Pushback from a primary care physician

Responses to “PCPs in the Hospital” from our March issue.

Regarding the article “PCPs in the Hospital” in the March ACP Hospitalist, I am a board-certified internist who never gave up hospital rounding. My six associates and I take turns doing the hospital rounds for our group even though there is a competent and active group of hospitalists in our facility. It is hard work. We have considered giving up the hospital but have not wanted to lose touch with our patients, give up the hospital skill set, or miss out on collegiality with other physicians.

I am not at all surprised that having the same group of doctors for inpatient and outpatient care helps with transitions of care and mortality. I believe it also helps with patient satisfaction.

I am flattered that, in the model described in the article by Allan H. Goroll, MD, MACP, a hospitalist team might allow me to do an “in-person consultation on admission, be available . . . during hospitalization, and participate in the design of the discharge plan,” as well as “provide the hospitalist team with a distillation of essential information about the patient, including a focused history, any relevant psychosocial issues and patient preferences, and recommendations for scope and intensity of workup and management.”

If I were to do all the above, basically be the physician for that patient, Dr. Goroll feels that it would “save the hospitalist team precious hours and stress, facilitate the delivery of personal care, better support patients and their families, and make for a more efficient hospitalization, not to mention hopefully reduce the readmission rate.” If you want me to do all the work of being a physician in the hospital, I will happily bill the appropriate E&M codes and spare the poor hospitalists the stress of caring for my patients. There is no novelty in the model of PCPs seeing their own patients in the hospital. This is what physicians who care for their patients do. Or used to do.

I am accustomed to the snide use of LMD (“local MD”) in university hospital history and physicals by ivory-tower residents who think no one but them knows anything about practicing medicine. I don't expect to see this attitude from our colleagues and friends who practice just in the hospital. In an evolving system where primary care physicians get a lot of lip service but are expected to shoulder much of the load for the whole triple aim, I am amazed by the extremely patronizing tone of this article.

Karl Bushman, MD, FACP

In response: I don't think Dr. Bushman realizes that I am one of those “LMD” primary care general internists. Our initiative to encourage primary care physicians to contribute to the care of their inpatients grew out of concern and sadness for the accelerating withdrawal of so many of our colleagues from inpatient care, something Dr. Bushman also aptly observes. Our goal is to design approaches that encourage their return in a meaningful, practical manner that is respected, valued by patients and the ward hospitalist team, and compensated. When I and my colleagues designed the nation's first primary care internal medicine residency track in 1973 at the Massachusetts General Hospital, it was with the express intent of fostering proficiency in both inpatient and outpatient medicine. That core training objective continues to this day and is also reflected in the content of the American Board of Internal Medicine certification exam. The increasing intensity and pace of both modern inpatient and outpatient practices require new approaches to care in both settings. Experimenting with thoughtful ways of collaborating with our hospitalist colleagues is done not to “spare the poor hospitalists the stress of caring for [our] patients” but to improve our patients' hospital experience and outcomes, not to mention rekindling the professional satisfaction that comes from our patients saying, “Thank you for coming.”

Allan H. Goroll, MD, MACP