The comments to my original post on this topic are so striking and passionate that I wanted to answer them in a new post rather than as another comment.
First, “LPrieto” wrote, “I think the death of outpatient general Internal Medicine is inevitable.” Then “C33333″ wrote that 16/17 of his or her (hard to sort out the gender of people named C33333) residents this year chose to go into hospital medicine.
All I can say is, Wowza! That’ll cheer all the hospitals and staffing companies who are in perpetual hospitalist recruit mode. But it is a remarkable statement re: the future of primary care.
Won’t that be ironic – if docs who chose hospital medicine over primary care are forced back into the office because there is no one else who wants to do the job. For hospitalists who are now in a cold sweat, having left their office practice vowing never to return, I think you can calm down: my guess is that there will be some hospitalist mission-creep in the form of post-discharge clinics staffed by hospitalists, to which patients can return within a few days or weeks for a single check to be sure they’re improving. But hospitalists can no more solve the PCP shortage than they can solve the malpractice crisis or the nursing shortage. This’ll have to be solved on the merits, with payers and others deciding that primary care is valuable, that it needs to be adequately supported with money, staff, IT, and respect, and that the consequences of not providing that support are unacceptable. You might say, “well, it is unacceptable now!” and I’d reply, “obviously, it is acceptable to somebody, since it is being accepted.”
One new twist to throw into this particular martini: look for the Next Big Thing in quality measurement and reporting to be 30-day readmission rates. Then look for the next mega-trend in hospital payments to be “episode-of-care” payments: bundled payments that include the initial hospitalization and some reasonable (1 month, 3 months?) post-hospital period. When both of these things happen (I’m guessing 1-3 years), hospitals will change their worldview from a DRG-induced myopia that says, “how do we provide high quality care with the shortest LOS and lowest hospital costs” to one that says, “how do we provide high quality care with the lowest costs during the entire period of the bundle, while avoiding readmissions like the plague.” Why? Because a readmission will become a two-fer from hell: an exceptionally expensive complication for which they will not be paid, and a big-time ding on the public report card.
When that happens, you’ll see hospitals becoming very creative about one piece of the PCP shortage: how to at least be sure the patients are well cared for in the period after a hospitalization. Obviously, this would solve only one sliver of a much larger problem, but put enough slivers together and you have… well, come to think of it, not much. But something.
Anyway, thanks for the thoughtful comments. Keep ‘em coming.