Are attending physician rotations costing hospitalized patients their lives?

Dr. Ladouceur’s editorial in the April 2017 issue of the Canadian Family Physician journal (1) is the latest in a long series of CFP commentaries (2-4) where the authors nostalgically reminisce about a bygone era when family doctors did everything and “comprehensive family practice” was the norm. A common thread among these editorials is the assertion that the traditional family practice model is the gold standard and the progressive sub-specialization of family doctors and the emergence of areas of focused practice is a perversion of family medicine. Interestingly, other than personal anecdotes and nostalgic references to the past, no actual evidence is provided by the authors that the quality of care delivered by family doctors during this presumed “golden era” was actually better than what is currently being provided by more focused general practitioners.

This latest editorial however is particularly disturbing on a number of levels. First, it is simply not true that hospitalist care is associated with increased harm levels for patients. In fact, an increasing body of Canadian evidence suggests the opposite. In 2013, we published our analysis of over 30,000 patients admitted to the hospitalist program in a large community hospital in Ontario (5). Our study demonstrated that compared with traditional family physicians, hospitalist care was associated with a 12-75% reduction in mortality odds. Our study of course had a number of limitations, namely that it was limited to one particular institution. Since then, Dr. Heather White and her colleagues have demonstrated that hospitalists in Ontario significantly reduce odds of mortality for patients admitted with 4 common conditions (delirium, pneumonia, congestive heart failure and COPD) by 7-31% (6). Their study utilizes a robust methodology to look at care outcomes for over 55,000 patients admitted to 151 hospitals in Ontario. Both studies, as well as a number of others (7, 8) have also shown similar reductions in readmission rates when hospitalists are involved. These studies certainly raise a number of questions: should community-based family physicians with low volumes of inpatients be allowed to continue working in hospitals? Are family physicians who continue to maintain a broad range of practice able to maintain competencies required to provide inpatient care?

The second reason why Dr. Ladouceur’s article is upsetting is that physicians with family medicine training continue to comprise the majority of hospitalists in Canada (9). While the growing number of internists who are now working as hospitalists (10) is helping the specialty to evolve, hospital medicine in Canada continues to maintain strong ties with the family medicine community (11). In my institution, 95% of over 300 individuals in the Department of Hospital Medicine are CCFP certified, and many of the Divisions of Family Practice in British Columbia are making efforts to strengthen their ties to hospitalists in their local communities. Results of the 2012 National Hospital Medicine Survey also shows that the majority of respondents had over 10 years of experience in clinical practice, with many having spent years practicing community-based family medicine prior to making a career change to focus on hospitalist work. Undermining the quality of the work of hospitalists also brings into question the ability of the family medicine establishment to train qualified individuals to do the kind of inpatient care that hospitalists engage in.

Finally, using a study of residents and interns in the United States (with all the limitations that Dr. Ladoceur himself outlines) and somehow tying that to hospitalists in Canada and concluding that their care may result in more harm for patients is a rather large leap that is reminiscent of the acrobatics observed in a Cirque du Soleil theater! The suggestion that being a hospitalist is no different than being a medical trainee is insulting to the many thousands of experienced, highly skilled individuals who work under extremely stressful circumstances to look after an increasingly complex and multi-morbid hospitalized patient population.

The nostalgia expressed by Dr. Ladoceur and many others about family medicine’s past fails to recognize the reality that the era of comprehensive family medicine is long gone. Apart from a small number of family physicians who work in rural areas, the majority of primary care doctors who practice in urban areas (where over 80% of Canadians live) no longer practice comprehensive “cradle-to-grave” family practice. The traditional model of the general practitioner who knew a little about a lot of things and who provided a broad range of services worked well in the 19th and 20th centuries when medicine was simple and treatment options limited; when the entire care team in a hospital was comprised of a few nurses and physicians and there were no such things as CT scanners or respiratory therapists (or any of the long list of health care professionals currently working in the acute care setting). The evidence for the demise of this model has been mounting over the past 20 years, with many studies conclusively demonstrating a progressive erosion in the scope of family physicians (12), major attitudinal changes among the new generation of family doctors about the role of hospital care in their careers (13), and changing perceptions of the importance of work-life balance and career expectations (14).

At the same time, Canadian hospitalists have been filling the gaps in inpatient care that resulted from the voluntary mass migration of family doctors out of acute care settings, with better quality results (5,6) and better or similar efficiency despite looking after a more complex patient population (15,16). Hospitalists are taking a leading role in teaching family medicine residents (17) as well as engaging in quality improvement activities on a mass scale (18). Moreover their presence is associated with high satisfaction rates among the inter-professional care teams (19,20) as well as community-based family physicians (21).

Across Canada, hospitalists have demonstrated that they are an essential component of a modern acute care institution, and that they bring value both to patients and the broader healthcare system. Hospitalists are here to stay, and it is high time that their primary care colleagues acknowledge their enormous contribution to the medical landscape.

Vandad Yousefi, MD, CCFP, FHM
Clinical Instructor, Faculty of Medicine, University of British Columbia
Regional Department Head – Hospital Medicine – Fraser Health, BC

References
1- Ladouceur R. Are attending physician rotations costing hospitalized patients their lives? Can Fam Physician 2017, 63 (4) 264
2- Ladouceur R. Where is family medicine heading? Can Fam Physician 2015;61:1029. (Eng), 1030 (Fr).
3- Ladouceur R. What has become of family physicians? Can Fam Physician 2012, 58 (12) 1322;
4- Pimlott N. The changing landscape of family medicine. Can Fam Physician 2017, 63 (3) 184;
5- Yousefi V, Chong CA. Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? An observational comparative analysis of hospitalists vs. traditional care providers. BMC Health Serv Res. 2013; 13:204-211.
6- White H. Assessing the Prevalence, Penetration and Performance of Hospital Physicians in Ontario: Implications for the Quality and Efficiency of Inpatient Care. Doctor of Philosophy Dissertation. Institute of Health Policy, Management and Evaluation. University of Toronto. 2016
7- The Advisory Board. Hospitalists – the New Care Leaders, 2015
8- McGowen B, Nightingale M. The hospitalist program: a new specialty on the horizon in acute care medicine, a hospital case study. BCMJ 2003. 45(8): p. 391-394.
9- Yousefi V, Wilton D. Redesigning hospital care: learning from the experience of hospital medicine in Canada. Journal of Global Health Care Sustems. 2011; 1: 1-10.
10- White HL, Stukel TA, Wodchis WP, Glazier RH. Defining hospitalist physicians using clinical practice data: a systems-level pilot study of Ontario physicians. Open Medicine. 2013;7(3):e74-e84.
11- Maskey JM. A change of place and pace, Family physicians as hospitalists in Canada. Can Fam Physician 2008, 54 (5) 669-670;
12- Chan BT. The declining comprehensiveness of primary care. CMAJ 2002. 166(4): p. 429-34.
13- Neimanis I, Woods A, Zizzo A, et al. Role of family physicians in an urban hospital: Tracking changes between 1977, 1997, and 2014. Can Fam Physician. 2017;63(3):221-227.
14- Yousefi V, Maslowski R. Health system drivers of hospital medicine in Canada: Systematic review. Canadian Family Physician. 2013;59(7):762-767.
15- Seth P, Nicholson K, Habbous S, Ménard J. Implementation of a Hospitalist Medicine Model in a Full-Service Community Hospital: Examining Impact Two Years Post-Implementation on Health Resource Use and Patient Satisfaction. Abstract Submitted to Canadian Society of Hospital Medicine Annual Conference – 2015
16- Gutierrez GA, Norris M. Impact of a newly established hospitalist training program on patient LOS and RIW. Abstract submitted to Canadian Society of Hospital Medicine Conference - 2011
17- Gibson C. Educational tool for hospital-based training in family medicine. Can Fam Physician 2014, 60 (10) 946-948;
18- Ligertwoord S, Tukker R, Wilton D. BC Hospitalist VTE Collaborative. 2013 – Quality Forum , Vancouver BC. Available from http://qualityforum.ca/qf2013/wp-content/uploads/2012/03/E3-Rapid-Fire-S...
19- Webster F, Bremmer S, Jackson M, Bansal V, Sale J.. The impact of a hospitalist on role boundaries in an orthopedic environment. J Multidiscip Healthc. 2012;5:249-56.
20- Gotlib Conn L, Reeves S, Dainty K, Kenaszchuk C, Zwarenstein M. Interprofessional communication with hospitalist and consultant physicians in general internal medicine: a qualitative study. BMC Health Services Research. 2012;12:437. doi:10.1186/1472-6963-12-437.
21- Yousefi V, Linett L, Reid C. Perceptions of community family physicians of a hospitalist program in Ontario, Canada. Abstract Submitted to Canadian Society of Hospital Medicine Annual Conference – 2011