I just returned from IDWeek in New Orleans where one of the running themes was on the future of the infectious disease specialty. In brainstorming what we could do differently one question revolved around what could infectious disease physicians learn from hospitalists who have become an attractive specialty in just two decades.
The New England Journal of Medicine (NEJM) recently published must-read articles on the state of hospital medicine. The first was a Perspective celebrating the 20th anniversary of the hospitalist. Has it been that long? Wow! It was written by Drs Wachter and Goldman, the creators of the term “hospitalist”. Essentially it describes how the internists who became known as hospitalists took ownership of their careers and made their worth known to the healthcare system, something infectious disease physicians should learn from. Hospitalists quickly showed that their involvement in patient care “reduced costs, shortened lengths of stay, and preserved or even enhanced quality of care and patient satisfaction” to the point that hospitals today are more than willing to subsidize hospitalist salaries. And boy are they attractive salaries to those medical residents swamped with medical education loans who might otherwise be attracted to non-procedural fields like infectious disease that not only require further years of specialization and debt forbearance but also are not as well compensated.
The second NEJM article is also a Perspective published in the same edition and actually precedes the Perspective above. Written by Dr. Gunderman it is titled Hospitalists and the Decline of Comprehensive Care and it does not paint a rosy picture. It argues that patients ultimately suffer from the breakdown of the patient-doctor relationship on multiple levels and from making the hospital setting central to healthcare delivery. Sadly, this is true. More than the breakdown of care of a patient who moves from the outpatient to the inpatient and back, or between hospitals in the same neighbourhood, is the breakdown of care of a patient who is hospitalized in one institution for a period of time and is assigned different “primary doctors” day-to-day depending on the hospitalist schedule. As a community infectious disease physician with privileges at several hospitals, an outpatient practice, and a schedule that often has me working 12 days in a row, I sometimes find myself in the unique position as the one physician on the inpatient team who has been with the patient from Day 1. I have had patients and their families joke that they can’t get away from me but their relief at seeing a familiar face when I walk into their room for a consult is obvious.
Hospital medicine is not going anywhere. As remarkable as the growth of this now recognized specialty has been, there is wide variability in quality. Sadly, I have come across hospitalists in the community who seem to be utterly useless, who don’t take ownership of their patients, and who can’t make decisions for a patient without the approval of a specialist. They seem to work as the second level of triage. It’s mind-boggling taking a step back and watching the inner functions of how their patients are taken care of. For example, they admit a patient that the Emergency Room physician has worked up as sepsis and run with that diagnosis. They consult Cardiology to say that the troponin of 0.3 is a troponin leak in the setting of sepsis. Hematology to say that the platelet count of 50K is thrombocytopenia probably due to sepsis. Endocrinology to say the elevated glucose is probably because of the stress dosed steroids given in the setting of sepsis. Gastroenterology to say, yep that is a liver abscess as seen on the CT-scan. General Surgery to say consult Interventional Radiology to place a drain into it. And yours truly to say please send a culture of the drained liver abscess. I suppose we all should be happy to get a piece of the cake. If that’s the way it’s going to be though, a hospital system will do well to get rid of hospitalists, who earn more than your average infectious disease physician (yes, I’m salty), and let nurse practitioner’s and physician assistants take that role of pan-consulting away. Of course, I’m not advocating this because I believe it will be terrible for patients. I just resent working with terrible hospitalists.
And then of course the opposite. The hospitalists who are excellent clinicians and who by their very existence refute the necessity of specialists in the care of a patient. The hospitalists who are self-sufficient. The hospitalists who command your respect and trust. The hospitalists who when they ask you to consult on a patient, you know you better get your Super-XL thinking cap on. The hospitalists who after hearing your impression and recommendations say “nah, I don’t think so”, tell you why and make you reconsider your plan of action. Of course some of them take it to the extreme. Those who insist on taking care of a patient with Staph aureus septicemia on their own because “they know what to do” despite the fact that even if that is true the patient will at some point be discharged to the outpatient setting on a prolonged course of intravenous antibiotics which they the hospitalist will not be monitoring and which the patient’s primary care physician will be loath to monitor.
There is a lot that infectious disease physicians as a society can learn from the rise of the hospitalist movement in terms of increasing the perception of our value in the healthcare system. I don’t think we will rise to the level of being advertised on hospital owned billboards however, I would hope that we don’t succumb to the pressures of financial medicine. We too can save a hospital money by decreasing patient length of stay and by optimizing the use of expensive antibiotics and microbiology diagnostics but that should not be what we run with. Chasing the money will end us in a situation where a less effective antibiotic is championed simply because it’s cheaper. Or a situation where a hospital decides to not do gram stains in-house or to not process cultures on catheter tips which sadly I have already seen happen.
Infectious disease is not a field to be diminished into the role of just another cog in the wheel in the way some hospital-employed hospitalists are becoming. In our struggle to define ourselves, we should not allow ourselves to be reduced to people following protocols and checklists and as such become indistinguishable from each other and thus dispensable. For if the infectious disease doctor is not thinking about our patients, who will? If no-one is thinking, no-one is innovating and no-one is discovering a new infectious process or pattern of antimicrobial resistance. Ask two infectious disease physicians their advice on the same case and you will get two different answers is often the joke. I’ll argue though that is a good thing. That means we are still thinking about our patients as individuals and not as an entity that should fit a checklist. Our continuity of care is our worth. Our ability to see the big picture and marry the inpatient and outpatient worlds is our worth. Our analytic processing is our worth. Our committment to our patients and our colleagues is our worth. We need to appreciate our worth so others can appreciate it too.
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