Family Medicine in the House

Why should family physicians provide care for hospitalized patients?

Caring for patients, especially our own patients, is an inherent part of who we are and what we do. It is good for both our patients and ourselves. It is necessary for relevance and impact in academic health centers and communities, aids our ability to enhance patient care through research, and can open doors for leadership. Family physicians bring value to patients and systems by providing hospital-based patient care.

Providing hospital care is implicit in the definition of who we are and what we do. From the American Academy of Family Physicians Congress of Delegates in 1984 (revised in 2024): “Family medicine is the medical specialty that provides first contact as well as continuous, comprehensive health care for individuals, families and communities across their entire lifespan, while also including care of all genders and reproductive stages. This specialty is distinctive in its broad integration of biological, clinical and behavioral sciences, ensuring a holistic approach to patient care. Family medicine engages in education and advocacy efforts to promote the health and well-being of all individuals while removing barriers to equitable care for all populations.”¹

First contact between doctor and patient can occur in the office, hospital, emergency department, urgent care, nursing home, or patients’ home. Care across healthcare sites enhances continuity of care. Care in multiple settings is a part of comprehensiveness and reflects a holistic approach to patients. Patients are often relieved or encouraged to see their trusted personal physician enter their hospital room. Additionally, providing patient care in the hospital keeps family physicians aware of and exposed to new technologies and approaches to care.

We are trained and able to provide care to hospitalized patients—9% of family medicine residency graduates become hospitalists, 46% of family medicine residents intend to include adult inpatient care in their scope of practice, nearly 40% do so early in their career, and 25% continue to do so into the middle and later portions of their career.²

In academic health centers and community hospitals, it is critical for family physicians to deliver care in the hospital. Not being there is to be invisible, forgotten, and to be valued only for generating downstream revenue by ordering tests, procedures, and referrals. Being present on the floor allows us to demonstrate the range and scope of what family doctors do and who we are in the larger medical ecosystem.

From a research perspective, given the holistic nature of family medicine and primacy of outpatient practice, we tend to ask different types of questions. Presence on the inpatient services presents opportunities to participate in decision-making and policy-generating committees, and lead initiatives and programs. Furthermore, it informs and expands the type of quality improvement and research questions we might ask.

There are, however, arguments for family doctors to abandon hospital care. For example, outpatient-only doctors may be quicker and easier to train. Or, the quality of outpatient training is diluted by time spent in the hospital. When access to outpatient care is limited, as it currently is, time spent providing inpatient care is time that could be spent delivering outpatient care. Relinquishing hospital care could rid us of some of the privileging battles and feeling like we need to “prove ourselves.” Work-life balance or blend is a premium expectation; limiting care to only outpatient medicine can simplify work and life. These are all valid considerations; some of them, however, are either refuted by or not aligned with current research, and some provide fodder for future research.

Family physicians practicing hospital-based family medicine benefit not only patients, but ourselves as well.^3–5 Depending on how the inpatient service is structured, it can increase continuity of care and help smooth transition of care. Who better knows how to prepare a patient for discharge, what the receiving outpatient physician needs to know to increase the likelihood of successful transition of care, and what is achievable in the scope of outpatient care than doctors extensively trained to deliver both inpatient and outpatient care? Practicing inpatient medicine is intellectually stimulating, supports resident training, and provides opportunities for broader role modeling and mentoring. Additionally, it further distinguishes family physicians from physician assistants and nurse practitioners.

Family doctors with a broader scope of practice are less likely to report burnout. Early career family physicians who provide a broader scope of practice—specifically, outpatient medicine plus some combination of inpatient medicine, obstetrics, or home visits—report significantly lower rates of burnout. Comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness.³ Although it occurs in the hospital, obstetrics as part of comprehensive family medicine is a discreet topic for its own discussion.

Family medicine (FM) should grow rather than cede our presence and influence in the inpatient setting, even if the nature of that presence may need to change. A continuing FM presence in the inpatient setting is essential to maintaining our relevance in discussions around healthcare reform in the US. We have always been the only truly poly-lingual specialty. Because of our broad scope, we can walk the halls of every unit and communicate with every type of specialist. The value of this uniquely broad perspective would be diminished if we no longer participated in inpatient care. If we are not present at hospital leadership meetings, our perspectives will not be heard, and we will lose our opportunity to affect positive change.

Some of the benefits family doctors bring to the care of hospitalized patients include:

• Holistic Patient Care.⁶ Family physicians are trained in the biopsychosocial model, which helps contextualize illness within the patient’s life. This leads to more empathetic, patient-centered care and better communication with patients and families.

• Continuity Across Care Settings.⁶ Dual roles in outpatient and inpatient care allow for smoother transitions, reducing readmissions and improving follow-up. This continuity is especially beneficial in safety-net hospitals and underserved communities.

• Cost-Effective and High-Value Care.⁶ Family doctors often practice judicious restraint in ordering tests and procedures, helping control healthcare costs while maintaining quality.

• Versatility and Breadth of Training.⁷ Our training spans pediatrics, obstetrics, geriatrics, and internal medicine, making us adaptable to diverse inpatient populations and capable of managing complex cases.

• Improved Health Outcomes.⁸ Increasing the number of family physicians in a population correlates with lower mortality rates, fewer hospitalizations, and better chronic disease management.

• What could be better for transitions of care than to be part of the care team already?

There are additional reasons family physician should practice hospital-based medicine:

• Addressing Workforce Shortages.⁷ Demand for hospitalists exceeds supply, especially in rural and underserved areas. Family physicians can help fill this gap effectively.

• Educational Impact.⁷ Many family medicine hospitalists are involved in training residents and medical students, shaping the next generation of physicians.

• Enhanced Career Satisfaction.⁹ FM doctors who include hospital care in their scope of practice report higher job satisfaction, better pay, and improved work-life balance compared to their outpatient-only peers.

• Flexibility and Career Options.⁹ Practicing hospital medicine allows family doctors to explore and broaden different career paths without abandoning their core identity as comprehensive care providers.

• Training and Professional Growth.⁶ Hospital medicine offers exposure to acute care, interdisciplinary teamwork, and opportunities for leadership in hospital administration and policy.

Continuous, data-driven improvement should be a hallmark of our hospital work. Tracking metrics and working to continually advance the quality of care enhances successful hospital service. Key metrics include length of stay (LOS) relative to patient complexity, transition-of-care appointment follow up, readmission, continuity (inpatient and outpatient), patient experience, discharge prior to noon, and physician well-being. A prior study found similar costs of care, rates of death, and 14-day readmission rates when comparing family physicians (FPs) to hospitalists.¹⁰ Compared to general internists (GIMs), hospitalists had higher costs with similar rates of death and 14-day readmissions. Both FPs and GIMs had slightly longer lengths of stay.¹⁰ In one of the author’s institutions, the LOS on the family physicians is less than that of GIM after adjusting for comorbidities. A study of 560,651 Medicare patients found that patients cared for by their own primary-care physicians, including family physicians, had the lowest 30-day mortality across all physician groups, even after adjusting for diagnostic/diagnosis-related group (DRG) complexity and comorbidities.¹¹

Scale matters and staffing models may vary. The more present we are, the more we will contribute to the overall quantity, quality, and atmosphere of care. Staffing models vary. For example, there could be rounding in the morning then attending to other work duties, or providing a presence on the floor all day with availability by phone at night; 3 or 4 days at a time versus 7 days, or 7 days of 12 hours daily on alternating weeks. Some may be fuller-scope doctors or provide only hospital-based medicine. Even those who only practice exclusively inpatient family medicine bring an important family medicine lens and approach to patient care.

Overall, family physicians should be practicing hospital-based medicine (Table 1). Doing so fulfills part of our mission, opens opportunities for us to improve patient care and metrics, advance in leadership, teach residents and medical students, and influence and do research; and doing so brings value to patients, the system, and to family physicians as a group. Furthermore, a broad scope of practice is essential in rural areas where the comprehensiveness of skills of each physician is an asset that can help mitigate the scarcity of quantity. The question is not, “Should family doctors practice inpatient care?” Rather, it is, “How should we adapt our delivery of inpatient care given changing practice environments and workflows, work-life expectations, and that most family physicians are now employed by a system or medical group?”