The Interface between Primary Care and Hospital Medicine

Introducton

It is estimated that the United States currently has over 222,000 practicing active generalists that are either office or hospital based. This includes trained internists, family physicians, and pediatricians who provide primary care to the great majority of the U.S. population. Physicians in family medicine, general internal medicine, and general pediatrics are the foundation of U.S. health care, providing 52% of all ambulatory care visits, much of the inpatient care, 80% of visits for hypertension, 70% of visits for chronic obstructive pulmonary disease (COPD) and diabetes. Yet it is expected that there will be a significant shortage of primary care physicians over the next 20 years because the U.S. population is expected to increase by 18% between 2005 and 2025, and the population over age 65 (which utilizes the health care system twice as often as younger adults) will increase by 73%.

State of Primary Care

At the same time, the number of medical school graduates who plan to enter general internal medicine has decreased annually since its peak in 1998, by nearly 40% overall in 2009. Increasing numbers of graduates who are entering general internal medicine are choosing to practice Hospital Medicine exclusively. More women are entering medical school and the physician workforce (at a nearly 50% expected even representation by 2025), and women are more likely than their male counterparts to work in part-time positions. Finally, the number of hours working and patients seen by older physicians who are approaching retirement is unlikely to be matched by the newly graduated physicians that are their replacements.

Between the growth of the population over age 65 and the decrease in physicians practicing outpatient primary care, there is expected to be an outpatient physician shortage by 2025. An expected 30% increase in ambulatory care visits for adults will significantly increase the workload for those who primarily practice outpatient medicine. Deficits of 35,000 to 44,000 adult generalists are expected by 2025, threatening the foundation of primary care for adults. Geographic differences in physician supply indicate that shortages will be more acute in rural areas. These numbers do not take into account health care reform, with the provision of universal coverage. This will add an additional 31 million people into a system that is already challenged, with expected increases in wait time for visits and further increasing workload on primary care providers.

Compare this to the physician workforce in Great Britain and Canada. The United States spends the most per capita on health care in the world, accounting for 15% of gross domestic product (GDP), yet, according to the World Health Organization, it ranks 37th in the world in several leading health indicators. In comparison, Canada spends about half as much per capita, and health care spending accounts for 10% of the GDP. One of the differences quoted between the two systems is access to primary care providers who act as “gatekeepers” to specialty care, helping to keep costs down. The number of physicians entering primary care in Canada is rising faster than those entering specialty fields, up from 96 per 100,000 in 2002 to 98 per 100,000 in 2006 (Canadian Institute for Health Information). In Great Britain, the National Health Service provides 90% of the health care to its population, and about 6% of GDP is spent on medical services. In Great Britain, nearly 50% of medical school graduates will enter the field of general practice.

In response to the aging population with its anticipated increase in health care utilization, the Association of American Medical Colleges called for a 30% increase in the number of medical students across the country. However, an increase in the number of medical students does not equal an increase in primary care providers 10 years from now. U.S. medical students have chosen primary care in declining numbers over the past 10 years for a variety of reasons, including less income as compared to procedural-based specialists, high debt burdens from medical school, the perception of primary care having less prestige with high work-related stresses (work harder for less money), and medical education favoring training in nonprimary care fields. Initial plans for a primary care career may be deterred by a chaotic resident clinic experience, and inadequate training in ambulatory topics.

Growth of Hospital Medicine

Contrast the growth of primary care with the growth of Hospital Medicine, which is the fastest-growing field in medicine. Since 1996, the number of physicians who identify themselves as hospitalists has grown to nearly 30,000, similar to the number of cardiologists, and second only to the number of primary care physicians in the United States. The precedent of this “site-based” specialty was set by emergency medicine and critical care medicine, where physicians manage a wide variety of diagnoses but limit their care to a specific location within the hospital. In the U.S. health care system several factors have contributed to the rapid expansion of hospital medicine, including economics, quality, and changes in residency training.

In the early 1980s, Medicare changed its reimbursement of inpatient care from a daily rate to using diagnosis-related groups (DRGs) giving fixed payments for a given diagnosis. This created an incentive for hospitals to support strategies that would safely shorten length of stays, thereby decreasing hospital costs.
The growth of managed care in the early 1990s often increased panel sizes for primary care physicians (PCPs), and therefore the number of patients seen daily. This drove inpatient care to the extremes of the day before or after their outpatient schedule. Care of patients in the hospital was seen by some as a barrier to the efficiency of inpatient care, often resulting in an increased average length of stay, a major driver of health care costs. At the same time, there was insufficient coordination of care provided by consulting subspecialists, further increasing costs and duration of stay. Hospitalists, who dedicated their time to patients in the hospital, fulfilled a growing need.
In 1999, the Institute of Medicine (IOM) released “To Err Is Human” and in 2001 “Crossing the Quality Chasm,” drawing national attention to the issue of quality. Hospitals are expected to be the leading force in improving quality and safety gaps nationwide. Often, hospital administrations turned to the new workforce of hospitalists who spent all of their work time in the hospital, monitoring care across several spectrums. This new workforce was often recently out of training and open to new ideas, practiced by evidence-based guidelines, and interested in team-based solutions to address quality issues. Quality improvement quickly falls into the domain of hospital medicine. Subsequent studies support that hospitalists lower cost (primarily by decreasing length of stay) while maintaining quality.
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 80-hour resident work week, and in 2008 there was a shift toward increased emphasis on ambulatory medicine. Academic hospitals, which may have been resistant to the use of hospitalists prior to this time, now see hospitalists as a means to cover work that can no longer be performed by residents. Hospitalists are hired to cover “nonteaching” services in academic centers, and to supervise midlevel providers. With the sure advent of further limitation on resident work hours based on IOM recommendations, hospitalists will continue to fill in these gaps.

In the past few years, hospitalists have expanded their role of caring for inpatient internal medicine patients to include surgical patients. Surgeons are thus able to focus their time in the operating room (similar to PCPs focusing on care of patients in the office). Furthermore, reported hospital quality measures such as antibiotic use, venous thromboembolic prophylaxis, pain management, and preventive care are viewed as medical issues better managed by hospitalists. In addition, this allows surgical residents, under the same ACGME duty-hour restrictions as medical residents, to spend their time on becoming technically competent. Finally, with the aging of the population, many patients on the surgical service have increasingly complex medical issues that require comanagement by a trained internist.

The rapid growth of the field of hospital medicine occurred without clear guidelines as to the knowledge and skills necessary for successful practice. Early on, hospitalists functioned as internists in the hospital, focused on acute care in internal medicine, the same type of care as delivered during residency. Over time, the role of the hospitalist has changed from traditional medical consultant to comanager of patients admitted to other services (surgery, neurology, obstetrics); hospitalists are key players in the development of practice guidelines and implementation of information systems such as the electronic medical record and computerized physician order entry; and hospitalists are leaders in health care economics, including quality improvement and utilization review work.

In 2006, the Society of Hospital Medicine developed The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, standardizing the expectations for training and professional development. The competencies have written learning outcomes and are divided into three sections: clinical competencies, procedures, and health care systems, with learning objectives categorized as knowledge, skills, and attitudes. The development of this curriculum can serve to address some of the deficiencies in residency-based education for those pursuing a career in hospital medicine.

In September 2009, the American Board of Internal Medicine (ABIM) recognized hospital medicine as a focused practice within internal medicine, with a separate maintenance of certification (MOC). This was done with the recognition that the practice of hospital medicine had reached a state of maturity within the field of internal medicine, demonstrated by the large number of physicians who self-identify as hospitalists, the growing number of general internists who no longer practice in the hospital setting, and acknowledgment of the value that hospitalists bring to improving patient care in the hospital setting. Recognizing the knowledge, skills, and attitudes needed beyond those developed in residency training, an internist pursuing an ABIM focused practice in hospital medicine program must complete training in internal medicine, be ABIM certified, and engage in a practice primarily focusing on hospital medicine for at least three years before sitting for the MOC.

Since 1996, the hospitalist model of inpatient care has experienced tremendous growth, and it is now seen as unusual for PCPs to admit and care for their patients in the hospital. Support for hospitalists delivering the majority of inpatient care comes from demonstrated reduction in resource use, including decreased hospital costs and length of stay, while preserving patient satisfaction. Initially, there was resistance on the use of hospitalists by PCPs with concerns over the loss of camaraderie that comes from being in a hospital and interacting with other specialists, as well as the feeling by PCPs that they would be abandoning ill patients to be cared for by strangers at a time when they need their regular physician the most. PCPs have now come to accept the hospitalist model as the standard of care and report that the use of hospitalists has decreased workload, while not affecting income. Hospitalists are the go-to caretakers for inpatients—they are able to provide round-the-clock care and facilitate and coordinate care of multiple consultants, and they are taking the lead in improving the overall system of care through quality improvement. In addition, for PCPs with busy practices, the need to cancel appointments or curtail the workday to attend to admitted patients is eliminated with the hospitalist model, resulting in increased availability of outpatient doctors to their patients.

Despite this, concern over the potential for discontinuity of care and disruption of the physician–patient relationship remains paramount. For outpatient doctors who have practiced medicine in both eras, “visiting patients (in the hospital) now feels like entering a foreign world.” In an opinion piece (Annals of Internal Medicine), Dr. Howard Beckman describes, “when I agreed to the hospitalist system, I believed that I would be a member of my patients’ hospital team…. However that fantasy has yet to be fulfilled. My belief that hospitalist care would result in abandoning my patients has largely been validated.”1 In the inaugural issue of the Journal of Hospital Medicine,

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