Our hospital finally got its full-time hospitalist program off the ground this past August. Basically, there are now two hospitalist-run services, one for teaching (ie, unassigned and or clinic patients followed by the residents), and one is non-teaching (mostly patients of private family docs and internists who don’t come to the hospital and leave the inpatient management to the hospitalists without resident input). Two things have happened. First, the residents have gotten MUCH better and cohesive teaching. The hospitalists JUST do inpatient medicine and are very good at it - they subsequently tend to be much more comfortable managing numerous problems without the input of surgeons and subspecialists. In the past, the teaching service was run by a random assortment of docs from the community when they were on call. Some were good, many were terrible at inpatient medicine - consulting everyone under the sun (”Pneumonia? Call Pulmonary!) and often flailing with more complicated cases. Thus the residents got a totally disjoint education. Also, along with this, the ER docs are happy since when we call for an unassigned admission, we get an attending who can come down and see the patient at the time of admission, not the next day or whenever. They also frequently help us with cases, something the PGY 1 and 2 residents usually cannot do.
The second major thing to happen is the point of this post. Over the last few weeks I get medical subspecialists (mostly GI and Cardiology) and some surgeons coming up to me to express their dismay and annoyance with the lack of consults they get from the hospitalists. The “easy” “feed the bulldog” consults - such as asymptomatic guiac positive stools (trace rectal bleeding) and cheap, low risk chest pains, are drying up. And this is what apparently brings home their bacon. NOT the really sick cardiogenic shock patient or the massive upper GI bleeder. The mortgage is paid with easy, low stress consults on basically stable medicare and privately insured patients. So now the battle begins. The specialists are convinced that the hospitalists are playing favourites - ie giving the easy (and insured) consults to their buddies . while giving none or the uninsured difficult ones to the colleagues they don’t like. Some specialists are even accusing the hospitalists of commandeering their patients and admitting them when they themselves should be admitting them as their primary doc. A smaller number of them are just annoyed that the hospitalists exist - since they liked the easy consults from the less comfortable internists who previously admitted unassigned patients. They HATE the fact that the hospitalists are GOOD. I think they like to feel like they swoop in and save the day (and collect the moolah) but then DON’T have to do the discharge summary! I am being a little harsh since many of these specialists are good docs and nice people - but I have to say that as everyone knows, once you get a consult, you increase healthcare costs - not just the billing of the patient by the specialist, but because they tend to order expensive tests - like echos, EGDs, CTs, MRI’s, etc. This is part of what is bankrupting medicare. Anything that can SAFELY bring down unnecessary consults is a good thing. Assuming the hospitalist patients have just as good outcomes as the non-hospitalist ones, it is a good thing that they did not call Urology for the UTI.
The winner here is not yet predicted, but in other parts of the country, hospitalist programs are well entrenched so I think everyone is going to just have to get along.
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I agree with everything you said.
What a great and insightful post and so so true. I am going back and linking it on a blog I just this moment finished on “hospitalists”.
This also relates to my post a couple days ago about how doctors are retreating to their office work and outpatient surgical cases that are generally easier to manage, quick, pay well and are easy to scale on volume. Hospital work? The patients are sicker and you don’t get paid more for taking care of sick people.
do you avoid echo’s, or are they just done outpatient? i suspect the latter. in that case, you just made things less convenient for the patient, and potentially more expensive for them.
in any case, you will probably see contraction of specialists if the volume of consults drop enough. specialty groups will ally themselves with one hospital in exchange for guarantees of work volumes. that may mean less availability of docs for the sicker patients as well.
no free lunch here.
to the anon just above. I order an echo if I think I need an echo to manage a patient, which is far less often than a cardiologist, I’m sure. If the echo suggests the need for a cardiologist I get a cardiologist involved. I don’t need a cardiology consult to order an echo. Any more than I need a pulmonologist to order PFT’s. Any more than I need a gastroenterologist to order a small bowel series. I am capable of interpreting the results of these tests in the context of clinical medicine.
Internists, shocking to some, are trained to manage many organ system diseases that stake claim to a specialty. The rational that hospitalists had better consult the specialists for the bull dog cases or they will leave the hospital is ridiculous. Too many cooks lead to a pile of burned wasted expensive pasta.
the original post posited that one way money would be saved is by fewer echo’s or pft’s being ordered. i simply raised the question of whether that was true or not. whether you ordered it, or the specialist ordered it, or an outpatient doc ordered it, if the test was ordered, there would be no savings.
the specialists leaving comment is not ridiculous. you may not have seen it, but that does not make it true. that does not imply that the hospitalists ‘had better’ consult the specialists for easy cases, just that there are multiple consequences for the decisions we make.
The point of my post was that specialists tend to order lots of tests - that specifically pertain to their subspeciality. This includes things like Echos, PFT’s, Small Bowel Series, CT’s, Thalium Scans, MRI’s, etc. These tests can often be done as an outpatient and are thus less expensive. This is in addition to the billing that the specialists do for their consult. Internists/Hospitalists that manage a case by themselves tend to order less. In my opinion, if the outcomes of the patients are the same (ie, they do just as well), it is better to order less and save money.
It has always been my understanding that you will pay much more for an inpatient test than an outpatient test.
Alo t depends on the quality of the hospitalist, ours can’t seem to function independently, basically they need someone to blow their noses for them. The patient waits for the specialist to consult prior to treatment at times, or the hospitalist not knowing what to do orders a lot of unnecessary test practicing preventive ( litigation) medicine. There is a big disconnect with our hospitalist program. They spin trying to figure out what is going on with the patient, can’t complete a task and write orders constantly contriadicting each other. They don’t want the nurses to bother them, thus leaving patients again waiting for care.
This may work in large hospitals but it is a failure at ours.
Well, RN, you are right, if the hospitalist does not know what he or she is doing, the point of their existance is moot. Ours happen to be very good luckily.
[…] for an argument, she had insurance, so I figured I might be able to get one to see her as a “feed the Bulldog” […]
This seems like a very tunneled vision/view.
The sub specialists are likely sub standard at your hospital.
Sub specialists do help (and again not everyone is created equal) in timely diagnosis and sometimes in quicker discharges, ultimately to the patient’s benefit. I work as a sub-specialist and as an hosptialist and YES there are times (when a PCP consults me) that I do order more tests (if I think appropriate), however that helps me pick something up that either fixes the prob or convinces me that the patient can be discharged with further out-pt follow up. This is not as black or white to me, the hosp vs sub-specialist arguement.