What international hospitalists tell us about our current situation and the future

Robert Chang, MD writes –

One of my long-term goals for our hospitalist group would be the establishment of multiple relationships with academic centers overseas, in particular in the sub-Saharan subcontinent, Africa or China.  The benefits would be enormous for us as well as our partners would include professional satisfaction, exposure to other educational systems, and a highly mutual exchange of information and clinical experience.

As far as I know, hospitalist medicine has little presence outside of the United States, Canada and Britain.  “Globalization of hospital medicine” will be a major leap that may face us in the not-so-distant future as we settle our presence in the United States.  It is no small surprise that the three countries with a hospitalist presence have very well-developed infrastructure and medical systems.  Having personally spent some time overseas in Togo, West Africa and Honduras, the stability and infrastructure of the society plays a huge role in the success or failure of health care as a whole – and much more so with hospitalist medicine.  The frustrations of medical relief efforts in the bombings of the Gaza Strip, the cholera outbreak in Zimbabwe, or even the earthquake disaster in China in 2008 reveal just how dependent we are on communication, a system to bring people to us to receive care (or a way to go to them) and a place to send patients once they are well enough to leave the hospital.

Talk of the international field can seem distant to us.  To bring it closer to home, my thought experiment about international hospitalists has left me with two major points that suddenly become clearer when considering situations overseas.

My first thought is we continue to have great responsibility to the medical field.  As we continue to grow, we need to be very concerned about the health of general medicine as a whole.  One of the big issues working overseas is the lack of reliable communication with the follow-up physician, if they exist or are even accessible.  If we are interested in continuing as hospitalists, we need the primary care network to remain vibrant, resilient and strong.  The dismal growth in the number of primary care physicians is critical and we should lend our support in that arena.  We should be highly involved in initiatives such as the advanced medical home, which eases the burden on the primary care physician to bridge the gaps from home to hospital to home.  Overall, while hospitalist medicine faces a physician shortage, growing our field while sacrificing primary care is short-sighted and suicidal, not just tactically speaking but from a societal and patient perspective.

My second thought is that we need to engage ourselves on a societal level.  Working at a state-funded, tertiary academic medical center, we provide care for incredibly sick people, who sometimes have little to no financial reserve.  When their medical care is done, there is no place for them to go.  Perhaps this is unique to the academic setting, but debilitated patients can linger for weeks to months “waiting for placement”, incurring an increasing risk of iatrogenic complications relating to clots, medications, infections, decubitus ulcers and so forth.  Some patients cannot afford their medications and we struggle with prior authorizations and insurance companies and hope that we can prescribe something that is $4 at Walmart.  The hospital remains the last solution for many societal woes which it was never intended – and soon may not be able – to handle.  These issues represent a much broader societal problem of how we chose to deal with the sick and ill than any individual hospital.  With the damaging effects of the recent economy, coupled with the burgeoning elderly population, SHM needs to retain its vigorous role on shaping future policy, especially hospital and hospitalist reimbursement, to ensure that both we and our patients can remain financially solvent.

International medicine is a world that is often distant and foreign and yet, experiencing it, is often very revealing about our home, how we live and the strengths of our society.  In our growing numbers and continued need for more physicians, we should remember who we depend on to give the great care that we provide.  We cannot disengage from the political landscape that we see through the window on society that hospitals afford us.