“Realistically, I am providing better value to the healthcare system than a specialist does, and yet we pay specialists much more,” she says. “And until that’s different, people go where the money is and they also go where the respect is, and I think it’s going to be very hard to recruit more people to primary care.”
Despite research pointing to financial concerns, lifestyle perceptions, and training inadequacies as key factors in the decline of primary care, perceptions that HM is poaching young talent have been hard to shake. A recent article in The Atlantic asserts that HM might be a “rational choice” given the profession’s more favorable training, lifestyle, and financial considerations.4 The author, a general internist, contrasts those enticements “to the realities of office practice: Fifteen-minute visits with patients on multiple medications, oodles of paperwork that cause office docs to run a gauntlet just to get through their day, and more documentation and regulatory burdens than ever before.”
Nevertheless, the article describes PCPs who resist hospitals’ calls to move to a hospitalist system as honorable “holdouts” who are committed to being directly involved in their patients’ care.
In her blog post at KevinMD.com, “Hospitalists are Killing Primary Care, and other Myths Debunked,” Vineet Arora, MD, MPP, FHM, a hospitalist at the University of Chicago, addresses those perceptions head-on. “If hospitalists did not exist, there would still be declining interest in primary care among medical students and residents,” she writes.
In a subsequent interview, Dr. Arora contends that both primary care and HM instead might be losing out to higher-paying subspecialties, especially the “ROAD” quartet of radiology, ophthalmology, anesthesiology, and dermatology. She also questions the notion that the professions draw from the same talent pool. “Anecdotally, I can tell you that I don’t see a lot of people choosing between primary care and hospital medicine,” she says. “They’re thinking, ‘Do I want to do critical care, hospital medicine, or cardiology?’ Because the type of person who does hospital medicine is more attracted to that inpatient, acute environment.”
Dr. Horwitz agrees that the choice between a career in primary care and HM might not be as clear-cut as some detractors have suggested. Even so, she describes hospitalists as a “double-edged sword” for PCPs. “On the one hand, primary-care docs get paid so little for their outpatient visits that most need to see a high volume of patients in a day just to break even. So they have less and less time to go to the hospital to see hospitalizations,” Dr. Horwitz says. “The hospitalist movement was really a godsend in that respect, because it allowed primary-care docs to focus on their outpatient practice and not spend all that travel time going to the hospital.”
Other PCPs have lamented the erosion of their inpatient roles while recognizing that current economic realities are gradually pushing them out of the hospital. In fact, Dr. Horwitz says, PCPs often don’t know when their patients have been hospitalized, leading to a breakdown in the continuity of care. A weak primary-care infrastructure in a community, hospitalists say, can likewise imperil safe transitions. With the partitioning of inpatient and outpatient responsibilities, the potential for such miscommunications and lapses has clearly grown.
“We’re all in the same workforce; we’re all trying to take care of patients,” Dr. Heim says. “The discussion needs to be on how do we coordinate, not over turf wars.”
Signs of Life
Experts are focusing more on team-based approaches among the few potential short-term solutions, a common theme in HM circles. Advanced-practice registered nurses, physician assistants, and other providers can be trained more quickly than doctors, potentially extending the reach of primary care. In turn, the concept of team-based care could be beefed up during medical residencies.