Use of hospitalists creates concerns over continuity
Providers say communication is key
Hospitalists, very simply, are physicians who provide hospital-based care exclusively, and it is increasingly the model used by institutions in order to have physicians on staff and on call at their institutions on a 24/7 basis.
But there are concerns that the increasing dependence on hospitalists vs. care of patients by their primary care physician on an inpatient basis can lead to disruption of care and harm the patient-physician relationship.
According to Mark V. Williams, MD, FACP, FHM, professor & chief, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, in Chicago, the Society of Hospital Medicine, there are between 25,000 and 28,000 hospitalists in the United States.
When Robert Wachter, MD, wrote for the first time about hospitalists in the New England Journal of Medicine in 1996, Williams says there were about 1,000.
Williams is also editor-in-chief, Journal of Hospital Medicine, and past president, Society of Hospital Medicine in Philadelphia.
Of today's number, about 75% of all hospitalists take care of patients in the intensive care unit.
The hospitalist movement, Williams says, is "the fastest-growing medical specialty in the history of American medicine."
"And I think hospitalists have grown in number and in popularity primarily because of the increase in quality of care that they bring to patients in the hospital," he says.
Williams says they can respond quickly to patients and to nursing staff, when patients do poorly.
"And if you will, it's what's been going on in academic medical centers for decades," he says. "They had hospitalists — but called them residents. The difference is now you have somebody who's experienced, and you have somebody who's on a long-term career basis, and they're also becoming actively involved in quality improvement projects at hospitals."
In fact, The Leapfrog Group in Washington, DC, includes intensivists as one of the requirements for hospitals focused on quality.
Some physicians have concerns over scenarios and situations that could be created — perhaps to patient detriment — through a disconnect between the admitting physician and hospitalist, who cares for that patient within an institution.
In an editorial in the March 12, 2009, issue of the New England Journal of Medicine titled "The Growth of Hospitalists and the Changing Face of Primary Care," Mary Beth Hamel, with her co-authors, raise some of those concerns.1
The NEJM editorial authors say that "studies generally have not shown either adverse or favorable effects of hospitalist care on hospital mortality or readmission rates." The editorial also cites the valuable role hospitalists play in the supervision and training of residents and medical students, a role for which they receive "high grades."
While there are "obvious advantages," including the one that allows primary care physicians to see more patients on an outpatient basis, they do cite concerns.
The authors write: "Although hospitalists provide important benefits, their involvement disrupts the continuity of care provided by the patients' primary care physicians, resulting in potential adverse effects for both patients and doctors. With the increasing burden of chronic illness and complexity of medical care, coordinating care across settings and providers has become especially important.
"When primary care physicians are not at the bedside of their acutely ill patients, valuable opportunities to deepen the patient-doctor relationship are missed," they write.
Lauris Kaldjian, MD, PhD, director of the program in bioethics and humanities, as well as associate professor in the Department of Internal Medicine at the University of Iowa Carver College of Medicine in Iowa City, IA, says that while there is a tendency to focus immediately on the doctor-patient relationship within the hospitalist model of care, "I think this is a great example in health care — and in the ethics of health care — where one has to try to take in a systems perspective, not necessarily to agree with it, but at least to understand it."
Kaldjian says that economic pressures are such that currently, "it's not surprising the frequency of what we call dual coverage — coverage of both inpatient and outpatient by the same clinician — is much less today than it used to be."
To a certain extent, Kaldjian says, "one simply has to accept that as fact."
"Then, from the ethical perspective, the question is: Should we accept that and go along with it simply because all sorts of economic and social and regulatory pressures have pushed things forward [in this direction]?" he asks. "And then the question is: Is it something to which we can reasonably adapt and provide excellent care, or is it intrinsically problematic?"
The so-called ideal image of the long-time physician admitting the patient when he or she becomes sick and then rounding on that patient each morning until he or she is discharged has — as an ideal — a "beautiful, seamless continuity to it," Kaldjian says.
And while Kaldjian suggests that still may occur in some places, "the frequency of that has greatly diminished."
Another concern is that hospitalists may have a tendency to be concerned with decreasing a patient's length of stay (LOS) to improve profitability in the care of a particular patient, based on the DRG.
While there are good reasons — often patient-centered reasons — to have people leave the hospital as quickly as medically feasible, Kaldjian says that "as far as ethical challenges go for the hospitalist model of care, I think it is fair to say that each clinician has to wrestle in his own mind and heart with what is the optimal length of stay for a patient — and is what's good for the budget also good for the patient?"
Managing patients within the hospitalist model
From Kaldjian's perspective, "the domain of communication is key." He also is hopeful that the increasing utilization of electronic medical records will improve communication among health care providers.
"It is remarkable how many errors can occur simply because we don't speak to each other, or don't communicate with each other — or don't communicate completely or thoroughly about the most important features of the patient's care."
The moment more than one party is involved in a patient's care, it leads to handoffs.
The Society of Hospital Medicine is addressing one major issue associated with the hospitalist movement: the discharge process. It's doing that through Project BOOST (Better Outcomes for Older adults through Safe Transitions).
The program has been developed through a grant of more than $1 million from the John A. Harford Foundation. Williams is the project's principal investigator. Project BOOST uses a team approach to assess a patient's risk of readmission to the hospital, and it focuses on "risk-specific discharge planning activities," the society says.
Williams notes that the rise of the hospitalist movement has parallels with the rise in physicians who specialize in emergency medicine.
"Believe it or not, if you go back to the '70s, if you went to an emergency [department] (ED), there was no doctor there," he explains. "There was a nurse triaging [patients], and so sometimes there would be marked delays, and you would basically have to get a doctor running in based on their initial complaint.
"We quickly realized this wasn't the ideal way to do this, and you had the growth of emergency medicine," he says. "And I promise you, there were all kinds of complaints initially."
Those complaints of having a condition-specific physician or surgeon respond to a particular patient's ailment quickly gave way to an appreciation of physicians who were experts in emergency medicine — and on-site and available immediately to care for the patient, according to Williams.
"You know, I think, ideally, if you asked a patient, 'Do you want your primary care provider to take care of you in the hospital, they would say, of course I do.' But if you said to them, 'If you get sick, do you want a physician based in the hospital there taking care of you, or do you want to call your physician in their clinic, who won't be able to come see you, likely, because they are 30 to 40 minutes across town — you know, that changes the equation dramatically," Williams says.
Reference
- Hamel, MB, et al. "The Growth of Hospitalists and the Changing Face of Primary Care." NEJM, 360;11: 1141-1143.
Sources
- Lauris C. Kaldjian, MD, PhD, Director, Program in Bioethics and Humanities; Associate Professor, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IO. E-mail: [email protected]
- Mark V. Williams, MD, FACP, FHM, Professor and Chief, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago; Editor-in-Chief, Journal of Hospital Medicine. E-mail: [email protected].
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