Anecdotal experience of a family medicine expert as a hospitalist.

There is something more a family medicine specialist can do than having a busy outpatient practice in a community. Have you ever wondered how we can improve healthcare in the community by working in secondary and tertiary care centers? Yes! I am talking about “Coordinated” Inpatient care by “Generalists”.[1]“Hospitalists”, who are generalists, play a vital role in managing inpatients. They are qualified in family medicine and internal medicine specialists. This is quite a popular culture in the US health system. The Indian healthcare system you know is already fragmented into specialists and super specialists, as many patients get referred to multiple places for an ailment or multiple ailments.[2] The existing super-specialty system in the tertiary care centers will need moderation by generalists to reduce the cost of care and free up specialists to see more patients. This role of a generalist is filled by hospitalists. Patients may have multiple problems even though they are admitted due to a single serious illness.[3] Family medicine specialists can assess admitted patients “as a whole” by applying the concept of “holistic and comprehensive approach”. They would be great advisors to the family of admitted patients, being empathetic in approach and at the same time coordinating the patient care with specialists. They are the right kind of doctors who would round on patients every day and assess the progress of patients as a whole (examining all the systems and evaluating all the parameters). Family physicians are trained in managing basics of surgery, ophthalmology, otolaryngology, orthopaedics, Ob-Gyn, paediatrics and what not! They would play an important role in picking up the illnesses across such specialties and guide appropriately.

My journey as a hospitalist was quite enriching. I would like to share a few examples of how family medicine training helped me in managing patients for better outcomes. An elderly lady who was a diabetic was admitted with severe back pain, a diagnosis of spondylolisthesis was made based on X-ray findings and she was put on analgesics. When she started vomiting, I was called in to examine her. At the outset, I was not sure if the vomiting was due to the intractable pain. A detailed examination of other systems revealed suprapubic tenderness and renal angle tenderness. Urinalysis and USG KUB confirmed findings of pyelonephritis. She was started on antibiotics and underwent DJ stenting by the urologist and could walk back home after a couple of days. There was another time when I was comanaging a term, pregnant lady admitted with dengue fever. It was in the middle of the night and the patient family were worried about the baby. They were anxious and asked me if the baby was alright. A doctor from another specialty would probably want Ob-Gyn to answer such concerns. But being trained in family medicine, I did a brief examination and looked for fetal heart rate with the help of a stethoscope, and it sounded good. So I reassured them. Minutes later, the Ob-Gyn registrar assessed the patient and confirmed that the baby was healthy by clinical exam and CTG was reassuring. An elderly man was admitted with sepsis secondary to urinary tract infection. He was shifted to the inpatient ward from ICU, after stabilization. When I asked him, his main concern was that he was not able to see through his right eye. This had been bothering him for 6 months. I did a brief ophthalmic examination starting from visual acuity and found that he had the only perception of light in his right eye and he was able to localize the light source. Having learned the basics of ophthalmology in family medicine training, I was pretty sure that his optic nerve was intact as he was able to localize the light source. When I examined his eye, I could find a mature cataract in the right eye. A provisional impression was already made. I referred the patient to the ophthalmologist, who confirmed the cataract and performed its removal with intraocular lens implantation. His vision was restored. I could quote many more examples of how family medicine training made a difference in the lives of the patients by picking up the disease early and guiding appropriately. I also happened to mentor students and would always give the advice, “Never investigate or treat a patient until you have taken a good history and examined all the systems. Give referral only if it is needed and make sure the patient is properly evaluated before referral. Moreover, give adequate time in counseling patients and their families”

Having hospitalists is a good way of minimizing resource expenditure in hospitals and a better way of managing inpatients.[1] Both family medicine and internal medicine specialists would serve the purpose. There might be few differences in approach by family medicine trained and internal medicine trained hospitalists. The former would have spent more time in ambulatory medicine during their core training and the latter in inpatient medicine, intensive care and medicine allied super specialties. There are a few studies which concluded that the hospitalist model led to better outcomes in patient care and decreased the length of hospital stay than the nonhospital model while utilizing minimal hospital resources.[45] The same concept of “hospitalist care” could be initiated in India in district and community hospitals. There might be concerns regarding family physicians switching over to hospitalist practice, thereby compromising community-based outpatient clinics. This could be tackled by introducing more hospital-based community outreach clinics; periodic rotations of hospitalists between hospitals and clinics. This would not only help in referring sicker patients from clinics to the attached hospitals but also would serve the purpose of “continuity of care” and “coordinated care” with the help of specialists.

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Conflicts of interest

There are no conflicts of interest.