Good for Healthcare?
Sarah Jones was an anomaly in contemporary healthcare. Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years. Over this time, patient and physician had gotten to know each other well and had developed a fine relationship. Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding.
When the dreaded day came that she finally needed inpatient care, however, her hopes were dashed. Her physician explained to her that he no longer sees hospitalized patients. Instead she would be under the care of a team of physicians known as hospitalists. When she arrived, the hospitalist on duty introduced herself and told her that she would be the physician responsible for her care, while colleagues would be responsible during off hours. Unlike her regular physician, who would have been on hand only once or perhaps twice per day, the hospitalists would always be in house and ready to address her needs.
Mrs. Jones was surprised and disappointed to discover that her primary physician would not be involved in her hospital care. She had always assumed that she would be able to rely on their longstanding relationship for counsel and support. She imagined that if she were facing some really important decision, such as whether or not to proceed with a risky operation or how to manage her own end-of-life care, it would make a huge difference to know that she could count on a physician she knew well. Instead her hospital-based physician was a complete stranger.
Mrs. Jones’ experience is far from unique. In the past 15 years or so, medicine has seen the birth of hospitalists, a new breed of physicians who care only for hospitalized patients. There are now over 30,000 hospitalists in the US. From a patient’s point of view, such physicians offer a number of advantages. In many hospitals, a specialist in hospital medicine is always on duty, day or night. Moreover, because such physicians work only in the hospital, they are often more familiar with the hospital’s standard procedures, information systems, and personnel.
It is not difficult to see why hospital medicine might be so attractive to young physicians. For one thing, it provides them with a high degree of control over their working hours. They come on and off shift at regular times, and do not bear patient care responsibilities outside these hours. In addition, they are usually employed by the hospital, which means that they do not need to attend to a host of practice management issues that self-employed physicians confront. They can also focus on acute-care, in-hospital medicine, avoiding the challenges associated with long-term care of chronic-disease patients.
Some non-hospitalist physicians also find the rise of hospital medicine attractive. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue. They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges. And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.
Hospital medicine also offers benefits to hospitals themselves. Because hospitalists are generally hospital employees, it makes them easier to manage. They get their paycheck from the hospital, so they tend to be more responsive to the initiatives of hospital leaders and easier to integrate with other members of the hospital’s staff, such as nursing. In addition, the hospital has more control over the financial dimensions of this type of medical practice and can take steps to ensure that little or no potential revenue is lost because of the decisions physicians make.
For example, as healthcare moves toward a model in which hospitals are compensated not for the care they actually deliver but for patient populations for which they are responsible, the incentives shift toward delivering less care over shorter periods of time. This makes it advantageous to hospitals if physicians only admit patients who truly need it, and then take whatever steps possible to reduce lengths of hospital stays and total costs generated by each patient’s care. When physicians practice only in the hospital that employs them, such objectives become easier to achieve.
There are good reasons to think that hospitalists are here to stay. They reflect the convergence of a number of powerful forces in healthcare today, including physicians’ desire for a more regular and comfortable lifestyle, the trend toward increasing specialization in medicine, the growing complexity of medical systems, and the goal of hospitals and healthcare organizations to acquire more control over physician practice patterns. However, the rise of hospital medicine also entails some drawbacks, particularly from the point of view of patients such as Mrs. Jones.
Good for Patients?
Hospitalists are playing an increasing role in healthcare, but their rise is not universally embraced. I have known a number of physicians who, while admitting that they do not miss traveling back and forth to the hospital, also speak wistfully of the days when they cared for their patients in hospital as well as out. They sometimes worry that hospitalists cannot know their patients as well as they do, and they miss the days when they felt that they were delivering truly comprehensive care. As one physician put it, “When I told a new patient that I would be their doctor, I really meant it, even if they had to go into the hospital.”
Another problem with hospital medicine is the large discontinuities in care it inevitably introduces. Many patients admitted to the hospital are meeting their physician for the first time, meaning that strangers are caring for strangers. This is not uncommon in contemporary medicine – just think of what usually happens when a patient goes to the emergency department. However, it decreases the degree of familiarity between patient and physician at the same time that it increases the probability of miscommunication between multiple physicians, none of whom knows the patient as well.
Some think that new information technology systems can overcome such discontinuities. Because a state-of-the-art computerized medical record is immediately available to everyone involved in the patient’s care, physicians, nurses, and other health professionals can understand the patient better than ever before. However, information contained in an electronic record and true knowledge of the patient are not necessarily the same thing, and every time an unfamiliar person is added to the team, the possibility arises that important knowledge will not be conveyed and grasped.
Another pitfall of the hospitalist is the focus on short-term care. When someone is admitted to the hospital with an acute medical condition, such as a heart attack or stroke, there are definite advantages to being cared for by an acute-care physician. However, excellent care for many patients requires a physician who is focused on follow-up and long-term care, and who understands the patient’s life outside of the hospital. If patients are going to thrive over the long term, they need physicians who see beyond the boundaries of the hospital stay.
A related drawback concerns trust. Even if no important medical information were ever lost or overlooked, good medicine still requires a relationship between patient and physician. It relies not just on biomedical knowledge, technical skills, and error-free information transmission, but on human relationships that take time and effort to build. Patients whose physicians have known them for years are likely to feel a greater degree of trust than those who are being cared for by strangers they have never met before.
There is a problem with defining physicians by the contexts in which they practice instead of the kind of care they give. From the patient’s point of view, where the physician happens to be based is generally much less important than the quality of their relationship with the physician. Life-changing and even life-and-death decisions may need to be made during the course of a hospitalization, and both knowing their physician and knowing that their physician knows them makes a big difference.
The rise of hospitalists is symptomatic of larger and not always salutary changes taking place in healthcare today. We are focusing more and more on systems – procedural systems, information systems, and financial systems – and less and less on the relationships that need to be the core of good medical care. We make decisions based on criteria such as efficiency and cost, while neglecting the human side of the equation. To an increasing degree, many of us no longer have someone we can call our doctor – a single physician we have known for years who will coordinate our care through the years to come.
In the first half of the 20th century, a new pediatric disease was identified. Some infants cared for in hospital failed to grow and develop normally, despite adequate feeding. Many eventually grew sick and died. This disorder was more common in well-off institutions than poor ones. What was the problem? It turned out that these infants were not being picked up and cuddled, a practice more common in poor hospitals that could not afford fancy incubators. Human beings need human contact in order to survive and thrive. Now called failure to thrive, this condition was originally known as hospitalism.
Today healthcare is at risk for hospitalism. Some of us have forgotten that medicine is less an economic or technical endeavor than a human one, in which relationships between human beings make a big difference – sometimes all the difference. As it turns out, there is as yet little evidence that hospitalists, whatever their effects on healthcare’s revenue streams, actually provide better patient care than primary care physicians. From the point of view of Mrs. Jones and many other patients, there are good reasons to think that they may never be able to.
Richard Gunderman, MD, PhD, is Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy at Indiana University; he was a past president of the faculty at Indiana University School of Medicine and currently serves as Vice Chair of Radiology. Gunderman is also the 2013 Spinoza professor at the University of Amsterdam, the author of over 380 scholarly articles and has published eight books, including Achieving Excellence in Medical Education, We Make a Life by What We Give, Leadership in Healthcare and most recently, X-Ray Vision.
Categories: Uncategorized
Joellen, Bonnie, and Dr. faltkof,
As a patient recovering from my first hospital visit through the ER of the only hospital in Asheville, I can testify to the truth of what you shared here. I am wordering if the absence of a Primary as an overseer, and the lack of accountability that entails, the use of a hospitalist is an excuse for the hospitalist and other staff from nurses to phlebotomists , to mistreat and verbally abuse, physically and emotionally mistreat patients.You’ have a hard time convincing me I’m wrong on that!
I was admitted for chest pain of the type described by most as indicative of a heart attack. They did the enzyme tests, decided to admit, insisted that anxiety, a lifelong companion, could not interfere with their ability to draw blood from my veins. Told them to call my PCP. No, they said, hospitalist. That person came in, all smiles, hello, we will keep,you overnight, my partner will see you tomorrow. More sticking, horrible condescending nurses, harsh orders, hostile treatment. No patient advocacy, no one, only strangers, then another hospitalist, hello, if next test is no good, we talk alternatives then. How about now? No, I said after. At 7 AM next day, some guy gave me a shot in prep for nuclear stress test, he was also of the shut up, let me give the shot and get out of here persuasion that seems so overwhelmingly preferred as staff by this hospital. At that, I decided I had enough unkindness, and told them I was leaving, and would get the test at Asheville cardiology and got dressed.The lack of any kindness, compassion, care, or familiarity had sent my anxiety right into full blown Panic Attack, which I have not experienced since I was in my 20’s, early 60 now. No more hospitalists for me. New primary care physician shopping. Now at home, in bunker, still full of anxiety. Them system there also appears to subscribe to the, let ’em eat when we let them go, this is not a restaurant, after all” school of hospital stay. Not one meal offered, but I did wring out an orange juice, and a pack of unsalted saltines after the horsesasspitalist said I could have a meal. I told BCBS to send me the whole bill before they pay the claim, so I can point out charges that should be questioned. Way to go, Mission Hospital System, Asheville, NC!, you monopoly holding behemoth….
i am a patient who has gone through more deaths
in the past 10 years than i want to count. I am also
a Patient Advocate.
I do not see a difference between the hospitalist
system and socialized medicine, as practiced in
England and Ireland, countries in which i spent my
childhood summers and much of my adulthood..
My experiences with socialized medicine were far
better than hospitalists….
i have seen three ‘hospitalist’ run hospitals nearly
kill my loved ones….now i no longer go to a doctor
who is associated with a hospital that uses that
system…
hospitalists might be ‘in the hospital’ but just try and find them..
it reminds me of the comedy classic by the three
stooges, who is on first, what’s on second, except this
is the lethal version…the point here is that there are
multiple doctors each day using only their first names
and it is a real nightmare for patient and family alike.
I am fortunate to have choices…There are three
hospitalists hospitals in my area….and they practice
medicine that, without my intervention, would have
killed my husband, my father, a friend and so on.
Whatever happened to reading in, especially on older
patients with multiple life threatening conditions?
hospitalist proponents are arrogant to the extreme in thinking they
can manage anything…
In my personal experience, in the three major hospitals
closest to me, i have yet to meet an American born doctor..
Here they are all from the fall of the soviet bloc and
Roumania….countries whose medicine we have always
considered inferior….
Countries that had a much lower standard for care
concern and empathy,human rights, and patient rights. much less relationship…
and they do not speak english that I can understand,
much less the dying loved ones to whom I am responsible…
and they say things that are just plain, wrong, outrageous
and stupid….fortunately they speak quick and run away.
one friend was actually told she needed surgery in the
morning, had some bowel issue in the afternoon, and
inoperable cancer the next day, without the benefit
of having at least family or priest there, but they retracted
that the next day, and said she needed upwards of
100,000 dollars of invasive testing before they could
say yes or no….this woman had been in a coma for
two months at the nearby hospital….the patient did
not remember what happened at the other hospital
and no one even requested the records much less
wanted to read them…after all they are the acute
people…no need for history….just the eye of the
neeele so to speak. well the first hospital had found
the same thing, done all the recommended invasive
tests and found it to be benign…
They were about to put her through it again..
in part I am sure because the hospital needed the money.
and, by your own reporting, they have a lousy work
ethic. My Dad was a doctor….first a mash combat
surgeon for ww2 in England, France and Germany.
He had the hospitals for Normandy and the occupation
after dedicating 7 years of his life to the army, he
took a fellowship at the mayo clinic, married and
had a private practice as a urological surgeon, along
with a late marriage and three children…to whom he
was a very good Dad.but he worked 6 and 7 days
a week twelve hour days.
hospitals are no place for lazy clock counting doctors..
if they dont want to work hard, and have shorter
hours, let them be dermatologists, or do what the
9 to five guys always did work for the insurance
companies. doesnt get any easier than that. Guaranteed
cocktail hour.
but lets not feign that this system has anything to do
with medicine. it has to do with business. the president
of aetna, mark bertolini, makes 36 million dollars a year..
that sure doesnt leave much room for medicine…
right now the hospitalist system is about to explode
in scandal, not unlike Kaiser Permanente ‘managed’
care. How many poor patients need to die at the
hands of these people and their complete comfort
with no information, no history, and not much time at
bedside….
But we are putting less skilled people, with less
of a work ethic, in a sitation where they can do
a lot of harm.
these are not real doctors, they are not practicing
real life or death medicine, which is a thrill all
its own. this is a terrible system. it is very bad
for the people with whom I have been involved
and it is a cruel and inhuman thing to do to an
anxious and concerned family….
It is not the hospitalist’s fault that your surgeon abandoned you after surgery..
He could have remained in charge but obviously chose not to do so.
If the surgeon thought the patient should go home straight from the OR,
he should have and could have done so himself. He was too lazy to do so himself and so transferred the patient to the hospitalist. You are picking on the wrong guy.
Cost saving at what price? A few months ago I had the misfortune to need an AAA repair. Had a truly excellent Vascular Surgeon, but had a slightly more complex repair than expected. In the ICU I learned that I was now in the hands of a doctor I did NOT know, had never met, and most certainly did not trust. My instincts were, unfortunately, correct. The hospitalist was asked to divide a 2 mL dose of dilaudid in half and administer that dosage every 2 hours instead of the total every 4 hours. So, he did… to his mind… ordering 0.5 mL of pain med every 2 hours. When it didn’t work I asked the Nurse what she was administering. She told me and I needn’t describe my disgust to learn that I was in the hands of a graduate of some Medical School who thought half of 2 was 0.5 ! Yeah.. honest this is a true story. I solved my problem by calling the Surgeon’s office and having them fix the dosage… only to have the Hospitalist come in later and try to *correct* the dosage. (The Nurse was smarter than he was and I heard her showing him how to do the math ).
The point is that being admitted to a hospital for acute care is NO time to try to figure out whether or not you can trust a Physician who has just taken over your care whether you like it or not. I am sure there are many fine Hospitalists out there that I’d be happy to have responsible for me, problem is the patient does not have a choice of Hospitalists, does not have a way to judge the available Doctors anyway, and is usually in no condition to see to their own safety at that point. The system simply is not reliable for patients even if it does work for Hospitals and Primary Care Physicians. It’s only a matter of time before we start seeing a rise in lawsuits based on the lack of relationship between the Hospitalist and the Patient. Shouldn’t happen, but it will….. The system needs to be repaired before that happens.
AMEN! to this “In my impression, “Hospitalist” is the name applied to folks who take care of hospitals.” with an addition.. This should read “*Hospitalist is the name applied to folks who take care of hospitals, and their own pocketbooks.”
I spent today trying to get a medical reason for a hospitalist to keep my elderly landlady in the hospital an extra day postop for having a wrist pinned. No one, I mean no one in that hospital was able to explain why she needed to be there for a second night. Her blood pressure had stablilized, her pain meds were oral and working fine… and most important she was stressing out over being kept in the hospital for just 1 night let alone 2. However, there was a clue to the answer to be found from something I heard in the ER yesterday while waiting for surgery.
Two ER Nurses and two other Hospitalists were fussing because this one particular Hospitalist had written his name down as covering every single patient in the ER. They didn’t know I was overhearing them, or that I had the skills to understand what was going on.
The surgeon had told the patient that she could go home straight from the Recovery Room, so clearly HE didn’t think even one night’s stay was necessary. This was a percutaneous pinning with no incisions. We were informed that the Hospitalist had admitted the patient and that, therefore, she had to stay.
Then, today, I found that the patient had been re-assigned to a Nurse Practitioner who was keeping her over another night, quite unnecessarily. The Hospitalist hadn’t seen the patient one single time since surgery. (Not even in the Recovery Room).. The Nurse Practitioner had never seen the patient AT ALL… And, this is who made the decision to hold the patient over for another day in spite of the patient’s objections and the medical lack of necessity for the extra day. Talk about Medicare abuse!
Hospitalist=ripoff.
I think the costs of a hospitalist program are highly underestimated. The long term relationship of a physician and patient is not just based on trust but also information. The simple elimination of duplication of services and tests is one way,and the elimination of some of the ‘defensive medicine’ that protects against lawsuits are some low hanging fruit in reigning in avoidable costs.
The argument that hospital costs are a small part of overall healthcare I feel is invalid as such a large percent of person’s healthcare is spent in the last 6-12 months of life. My experience is that the life often ends very dramatically in a hospital with an extremely high bill. The discussions that can avoid chasing futile ends are grounded in trust.
I think I hold my physician’s work/life balance more sacred than they do. I don’t know how to maintain the balance of life/office and hospital now that employed physicians are placed under higher pressure to increase patient volume but I do not believe that the hospitalist movement is cost saving over the lifetime of a patient.
Has The Rise of the Ambulists started yet?
Much good discussion. Our primary focus should always be the patient. Hospitalists don’t care for hospitals, they care for (and about) patients. This is our calling, it is what we are trained to do. Bob is correct, in every field there are “good” and “bad” physicians. Our hospitalist community has to be driven to expect the best. The best part of my day is taking care of a complex patient and making sure that his or her condition can be treated effectively as an outpatient. I cannot tell you how many of my outpatient colleagues are very happy to have us working with them in the hospital. Glad to be your colleague…
Excellent discussion. Here is my proposed solution to the above, given my situation as an Ambulist who practices in a rural town in a house that is three blocks from an excellent community hospital staffed by excellent hospitalists:
“Follow” my patients using the capabilities of Family Health Network:
http://www.familyhealthnetwork.com
It is now tablet based and thus mobile. It unites the patient with: care givers, family members, care professionals (internists such as myself, specialists, hospitalists….etc), pharmacists, the public internet, medication management, self-care advice….etc
It is currently being implemented in the Advanced Care Clinic at UNC-Chapel Hill.
I intend to write a grant to support its use with my “advanced care patients” in my solo private practice in NE North Carolina in the “Inner Banks” – a very “rural and remote” (and relatively poor and diverse) area.
My goal is create a true “Rural Ambulist Model” of care where I am “on” 24 x 7 as an outpatient internal medicine physician (with the help of the 24 x 7 Mayo Clinic Nurse advice line associated with the Family Health Network) for seven days a week and then “off” for seven days except for the connectivity afforded by the Family Health Network.
Any suggestions for sources of funding? I have a literature track record in HIT and have written (and successully carried out) a multi-million dollar Health Services Research grant while I was a general internist in the VA.
An additional point: this network has PHR, EMR-interface, Telemedicine and Telehealth capabilities while claiming to be MU2++ capable.
Thanks Dr. Gunderman for a fair and well balanced overview of the pros and cons of the hospitalist industry segment which I believe has doubled in size from about 15,000 practitioners over the last ten years.
Fifteen years ago, some physicians in private, office-based practice in Rhode Island were concerned that not continuing to follow their own patients during an acute care admission might trigger patient abandonment charges by the Board of Medical Review and Licensure. It’s interesting that now even Level 3 Rhode Island PCMHs and ACOs are using hospitalists.
Hopefully, with the deployment of secure and fully interoperable HIE, much more usable EHRs and the level of patient engagement needed for long-term success in a value-driven accountable care era, the benefits provided by good hospitalists will outweigh the disadvantages.
The author makes a valid point assigning extraordinary value to the physician-patient relationship in making critical decisions e.g. end-of-life decisions. However, as previous comments have suggested, not all hospital care depends on that relationship but instead on specialized, short-term, high impact care e.g. trauma after a motor vehicle accident or cholecystectomy for right upper quadrant pain.
The solution is not reverting back to old days when PCPs took care of inpatients and outpatients. Instead, we need better transfer of care between the hospital setting and the primary care clinic. Moreover, PCPs can still have an impact on their patient’s care, even if they are not taking care of them directly in the hospital; PCPs can empower their patients, for example, by discussing end-of-life issues with them and making sure they have an advance directive on file.
One point that needs to be added is the increasing number of hospitalists at the expense of a decrease in the outpatient primary care workforce.
Many experienced FPs and Internists leave their office practices for “hospitalist'” opportunities. Why?
Because they pay a lot more,come with superior benefits and don’t involve the burdensome aspects dealing with insurance etc.
One can foresee the emergence of “mid level” practitioners offering the majority of outpatient primary care.
So many good points. I would like to take on the issue of the absent relationship. The idea that “a stranger is taking care of a stranger”. Before I had the honor of leading the largest Hospitalist group in the country and practicing as a Hospitalist years before the word had been coined and quite frankly at a time that many patients actually did suffer from “Hospitalism” (Bob’s definition of languishing in a hospital), I was a practicing Pulmonary Critical care Physician. The attraction of primary care is indeed the long term relationship but also mostly comes with impact achieved over a period of time. In the management of long term maladies this works and argueably is the best answer to proper care. But as patients become hemodynamically unstable or acutely ill, patients are in need of short term but very high impact care. This is the nature of every hospital based specialists care and relationship to the patient. It was rare that I had a long term relationship with a patient before I entered the room, had to rapidly develop a relationship. To gain the trust of a both patient and family. A relationship necessary before they would allow my to stick a needle in their neck. Slip a tube down their throat. Cut open their chest. In the years before Hospitalists, It was 100% of the time that it was me and not the PCP that led the end of life discussions that are common to the care of patients in the ICU. All of my relationships were short term but had very high impact. I learned to develop these kind of relationships as do all specialists. This made all that much easier by the vote of confidence the PCP who may have had this relationship gave to me by virtue of the referral to the patient. This same vote of confidence is given to the patient by the doctor with the long term relationship today by virtue of their referral to the specialist Hopsitalist.
One last point, Nothing, in the world changed by Hospitalists, prevents a primary care doctor that owns a special relationship with a patient, and where that relationship might impact the care of a patient, from coming to the hospital and participating in the care of a patient. If that relationship exists and care might be impacted I would insist on it. Maybe unfortunately this happens only rarely. In fact, for those of us spcialists practicing at the beginning of this change, it was the fact that so many PCP’s opted out of the hospital and were asking us to go solo on the care of these patients that many of us began to build our Hospitalist practices. Indeed it was the lack of an effective PCP with a relationship to the patient that could assist in the care that forced me to think up IPC.
Adam Singer MD
CEO IPC The Hospitalist Company
Welby would BE a hospitalist. But maybe his loans weren’t so onerous.
The claim that hospitalists improve care merely based on their presence is incorrect at worst and native at best. Hospitalists exist in so many hospitals for one reason and one reason alone. They make large sums of money for the hospitals they work for.
“We are focusing more and more on systems – procedural systems, information systems, and financial systems – and less and less on the relationships that need to be the core of good medical care. We make decisions based on criteria such as efficiency and cost, while neglecting the human side of the equation.”
Why the false dichotomy? Medical care and has gotten more complex. We can save lives today that in the past were futile with better treatments and medications. Evolving from a doctor who knows it all to team-based care and specialization whether emergency medicine (decades ago) to hospital medicine is natural.
But who says that becoming better means we need to lose the humanity of medicine? Why do we continue to hold on to the heroic “solo” doctor who does it all? As Atul Gawande points out in his New Yorker piece Cowboys and Pit Crews as well as The Checklist – medicine has arrived to a different level and our response to the challenge must be different.
So perhaps it is a generational shift that Sarah Jones is undergoing.
In my mind, however, health care will reach a point where we can provide both team-based care as well as personalized care if we believe we can do both.
From my favorite author Malcolm Gladwell he notes:
http://gladwell.typepad.com/gladwellcom/2008/12/
Roger Martin, the dean of the Rotman School of Management at the University of Toronto, has a wonderful book out on this very idea (“The Opposable Mind”). He argues that what distinguishes successful business leaders is their ability to reconcile apparently irreconcilable options. So, for example, the genius of Izzy Sharpe, the founder of the Four Seasons chain, is that he was the first to understand that a hotelier doesn’t have to choose between the advantages of a large hotel (breadth of services) and the advantages of a small hotel (intimacy). For years everyone assumed those were mutually exclusive categories. Sharpe realized that you can, in fact, do both.
With the rise of hospital medicine, team-based care, a focus on efficiency (breadth of services) we can still be intensely personal and embrace the humanity of medicine (intimacy). Why assume they are mutually exclusive?
Davis Liu, MD
The Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving Money (2012) & also Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
Blog / Website: http://www.davisliumd.com
Twitter: @davisliumd
In my impression, “Hospitalist” is the name applied to folks who take care of hospitals.
I have yet to have a patient come to me who was managed by a hospitalist who did not have at least 2 unnecessary imaging studies and 2 untreated deficiencies in labs or exam findings (sic).
The “Hospitalist” is a euphemism for care and the EHR is a provocative error causer for these “stranger” doctors who never get to know the patients.
And there goes Wachter again, exaggerating the available information to make his case.
Thanks to Dr. Gunderman for a mostly fair-minded piece that captures some of the benefits of the hospitalist model and some of the concerns. While I appreciated the post, the last two paragraphs on “hospitalism” represent an unfair appeal to emotions and a misstatement of the history of the word. The term “hospitalism” was used in the 19th century to describe the dismal state of patients who were confined to dirty, unsafe hospitals (largely in the UK). In fact, Webster’s defines the term thusly: “A vitiated condition of the body, due to long confinement in a hospital, or the morbid condition of the atmosphere of a hospital.” (More background on this term can be found here: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=481 )
In fact, hospitalists — by helping to keep lengths of stay down to a safe minimum and participating actively in hospital-based safety and quality improvement programs — help prevent “hospitalism.”
Those of us who were present at the birth of the hospitalist movement came to believe that the US’s traditional system of hospital care, with its expectation that the primary care doctor would be the physician-of-record in the hospital, had broken down under the pressure of increased outpatient workloads, fewer and sicker hospital admissions, and increasingly specialized expertise required to effectively manage hospital care. While it is theoretically attractive to have the same doctor in both the inpatient and outpatient setting, in most circumstances it doesn’t work, for several reasons: the primary care doctor cannot be in two places at the same time (thus leaving the patient abandoned or cared for by a roving band of subspecialty consultants without an orchestra conductor to pull together their recommendations into a coherent plan); improving hospital care is increasingly a matter of having physicians who not only are great at caring for individual patients but also at improving systems of care (something a primary care doctor who spends 5-10% of his or her time in the hospital simply can’t do); and the knowledge base required to manage hospitalized patients is increasingly large and specialized. Conversely, we also need our overwhelmed cadre of primary care physicians to concentrate on caring for their outpatients, not just via an office visit but increasingly through population management.
The evidence is strong the hospitalists improve the value of care. The fact that virtually every hospital in the United States with more than 200 beds now has hospitalists — in the absence of any mandate to do so and given the pressures that hospitals are under to improve quality, safety, patient experience, and efficiency — is a pretty good indication that the hospitalist model is solving some important problems. There is no published study that I’m aware of that shows a decrease in overall patient satisfaction under the hospitalist model. While there are certainly patients like “Sarah Jones” who wistfully long for their primary care doctor in the hospital, most patients recognize that their primary care doctor is seeing patients from 8 to 5 in the office, and they appreciate the expertise and availability of a good hospitalist, embedded in a good program.
Which brings me to my final point. There are good hospitalists and bad ones, good programs and bad ones. Surprise: there are also good PCPs and bad ones too. The hospitalist field is the fastest growing specialty in US medical history, and we have seen some growing pains in some places. But most hospitalists are good physicians who are delivering on the promise of improving the value of care, while doing their best to mitigate the inevitable downside of the inpatient-outpatient transition.
Would some patients benefit from (or prefer) having their regular doctor also care for them in the hospital? I’m sure a few would. But, has the hospitalist model improved our ability to care for both inpatients and outpatients more effectively by allowing expert generalist physicians to be constantly available in both these environments? Absolutely. Would our system be better if we rolled the clock back to the old days of a single physician trying to care for extraordinary sick hospitalized patients while also managing an office full of complicated outpatients? I don’t think so.
In fact, I’d bet that, if Marcus Welby were practicing today, he’d use hospitalists.
I’ve had HMO coverage my entire adult life and have little expectation that anybody I know will be around when I’m hospitalized. If I’m lucky they’ll be able to log into my medical records. At the least I have a sense that whoever is caring for me knows the system I’ll be released back to, and the few times I’ve been hospitalized/released I get a call from the Internist about my follow-up.
Several of my parent’s peers, folks who always had fee-for-service, lived in a small town and received care under the “I have a doctor and he knows who I am” model have been hospitalized and being cared for by hospitalists have been unhappy about the situation. In their 70s/80s the patients have not been so outraged, sadly they have often died, but their family/friends have been distressed by the lack of familiarity and rapport the doctor at the hosptial has offered.
As hospitals gobble up practices perhaps they could assign hosptialists to practices so that some bond/team of local doctor/hospital doctor could be formed. It’s hard enough to have your friends and families die without feeling like a stranger is caring for them.
My husband was recently hospitalized with a GI bleed from an esophageal tear post food poisoning and repeated vomiting. We saw 2 ER physicians (the shift changed) with a wait of 10 hours for admission before they were convinced he was bleeding. We then met our first hospitalist, who did not introduce himself by name, but stated “I won’t be here tomorrow morning” (it was then 2 am), I’m only admitting you.” And ordering a full diet, without knowing the cause of the bleeding. The next day we met another hospitalist, who was non-committal as to the cause of the continued GI distress, and the falling blood count. Each 12 hours, we got a new doctor, none of whom seemed to care about much more than the previous 6 hours. I called our GI specialist, who sent his APRN over; she initiated the investigation that lead to the diagnosis of the tear, and the repair. After her visit and subsequent visits by our GI physician, the hospitalists deferred to the specialists. I spoke with the hospital administrator and the VP for nursing during our 5 day stay: there was NOTHING patient centered in this care. I won’t return to that hospital, and dread having to deal with this depersonalized care paradigm in the future.
As with everything in medicine (and in life), there are tradeoffs.
The points raises here are excellent and accurate. It speaks to hospitalist medicine, but also to the broader context in which medicine is practiced today. Checklists, electronic records, procedures and guidelines, health systems, shift, etc are now guiding care in ways that didn’t exist a few years ago.
The problem isn’t that the new ways are bad or that the old ways are good (or vice versa). The issue is that dogma and being locked in a specific paradigm and thinking prevents us from acknowledging weaknesses and benefits of the different systems. Many of the advocates of these new systems take extraordinarily biased views, in part because they seem themselves as challengers to a status quo that doesn’t work effectively. Unfortunately, that limits creative ways in which the strengths from each view can be found.
Interesting thought, Cynthia, but is there any evidence for that, and how would it work? Do you think most people are actually aware enough of the existence of hospitalists to self-select into hospital care? Don’t many hospitals require admission by a GP anyway, at least when an insurance plan is involved? I would think even admission via an ER at least has the ER as a gatekeeper. Yes, widespread after-hours clinics do help lower ER use, but I’m not sure it has to do with the availability of hospitalists.
I have some experience working with an oorganization called Commonwealth Care Alliance which specializes in care for the disabled and the poor, frail elderly. They use NPs and PAs a lot. They do everything that they can to keep people out of the hospital, but they are heavily involved in monitoring and visiting their patients while in the hospital and in the home–even if they don’t make all of the decisions themselves.
They do operate their own unit for their patients with spinal cord injuries, because they want them to be cared for by people who know them well–literally as in, where’s the best vein to get an IV in. Of course, each NP has a patient load of about 40. Accountable Care Organizations affiliated with hospitals may be able to do something similar, although in a less resource-intensive way.
You raise some important points. Probably everyone would agree that it would be idea if OUR doctor is the one taking care of us throughout our illness, from the office to the wards. The problem is that many primary care doctors don’t follow their patients in the hospital, and, as you know, there is a significant deficit of primary care doctors to even see patients in the outpatient setting. Hospitalists fill this need. Is it ideal? No. But good care can still be delivered regardless–and as an ER doctor, I have met many excellent hospitalists who I would be very comfortable to entrust my care to.
The only problem I have with the so-called “rise of the hospitalists” is that it encourages patients, whether they are insured or not, to use hospitals as their primary source of care. Take away hospitalists and I believe that hospital admissions will drop significantly. One of the easiest and least costly ways to reduce hospital admissions is for outpatient clinics, including most specialty clinics, to remain open longer throughout the week and be open on weekends and holidays. Besides banks and daycare centers, most other businesses in the service sector, from hotels to restaurants to police stations, don’t keep banker’s hours, so there is no reason family care clinics, or even cardiology and orthopedic clinics, should keep banker’s hours as well.
Hopefully, hospital patients whose HMOs employ their own hospitalists will benefit from close collaboration between the primary provider (oftentimes a Nurse practitioner or physician’s assistant) and the electronic medical record (EMR) of the HMO. Without the HMO or Advantage Plans in the United States employing your hospitalist, the problems noted in the article are likely. This raises another issue for consumers. Are we ready to let a hospitalist outside your provider’s practice link with and use your provider’s EMR for your hospital stay? And are the current EMRs of value to the casual user?
Very good piece. From a quality-of-care perspective (focusing on hard outcomes as well as processes of care), the rise of the hospitalist does seem to make sense, as it helps reduce the fragmentation of the care within the hospital, while GPs working with hospitalized patients often run in and out and don’t have ongoing relationships with staff. However, now I can see how it can compromise patient-centeredness.
Rich
You raise perfectly reasonable points. I am considering your post more as an opinion piece than a summary statement of evidence.
HM done well raises little concern in my book. Done poorly, and patients wind up unsatisfied, or worse, harmed. We need folks like you to press and monitor our progress. I say with conviction, a well functioning hospitalist-ambulist relationship improves care.
However, the field of hospital medicine far from a “new breed,” and I can f/u on details if you wish.
We at SHM strive to move our profession forward (I speak as a founder and active member, not in an official capacity); and if you skim our site, you will note a trove of information on everything we work towards: 1) improve the wards (a woefully neglected place, even harkening back to the golden age–not so golden), and 2) advance a science we still know little about.
As a side note, when I entered hospital medicine over a decade ago, many ambulists had disconnected with hospital practice, if not in mind, also in body. The shift has been more than one sided.
http://www.hospitalmedicine.org/
Brad