Monday, November 1, 2010

Hospital Medicine and the details of revolution

My next rotation after the CCU (see previous post(s)) is something called "The Hospitalist Elective."  Although this is a bit of an enigma, I am quite excited for the 3 weeks course.  First off, my fellow residents and our faculty for the course are all top notch, making it a fun experience.  Second, Hospital Medicine is the most recent (successful) revolution in Internal Medicine, and there is much to be learned from their ascent.  One specific area we touched on today in the now ~15 year history of the field, was the resentment and resistance from entrenched primary care physicians and other specialists that felt that their profession and their patients' care may suffer from hospitalists. 

1.  Suffering patient care.  Perhaps this is a radical statement, perhaps it is not, but patient care is not that great in the United States.  Individual physicians are very dedicated to patients, but the systems set up with perverse incentives, government and employer interference, and many many third (and fourth, and fifth) parties really muck up patient care.  Despite all of these non-physician reasons, there is rarely a change to medical practice that does not result in affected but not participating physicians that the most recent change will harm patient care.  This leads more truly to complaint number 2.

2. Money.  Medicine is currently set up to be a zero sum game, with a fixed pie taken from the American tax payer in the form of Medicare/Medicaid and redistributed back to physicians via a centrally planned scale known as the RBRVS (Resources-based Relative Value Scale). This mentality of a fixed pie, abandoned in most the free world with the fall of mercantilism in the 1800s, is a direct roadblock to any change.  Any new physician action necessarily decreases the portion of the pie dedicated to other physicians, and therefore leads to backlash.  It is as though we have designed a perfect non-changing system through our finance.  There are at least two basic assumptions to challenge here. 

The first, is that there is actually ought to be a fixed pie of health care.  In the rest of the free market world, value and money are created with new ideas, technologies, and mutual exchange.  There is more total money in the world (inflation aside) because there is more stuff in the world.  The same COULD be true for medicine if we departed from our centrally planned failure of a payments system.

The second is the notion that physicians ought to consider the opinion of other blocks of physicians.  While I do not directly seek to anger or enrage my colleagues, I am unsure how important buy in of potential competitors really is?  Southwest doesn't care if United is on board with their routes and rates, they just fly.  In the same way, why do we really care about the opinions of physician groups that complain we are taking their money?  What made it their money in the first place?  Did they earn by best serving their patients, or by just serving as many patients in as many ways as possible?  Shouldn't we really be going after buy in from our patients.... our customers?

I was told that one of the founders of the Society for Hospital Medicine was booed off stage when he presented his ideas at my "home" organization, the Society of General Internal Medicine... now a much smaller organization that the Society it failed to spawn.  On hearing this I smiled, because if you aren't pissing anybody off, are you really making a difference?

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