Dr. Tom Roberts - December 23, 2005
"The Hospitalist"
My comments today are ones that I’ve repeated in some form to each of my patients over the last two or three weeks, so they come pretty easily at this point. Many or most of you in the listening area have already heard this, or will hear it in various forms as you interact with the health care system over the rest of your lives. The content of the talk today and the reality behind it reflect ongoing changes in the way medical care is provided. It’s definitely not the same as when I started here 25 years ago and the pace of change only seems to be picking up.
Today in most large hospitals in Montana, and very soon in all of these hospitals, people with medical problems will be cared for by a doctor who is not their regular doctor. This means that there will be a group of doctors working in the hospitals who just see people who have medical problems and are admitted to the hospital. These doctors don’t have a medical office and don’t take care of people outside of the hospital.
Until very recently, if someone got sick and went into the hospital, chances were that they would still have their regular doctor take care of them. This has already changed in Helena, Great Falls, Kalispell, and Billings. It’s about to change in Butte, Bozeman and Missoula. The medical system which already has split off many different specialties is heavily into the process of creating another one; the hospitalist. These hospitalists are often doctors like me who have practiced Internal Medicine in the office and the hospital, but are now changing to work just in the hospital. In fact, in many communities across the country and now across our state, primary care doctors either work just in the office or just in the hospital. This is becoming very common nationally and within a year or two it will be the norm here as well.
There are good reasons for this change, some having to do with the quality of care. But in our market driven health care system, the real driving force behind these changes is financial. From the doctors’ standpoint, it’s very inefficient to take care of people in the hospital. They come in at all hours of the day and night, frequently interrupting an already busy schedule, or a night’s sleep. The time investment and intensity of care is high for a hospitalized patient, and the financial payment is about the same as seeing a patient in the office. Because the cost of running a medical office continues to rise and the payment for seeing patients doesn’t rise equally, it is becoming more and more important for a primary care doctor to see lots of patients in the office and to see them quickly. Because of this, it’s no longer possible to see patients in the hospital during a regular working day. That has to be done early in the morning before the office opens, or late at night, after it closes. Not exactly the best for either patient care, or for physician lifestyle.
From the hospital’s standpoint, having dedicated doctors working full time in the hospital also makes sense. Most hospitals these days get paid a lump sum for caring for any one patient during one admission. This means they get paid the same amount for any given diagnosis whether the patient is in the hospital for one day or one week. Obviously the hospitals are interested in getting the patients taken care of efficiently. Having an overburdened office based doctor quickly seeing a patient once a day does not provide the most efficient care. Test results come back and illness progresses or improves, but is not reviewed again until the next morning. Having a team of dedicated hospital physicians tends to result in shorter lengths of stay, probably by providing more intensive patient management. Quality issues are also easier to address. This system tends to work well for the hospitals.
This change is coming soon, or has already happened in our communities. But it would be a mistake to think that the only change is that your regular doctor won’t be taking care of you if you happen to end up in the hospital. The days of seeing one doctor in his or her office and having that doctor available night and day, in and out of the hospital, over a period of decades, are rapidly drawing to a close, if they haven’t already left us. Due to financial realities, there are very few primary care doctors left who run their own offices. They’ve had to become part of larger entities or leave practice altogether. Because of finances and life style, lately we’ve seen very few medical students going into primary care practice. Some, like me, are leaving office practice to work as hospitalists, or to work in urgent care. Given this growing shortage, in the future most of us won’t even have a regular doctor. We will see very busy physicians for shorter visits, often in immediate care clinics. Increasingly we’ll see advance practice nurses and physician’s assistants who all work for the same system.
What we’ll have instead of a regular doctor is a regular place where we go to get our medical care. These places increasingly will be part of a hospital and more likely part of a multiple hospital system. Like the Mom and Pop stores of yesterday, economics have forced the solo physicians and the patients into one stop shopping mega operations. Some of the humanity and personal relationships will be lost in the process, but there’s no going back.
|
|
