During my internal medicine internship in 1980 a professor chided our team because housestaff no longer prepared and interpreted peripheral blood smears. He scoffed that they don’t make doctors like they used to. I have heard similar lamentations through the years. I imagine that millennia ago Galen griped that his apprentices did not examine phlegm and feces closely enough. I noted that I should not become a crotchety critic when I turn gray. And yet …
I am seeing serious downsides from the segregation of physicians into hospitalists versus outpatient practitioners. During hospitalization, patients suffer from loss of the support that accompanies longstanding connection and from lack of a knowing primary physician who protects them and coordinates care. My father was admitted to a coronary care unit with heart failure due to aortic valvular stenosis. His outpatient doctors were not on staff. Every day he was seen by a new ICU hospitalist who asked a few questions during a cursory visit. He also had brief daily encounters with a cardiologist and a cardiac surgeon he had not met before the hospitalization. Despite his worsening dyspnea and history of asthma as well as heart disease, none of the physicians touched a stethoscope to his chest. It seemed that without a personal connection to the patient, the hospital specialists were speeding along, conducting minimalist “drive-by” rounds. My father felt disenfranchised and isolated, despite the busy surroundings. On the day of his scheduled valve surgery, our family called for the procedure to be delayed. We were the ones who detected purulent phlebitis at an intravenous line site – no one else examined the patient.
One night a couple of years later, my mother suffered a minor stroke. She faced a different phenomenon: Hospitalists who stay at home. The radiologist reviewed her CT scan remotely. The neurologist requested that the emergency room doctor order a few tests but did not come to see her. My flight arrived hours later. I found her scared and alone (my father had died) in her room on the ward. There was no one to answer questions about diagnosis, prognosis, or plan. The neurologist’s answering service told me that he would talk with us the next day when he made rounds. Again, the lack of an established doctor-patient relationship seemed to foster hospitalist detachment, though I consider both cases to demonstrate suboptimal care regardless of the doctors’ purview. The next morning my mother’s old-school family physician, who still visits her patients in the hospital, delivered a hug. My mother shed tears of relief and gratitude, even though the family doc was not contributing to the workup. It was striking to observe how impactful it is to see your doctor in a time of crisis.
Some years ago, I moved to a city that was new to me. Who would be my physician? I went online and found an internist who had trained at a prestigious institution and who garnered favorable patient reviews. However, when I came under her care I learned that she, like almost all outpatient practitioners in the area, does not set foot in a hospital. If I require admission I will be on my own. As I reflect on the decades I worked as a nephrologist/internist, I believe that beyond offering technical expertise some of the most valuable services my partners and I provided to our patients were our availability, guidance, and support when they were in the hospital and most vulnerable. Importantly, we knew who to consult: which specialists were smartest, who was dedicated, who kept current, who demonstrated concern. We also knew who to avoid. We came in to see our patients whatever time they were hospitalized. Even when we had nothing to offer in the treatment of the immediate malady, such as a surgical condition, we would still provide a familiar face and reassurance. We would make sure the medication list was up to date. But in the new world of doctors with strict borders, no one will provide these protections for me. I will be at the mercy of the rotations of unknown hospitalists, be they the good, the bad, or the ugly.
Although it irks me that many physicians are no longer willing to see their patients in both the outpatient and inpatient settings, in fairness I recognize some potential advantages to the new way of doing business. I recall the sleep deprivation and exhaustion of providing round-the-clock availability, even when divvying up call among a group. Lost weekends, missed family events, lingering malaise. Also stressful were conflicts between office hours and pressing developments at the hospital or the dialysis unit. In fact, a sense of burnout contributed to my eventual career change from full time patient care to a clinical research path. Furthermore, having doctors specialize in hospital care or outpatient care alone might improve expertise in each setting. Perhaps in the long run it will benefit the delivery of medicine to “divide and conquer” to help keep providers energized and engaged. But my observations from the patient perspective of this new model of doctors with borders make me acutely aware of the shortfalls and distress that arise during hospitalization.
David A. Goodkin is a nephrologist.
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