, but with those who work with other physicians to help the patient manage their heart disease for 30 years; with physicians who ask about quality, teamwork, and the local community during the job interview and don’t begin with salary, patient caps, and weekend limitations.

Hospitalist group leaders need to expect these traits from their physicians. Otherwise practicing hospitalists will forever remain glorified residents and not leaders.

SHM needs to promote and recognize the values of being a physician in this field, instead of patting itself on the back for how trailblazing hospitalists could be while simultaneously ignoring what we are. TH

Edward Norman, MD, Internist/Hospitalist, Loveland, Colo.

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