Blog | Thursday, December 8, 2011

Where have all the young docs gone?

In my new role as one of the directors of an internal medicine training program, I help select new interns out of medical school for the three year training stint of residency.

At the end of residency, many graduates go on to subspecialty fellowships, another two to four year period of intensive training in fields like cardiology, nephrology, critical care, etc.

For those that don't choose a subspecialty, one choice remains: traditional internal medicine (opening or joining a medical practice) versus becoming a hospitalist.

At this point, it's no contest. Hospitalists earn more money. North of $200k. One standard job format involves 14-hour shifts, seven days on followed by seven days off. Our graduates are unanimously choosing this path.

I fear that young doctors don't see value in primary care careers. With health care reform set to kick in in 2014, there will be a tremendous shortage of available doctors for newly-insured patients to see.

I'm reposting a story I wrote about one couple's painful experience learning about what a hospitalist is. In future posts, I plan to explain the competing tensions between the alternate job pathways in internal medicine and examine the health care workforce as a whole.

A few weeks ago I got a call from Frank Wilson (not his real name).

He told me he and his wife were looking for a new doctor and a new hospital.

Mr. and Mrs. Wilson had been with the same doctor for nearly 20 years. The relationship had been warm, and, he explained, "We trusted him to follow us through thick and thin."

I could sense the hurt in his voice. Why, I wondered, would they give up on a doctor who knew them so well? Among people of my generation, doctors are switched more than toothpaste.

At a time of need, Mrs. Wilson became sick enough to need the hospital. They called their doctor, let's call him Dr. Gonomore, and he agreed to see her right away.

Mrs. Wilson was short of breath, and would need to be hospitalized, to figure out exactly what was wrong with her and to offer her the most aggressive treatment.

Dr. Gonomore phoned the admitting office at Fancy Hospital across town, where he's on staff. He also spoke to the team of residents that would accept Mrs. Wilson to tell them about her condition and offer suggestions as to how to care to her.

When Mr. Wilson had his wife at the door ready to leave the office, he casually remarked to Dr. Gonomore, "See you at the hospital."

Wanting to dispel any false notions, Dr. Gonomore informed the Wilsons that he no longer cared for hospitalized patients.

What really angered Mr. Wilson, more than this feeling of abandonment, was that Dr. Gonomore told them that he'd stopped going to the hospital (other than for meetings) about five years before.

Dr. Gonomore's practice group, like many other primary care medical practices (both private practices and non-profit-owned), had simply deemed it too inefficient to continue following their patients when they are sent to hospital.

Primary care docs do better financially, on average, seeing more patients in their clinics than they do by taking time out of the office to go and make hospital rounds.

That, coupled with the rise of the hospitalist movement, has changed everything about the way we relate to our patients.

A hospitalist is a doctor who spends most of his or her patient care time caring for hospitalized patients. It does not mean that they don't see patients in an outpatient (office) setting, but if they choose to, it's typically only a small part of what they do. Many hospitalists choose not to see patients in an office setting, preferring to spend their clinical time all in the confines of the hospital wards.

Numbers on how many hospitalists continue office practice are hard to come by. However, it's quite clear that hospitalists are here to stay. From the time the term was coined by Wachter in 1996, the number of doctors choosing to become hospitalists has risen exponentially.

Many in my field expect hospital medicine ("hospitalism?"), like emergency medicine before it, to become its own specialty field.

Younger doctors coming out of residency training often choose the 'certainty' of shift work in the hospital, leaving their concerns behind at the end of a shift. They can keep using the procedural skills (doing spinal taps, etc.) that they've learned during residency–something many office doctors give up due to low volume and little practice.

As an office based primary care doctor, my work comes home with me. There are always phone calls and emails to be returned, and doubts about patients and our shared medical decisions linger around for days until some clarity or progress can be achieved. There is much less of a shift work mentality, given that over time I start to see the same patients (my "panel") again and again.

"Hospitalism" (my term), the belief that hospitalists provide competent, efficient, slightly lower cost (mostly by achieving shorter length of stay for thier patients in the hospital) care, is here to stay.

Many internal medicine colleagues are happy about the change. Those that want to focus on in-hospital work can do so; those that abhor the hospital (ironic, right?) now can opt out. Still, for those who want a little of both, the middle road exists-but it is trod by fewer and fewer of us.

I was touched by the Wilson's story. (Happily, Mrs. Wilson was home from the hospital and feeling better.) Mr. Wilson seemed old school, and was looking for an old school doctor that would go to the hospital when he or his wife needed it.

Alas, I couldn't recommend coming to see me or using our hospital. I suggested starting with smaller private practices, and asking up front if doctors in the practice follow their patients in the hospital.

We in medicine of course assume everybody knows what a hospitalist is, and that people should have the expectation of seeing one.

Mr. Wilson's story convinced me otherwise.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.