Monday, May 14, 2012


  This month I'm working on a cardiology consulting team and with it, I've gotten a lot of exposure to the hospitalist side of internal medicine. Hospitalists are internal medicine physicians who only take care of patients in the hospital. They have no clinics and only deal with the short-term problems that the patient is hospitalized for. In effect, they do my internal medicine rotation all the time (except they are the entire team). It sounds terrible. One colleague called it "residency for life." However, it has it's benefits. It is essentially shift-work, so it has a pretty nice schedule. Most people go into it straight out of residency (so only 3 years after finishing medical school). Most hospitalists work a week on followed by a week off. So, a vacation every other week. They also get paid pretty well. 200000+ for working a total of 6 months each year. Because of these benefits, it's quickly becoming a popular choice.
  The problem comes with not having ownership of the patients. Without any continuity of care, hospitalists don't know their patients as well as internists who also have a primary care clinic. With the shift-work schedule, their is a lot of passing patients between hospitalists and resulting poor communication. Also, with 20+ patients a day, there isn't much time spent with each individual patient. Putting all this together, hospitalists tend to not think about each individual case as much. At least that's the trend I've seen when consulting for a hospitalist versus consulting for a resident-run team or a team run by a regular internist. This doesn't mean that patients under the care of a hospitalist are at risk. The more common result is that they are overtested and specialists are overconsulted. If you don't have time to think about why someone is having chest pain, you get a chest X-ray, CT-scan, EKG, an echocardiogram, stress test and lots of blood tests and you consult a pulmonologist and a cardiologist. One of these will figure out what the problem is and your specialists will tell you what to do about it. I've seen this pattern quite a bit recently, including one case in which the hospitalist ordered these tests and consults prior to seeing the patients or even reading their previous notes (the patient was transferred from another hospital and through testing had already shown that his heart was fine).
  Of course, there are great hospitalists who know their patients well, think hard about each of the cases and use hospital resources efficiently. However, there is a disturbing number who are wasting resources and their consultants time as well as running up the cost of healthcare.

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