Who’s your hospitalist?

Me: Hi, I’m Dr. Pal and I’ll be taking care of you here in the hospital.
Patient: Where the hell is my real doctor?
Me: He’s at the office seeing patients. He doesn’t come to the hospital anymore.
Patient: Why the hell not?
Me: Well, it’s complicated, but it’s getting harder and harder for doctors to pay their overhead. They have to see more and more patients, and in the time it takes to come to the hospital and see one patient, he can see 5 or 6 in the office.
Patient: What’s wrong with him just getting up earlier?

OK, time for a brief lesson on modern medical practice. First of all, I’m an internist. In the old model, an internist sees patients both in the office and in the hospital. Over the last decade or so, there has been a shift in practice. Fewer and fewer outpatient primary care doctors see their own patients in the hospital. Most now use “hospitalists”, internists who specialize in taking care of hospitalized patients.

There are several reasons for this.

First, hospitalized patients are much sicker than they used to be. To meet the “severity of illness”, and “intensity of service” requirements, you have to be pretty darn sick. This means that hospital care is more complex and specialized. Still, it’s not impossible to keep up with both outpatient and inpatient medicine.

Second, there are the financial pressures. Margins are very thin in small practices. Medicare pays me perhaps seventy bucks to see a patient. In the time it would take me to go to the hospital, I could have seen a whole lot of patients, and seeing a hospital patient doesn’t pay all that much more. Not only that, but to pay the bills, you have to see lots and lots and lots of patients, which leaves even less time for other things, such as family, eating, urinating.

I’m in a unique situation, in that I need to be at the hospital every day to teach, so seeing my own patients is no big deal. But for most internists, it’s becoming impossible. Taking care of hospital patients is not just the 10 or 15 minutes at the bedside; it’s the paperwork, phone calls, and pages; the discharge planning, the specialists. Each hospital patient is more work than any 5 office patients, for the same pay.

Where does that leave patients?

For the most part, patients get excellent care from hospitalists. Those of us who see patients in the hospital learn to develop a rapport quickly, and we communicate closely with the outpatient physician (hopefully). Still, patients can feel a bit abandoned by their doctor. Many outpatient doctors still call up or pay a brief visit to their sick patients. These visits aren’t billed, and because the doc isn’t actually managing the patient, they don’t need to come daily. These “social rounds” are important, and give the doc the flexibility to give inpatients some TLC, but without the responsibility of all that hospital care entails.

In many of my posts about the nature of medicine, there has been a bit of back and forth about whether medicine is somehow different from other professions. When a patient looks up at you from their hospital bed and says, “why can’t he just get up earlier?”…well, for me, that answers the question.