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I am a Med/Peds physician.  That means that my training was in both internal medicine and pediatrics.  I do basically what a family physician does (a little more pediatrics, and less procedures and well-woman care). 

My internal medicine residency training was mostly inpatient in nature.  We spent most of our time on the wards in the hospital, often taking care of intensive care patients.  I never spent much time taking care of patients in the outpatient setting, with a half-day each week alternating between adult and pediatric clinics.  So by the time I was done with residency, I was very comfortable in taking care of inpatients – even ICU patients – but with relatively little experience taking care of patients in the office.

I quickly adjusted, however, with a very complete understanding of the diseases I was treating and trying to prevent.  We cared for our patients both in and out of the hospital, often spending several hours in the morning on our patients in the hospital prior to spending a full day at the office.  We shared call with other internists on weekends, resulting in a number of weekends with little sleep and the vast majority of my time spent in the hospital.

This all changed when a group of intensive care/hospitalist physicians moved to town.  We were contemplating expanding our office hours with a morning walk-in clinic, and we were getting quite tired of our nights on call.  When we looked at the income we were getting from inpatient care for the long hours we put in, it was clear that it was financially best to opt out of it in favor of the hospitalists.  We would still take care of hospitalized pediatric patients (there was no hospitalists for children in our town, and pediatric inpatient care is much less demanding), but all of our adult patients came under the care of the hospitalist group.

It would seem like a no-brainer:  improve your quality of life by drastically improving your call, improve your income, and offer a new convenience for the rest of your patients (using a daily walk-in clinic).  Yet the decision was hard.  I loved inpatient care, and considered it a major part of what it meant to be an internist.  Plus, I would have to sacrifice the ability to care for my patients in the time of their greatest need.  What would our patients think?

It turns out that our fears were well-founded.  Whenever we told our patients that we no longer took care of our patients in the hospital, we were met by a look of bewilderment.  We always tried to counter that look by pointing out the fact that we were now open from 7:30 to 9 AM every morning and 5:30 to 7 PM every evening for walk-in visits.  While this did make sense, it did not erase the disappointment.  

Perhaps the biggest negative about using hospitalists, however, is the fractionation of the care of the patients.  I am not sure if this is the norm for hospitalists, but so far we have had three groups we worked with, and none of them communicated well with outpatient offices.  They don’t seem to understand that the vast majority of the patients’ care goes in in the outpatient setting.  Each hospital visit seems to be treated as an individual episode of care rather than part of their continuum of care.  We are rarely called when patients are admitted to the hospital, and rarely are told when they are discharged.  Often patients come to our office before we know they have been hospitalized at all. 

Despite our frustration, it is basically impossible for us to take back inpatient care.  The lifestyle improvement from using hospitalists is dramatic.  It has enabled us to continue our very popular walk-in clinics and to actually se our families.  Plus, I have now not done inpatient medicine for over eight years.  This means that we have very little leverage when it comes to demanding better communication from the hospitalist groups.  If we don’t like their care, we can do it ourselves.  It just won’t happen.

I have to believe that this is a common scenario.  Anyone who makes the jump to hospitalists will end up in a very weak bargaining position.  Yet the total lack of communication really does damage to the quality of care.  They end up duplicating much of what we do in the office.  When they don’t contact us regarding the patient, they are basically "flying blind," relying on the memory of the patient as to what has gone on with their care.  We would welcome phone calls, but they don’t come.

I don’t see a real solution here.  Are there any hospitalists out there with an answer to this one?