Primary Mystification

By  |  June 19, 2011 | 

Perhaps you have bought a new house or apartment.

You know the need for fixes and upgrades are prioritized based on urgency (broken washing machine), or personal pleasure (multimedia room).   However, you also realize the “to do” list is unknowingly long, and the approach to completing the makeover will meet with obstacles unknown, changing circumstances, and acquired wisdom.

In many ways, hospital medicine is undergoing the same process.  There is no discrepancy.

Twenty burgeoning hospitalists sitting around the table in 1997 collectively asked, “OK, we have the will to make something happen, and the start up money (quarters from our bedroom dresser jars), but how do we create an organization?”  Brilliantly, someone said we need a lawyer.  Correct.

Then, it’s, how do we create a 501(c)?  Subsequently we seek to assemble a board—all ramshackle like, and we rummage for a name.  Next, we discuss our purpose and strive to compose a mission statement.

Naturally, the evolving burden becomes excessive, and volunteerism takes on a different meaning.   Therefore, we hire staff and an EVP.

It goes on, and we realize development happens over years, and like life, it gets back to baby steps and discovery.

A good example is SHM’s recent conflict of interest policy update/overhaul.  Every organization believes they have their loose ends covered…until they do not.  From these missteps emanates growth, and good organizations persevere.   You put out the fires on a prn basis.

Another example is board certification and our evolving identity.  SHM discussed this for years— MOC evolution was not accidental, and the society did not scribe it in a concrete timeline.  Nevertheless, we are no longer in limbo, and today we have ABIM sanctioned credentials, distinct within internal medicine, stemming from a unique track.

This is an amorphous progression.  No playbook exists, and the issues present as they do—randomly or most commonly, as they ripen.   By that I mean, we know these matters need rendering and a verdict, but it is just a matter of the stars lining up, and all the parties in a unified voice agreeing, “It is time!”  Just like the house, first the painting, then the kitchen remodeling; hmmm, the landscaping can wait; oh no, the roof is leaking—fix now!

Why do I state the pseudo-obvious?

There is another issue that needs clarification, and is especially germane given the upcoming payment changes (SGR fix or not), as well as the reorganization of care delivery (PCMH or not).

We as a society have never elucidated our “primary” identity: by virtue of our generalist training, are we primary care providers or not?

The answer is no!

The conflation between hospital medicine and primary care originates from two notions.  The first is the legacy effect of IM training and the blur between PGY-3 year, and all that follows.  At that interface, there is no hospital medicine (HM) and primary care differentiation, explicitly, and like a phantom appendage, we view our paths similarly—as generalists.   The “all for one, one for all” mantra lingers however, and it obscures the considerable variances in our skills.  We have to recognize we share less than we think.

Secondly, we must scrutinize remuneration and our perceptions thereof.  Unknowingly, because of the legacy effect of point number one, when payment reform redirects additional funds for primary care, we feel entitled.  I say that inoffensively.  We have more in common with a primary care physician (IM, peds, FP) than an electrophysiologist, so it is not a leap to assume any disbursements favoring IM should move simultaneous between the two “generalist” fields.

However, I do not believe this is so.  We are not primary care practioners, and we know the salary imbalance between the two disciplines is at least 10-20% of IM base, favoring HM.  Form follows function, and in our case, HM salaries are signaling dissimilarities between the inpatient and ambulatory domains.   The market speaks.

Do you desire additional data?

If you review published definitions that characterize primary care providers, we do not make the grade.  Here are three, but there are others:

  1. AAFP
  2. IOM
  3. Academic Opinion

We do not provide first contact, chronic, continuous care, and this is but a piece.

Bottom line, primary care is not a label, but an organized approach to care.  Cardiologists may be primary care providers, but their management must go beyond heart disease prevention.   I doubt they will choose that role, but they may claim that moniker—if they do the deal.  Nevertheless, hospitalists, by our very nature, cannot answer that call.

However, if we are not primary care providers, and we do not exist as a specialty via traditional certification, what are we?  We are mutts regrettably, first in line with a unique ABIM-oid identity, but without “papers.”

Thus, our identity needs unlocking, but unfortunately, the definition hides behind many doors:

  1. By E&M code submissions
  2. By certification (ABIM or other)
  3. By self-declaration (CV)
  4. By CMS
  5. By institutional recognition

It will be number two eventually—more fully formed, and number four will follow; but today, it is anyone’s guess.  SHM however, must define what we are not, and that is primary care.

Here is how I see it:

Hospitalists are geographically based, specialty practioners.  We support primary care physicians when their patients require institutional care owing to acute or subacute illness for episodic management.  We contribute to the well-being of patients by organizing our practices to transition care back to the community, assisting outpatient teams or practioners responsible for supervising individual health, to promote patient driven outcomes.  Period.

I wish to make this clear once again.  Hospitalists do not practice primary care.  We are not primary care providers.

SHM, take the ball…


On another note, I am in Chicago at the AMA meeting.  The most contentious issue, and SHM is in this game, is the voting (or repeat voting) concerning the individual mandate and the associated personal responsibility to purchase health insurance (see pages 272 and 290—and SHM sign-on for resolution 102).  The hall was SRO, and the line to speak was tirelessly long, the lengthiest on any resolution I have seen during my five years there (see pic):


Statements were predictable, and ranged from rants on liberty, system sustainability, the doctor-patient relationship, and on and on. This is the vote to watch folks, and it will make the headline news.

Finally, here is a pic of me (thanks to Tosha Wetterneck, a fellow SHM/AMA member), and I include it only to, a) model SHM apparel, and b), let the world know SHM is young, brash, and, gulp, tieless. Yes, unbelievably, ties required at the AMA meeting. Not any longer…:)

“We Don’t Need No Stinkin Tieware”

UPDATE: See Here



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About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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