The Indispensable Physician

A recent pair of commentaries (RM Wachter, L Goldman. NEJM 2016; 375: 1009-1011, R Gunderman. NEJM 2016; 375; 1011-13) provides some insight into what has been gained and what has been lost with the proliferation of hospitalist care in the past 20 years.

The growth of hospitalist care has developed due to numerous factors:

  • evidence of cost savings/better outcomes
  • need for rapid evaluation of acutely ill patients/repeated evaluations which would be disruptive to efficient outpatient physician practices

Decline of comprehensive care:

  • at times of extreme vulnerability when admitted to the hospital, patients have a physician assigned to them who they have probably never met.  This has led to a diminishment of the patient-physician relationship.
  • increasing number of physicians creates opportunities for miscommunication, particularly on admission and discharge, but also at every step of hospital care during “handoffs”

The second commentary, in particular, challenges the way medicine is evolving.  This article stresses the central role of the physician as opposed to the hospital filling that role.

“The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians.”

The goal of developing personal relationships with our patients is often at odds with work-life balance.  Thus, having hospitalists and other ways of having cross-coverage, when we are unavailable, often conflict with being able to provide the best care.

My take (from 2nd commentary): “The true core of good medicine is not an institution but a relationship — a relationship between two human beings.”

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