The Emergence of the Proceduralist in Hospitals

First there was the intensivist in hospitals, followed in rapid succession by the hospitalist and the surgicalist. We now have the debut of the proceduralist, as documented recently by the Wall Street Journal (see: To Reduce Risks, Hospitals Enlist 'Proceduralists'). Below is an excerpt from the article (boldface emphasis mine): 

With a steady decline in the number of doctors trained to perform such skills-intensive medical procedures in recent years, {Cedars Sinai Hospital} and other large academic medical centers are looking for ways to fill the gap. They are creating special procedure services and new procedure- training programs for medical residents. Teams of doctors known as proceduralists are now available at some centers with special expertise in tunneling a catheter into a vein, slicing an incision in the neck for an airway, or plunging a needle into a patient's back for a spinal tap. While not a medical specialty in its own right, procedural medicine is emerging as an important new role for physicians with the manual dexterity and steady nerves to perform risky procedures. And hospitals say they see reduced complication rates when services are performed by physicians who are very well-versed in the procedures....[A]ccording to a survey of members of the American College of Physicians, internists on average perform 50% fewer procedures today than they did 18 years ago, in part because other specialists including hospitalists and radiologists do more procedures, and new technology such as ultrasound equipment has eliminated the need for some invasive procedures or changed they way they are done. Cuts in insurance reimbursement have also made it less lucrative to do many common procedures.

Well, you could see this one coming from a mile away. Physicians engaged in office practice have gradually lost the "procedural" skill set necessary to deal with acutely ill patients. Operating at the health system level, executives are increasingly wary of malpractice problems and are also anxious to market the quality aspects of their in-house services. They appreciate having patients being admitted by community physicians but also want their own full-time hospital-based physicians to take charge at the front door. The reimbursement system reinforces these trends by making it less remunerative for office physicians to perform certain common procedures.

By my reckoning, the professional gap between office-based physicians and hospital-based physicians is growing ever wider. This may result in a less appealing hospital-treatment scenario for those patients who crave a familiar face and decision-maker during  their hospital stay. On balance, however, I think that patients are better off having more skilled practitioners attending to them when they are acutely ill.

Pathologist practicing in hospitals will end up interacting primarily with full-time hospital-based physicians who should be more knowledgeable about hospital processes and procedures. But what are the long-term implications of this de-skilling of the office-based physicians and absence from hospital practice?  From an electronic record perspective, the integration of office and hospital records becomes even more critical under these new circumstances. The personal physician is no longer readily available to provide details about the long-term clinical history of a patient and the results of previous office procedures and tests.