On the one hand I want to say these aren’t really internal medicine problems, so I shouldn’t be the attending for these patients (but could serve as consultant). And while that might be a reasonable position to take today, I’m convinced that I can’t dig my heels in and insist that I never become the primary admitter for these patients. I think there is too big a need for a hospitalist to care for these kinds of patients at my hospital, and it’s unreasonable for me to take a hard line and insist I will never change.
While your list of diagnoses might be different than mine, I think there is a good chance that you’re often asked to care for patients that might be a little outside the traditional scope of the specialty you trained in. Do you think that the field of hospital medicine can—or should—avoid caring for these patients long term? I don’t. I think we need to gradually take on some of the new roles that our hospitals and physician colleagues request of us. Just like the ER doctors of the 1970s, I think we are in a period of significant evolution as our field “grows up.” And rather than resisting this change, I think we should thoughtfully decide where “the system” needs our services the most and work to develop the expertise to meet that need.
Some hospitalists are really uncomfortable with the idea of expanding the scope of their practice and raise a number of objections. They sometimes say “That’s fine if Nelson wants to care for patients with head bleeds, but there is no way I’m going to do it since it’s a sure path to a law suit.” Or “I’m happy to consult and manage the blood pressure, but there’s no way I’m willing to be attending.”
But don’t doctors in most specialties adjust their scope of practice regularly? Think about surgeons who have had to learn laparoscopic techniques after their residency training. And office-based internists who had little outpatient training during residency but have had to learn to be expert at it once they started practice. They are adapting the scope of their practice to the needs of the healthcare system, and they’ve found ways to gain competence and expertise in these areas.
I’m not suggesting we admit any type of patient someone might want us to. Nor am I confident that the two important areas for hospital medicine to become more involved in are hip fracture and hypertensive intracerebral hemorrhage (though they do seem to come up regularly). My point is that I don’t think we can dig our heels in and resist any change in our scope of practice. In our own local practices, and as a specialty, we need to decide the most valuable ways to adjust our practice scope and work diligently to become competent at them. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs, and could benefit from, hospitalists who have an increased role in caring for these patients. As our field evolves, training programs and CME courses will adapt to meet our need for more training in these areas that may feel new or unfamiliar to many of us.
Some days after the child with tonsillar hemorrhage presented, I learned that he had done OK and had gone home looking good. But the surgeon was furious that we had “dumped” this patient at his door without any warning and had sent the patient into his waiting room where other waiting patients were apparently horrified. The ER doctor could have responded that the surgeon should quit complaining and get used to this kind of thing because “it comes with the turf” of ENT practice. Or he could have told the ENT doctor he’d like for the two of them to work together to develop a way for the ER to play a much bigger role in the early emergent intervention.