Family Physicians Integral to Department Care

The article, “At Home in the Hospital,” in the fall 2006 issue of Medicine at Michigan describing hospitalist care of adult inpatients suggests that this type of care is valuable and necessary because: (1) hospitalists care more effectively and efficiently for inpatients than does the patient’s usual family physician; (2) patients often do not know who their family physician is; and (3) the patient has little need or desire to see their family physician in the hospital. While the hospitalist service described by Dr. Flanders is certainly one valid approach to caring for inpatients, and appears to be effective for general internal medicine patients, we have designed a different approach in the Department of Family Medicine. Our patients are very clear about who their family physician is, and are equally clear about their desire to have them involved in their inpatient care. We have developed a full-time family physician attending system for our adult inpatients at the University of Michigan that has quality and resource utilization performance equal to that of the hospitalist services described in your article; has developed innovative approaches to discharge planning and transition of the patient back to outpatient follow-up; and continues to involve the patient’s family physician in decision-making.

Thomas L. Schwenk (M.D. 1975)
Professor and Chair, U-M Department of Family Medicine
tschwenk@umich.edu

Pressures Weigh on Family Physicians, Health Care System

We enjoyed your fall 2006 issue of Medicine at Michigan, but would like to comment on two issues in regard to your article, “At Home in the Hospital.” We are all graduates of the University of Michigan Medical School and family physician faculty at Michigan State University, where we collectively have over 100 years of medical experience.

As this article has pointed out, the hospitalist movement has grown tremendously over the last decade with some data to support improvements in disease-specific outcome markers and improved costs by hospitalists versus primary care doctors. If true, we respect and commend them for their work; however, the jury is still out on this topic. As O’Malley and O’Malley discuss in the Archives of Internal Medicine in a January 8, 2007, editorial about studies comparing quality of care by specialty, are these findings valid, relevant or neither? We feel, as they do, that comparing outcomes by specialty is “divisive and distracting” and with questionable validity. It would do us all well to improve systems of care, both inpatient and outpatient, and keep our eyes focused on that which really needs our attention — improving access, care coordination and collaboration, and health system reform.

The second issue is the suggestion at the end of the article that the “family doctor of bygone days who would shepherd each patient through a lifetime of minor and major illnesses …” is gone. Primary care physicians (specialists in family medicine, general internal medicine and general pediatrics) are far from gone. We are, however, under huge pressure. Our worlds have always been primarily those of the outpatient, where the vast majority of patient care occurs. We are evolving rapidly to address the needs of our 21st century citizenry, while at the same time we face tremendous cost pressures, declining student interest, weak public health infrastructure, and an aging population with many, many problems. Worldwide, systems of care that advocate and support primary care physicians have better health status at less cost than those that do not. These are systems of care that the U.S. lacks, and our health care outcomes on an international scale reflect our poor health care infrastructure.

Among the many jobs of the primary care physician is that of managing undifferentiated illness, uncertainty, complexity and multiple morbidities; addressing prevention and advocacy; and doing this while constantly juggling cost and priority-setting. We are trained to do this, but it is extremely difficult work. The absurd situation that develops when patients have 15 doctors, but not a doctor who knows them, helps neither them nor the health care system. For the generalist physician to adequately do what is asked of us, however, will require huge levels of support. Projections for the state of Michigan include major shortages of primary care physicians in the next few decades. Without adequate support, reimbursement and understanding of the work that we do, who is going to care for you and me?

Vince WinklerPrins (M.D. 1986)
Vince.WinklerPrins@hc.msu.edu

David Weismantel (M.D. 1990)
David.Weismantel@ht.msu.edu

Roy Gerard (M.D. 1953)
Roy.Gerard@hc.msu.edu
William Wadland (M.D. 1975)
William.Wadland@hc.msu.edu

Education Key to Understanding Animal Research

I just finished reading an exceptionally well written article by Sally Pobojewski entitled, “Myths, Realities, Benefit Beyond Measure: Animal Research Might Not Be What You Think,” which ran in the fall 2006 issue of Medicine at Michigan. Ms. Pobojewski’s article is particularly noteworthy in that it concisely demonstrates the vital need for humane animal research, while featuring examples of Michigan’s pioneering research.

The Foundation for Biomedical Research is the nation’s oldest and largest organization dedicated to improving human and animal health by promoting public understanding and support for the humane and responsible use of animals in medical and scientific research. In this role we seek to disseminate outstanding works of journalism to the general public.

I welcome you to consider providing to your readers a link to our Web site to learn more about the role animal models play in humane and vital research. I feel the following is a valuable resource for readers interested in learning more about animal research: www.fbresearch.org/education.

George Goodno
Foundation for Biomedical Research
Washington, D.C.
GGoodno@fbresearch.org

Falls Was an Amazing Man and Walking Encyclopedia

In the fall 2006 issue of Medicine at Michigan, there was a notice about the passing of Harold Falls, M.D., emeritus professor of ophthalmology. This evoked many memories for me. Dr. Falls was an amazing man — a walking encyclopedia of genetics and eye disease. I remember his talks featuring one slide after another — non-stop, rapid fire, a panoply of exotic eye disease — coming at you as fast as you could absorb it. He was a remarkable human being and one of the many outstanding people one encountered in medical training in Ann Arbor. I count myself very lucky to have known him.

John B. Williams (M.D. 1971)
Sacramento, California
John.B.Williams@kp.org