The Rise of the Hospitalist
•Jury Still Out
•A Typical Day
•Controversial Issues
•Minding the Bottom Line
A new breed of provider, hospitalists are making waves in healthcare. You're likely to see them in your hospital, if you haven't already.
Briefly, a hospitalist is a hospital-based physician who practices internal medicine. This clinician oversees the care of other physicians' hospitalized patients, but doesn't care for private patients of his own.
Currently numbering 3,500, the number of hospitalists is expected to increase. Drs. Robert Wachter and Lee Goldman at the University of California/San Francisco (UCSF), which has one of the most well-established hospitalist programs in the country, estimate that the hospitalist workforce will eventually grow to 20,000.
Wachter and Goldman first coined the term "hospitalist" in 1996, but no one has pinpointed an exact time when hospitalists first arrived. A recent survey of 400 hospitalists indicates that many started providing inpatient services in the 1980s. The survey also indicates that:
- 50% of hospitalists are general internists (some estimate that 90% of hospitalists are internists)
- 40% are medical subspecialists (half of whom practice in pulmonary or critical care)
- most are employed by medical groups or hospitals.
Hospitalists began practicing in community hospitals; now, many large teaching hospitals include these MDs. In fact, UCSF has begun a hospital medicine residency program and a hospitalist fellowship.
"It's more than a phenomenon at this point," says Jill Howie, RN, MS, FNP, an acute-care nurse practitioner who works with hospitalists at the UCSF/Stanford Medical Center in San Francisco. "It's moving toward becoming a subspecialty."
The jury is still out on whether hospitalists will ultimately benefit patients by providing more cost-efficient, consistent, and better quality care than office-based primary care physicians. But some nurses already see benefits.
"Some problems that patients face in the hospital are better treated by a doctor who's familiar with acute problems," says Howie. "Hospitalists can provide better care [than office-based primary care physicians] because of their expertise."
Marti Lyman, RN, BA, clinical resource coordinator at the Hospital of the University of Pennsylvania (HUP; Philadelphia), agrees. Hospitalists started at HUP last July, and they see 40 to 50% of Lyman's patients.
"Without them, care can be fragmented," she explains. "You can get into situations where the attending has one idea and the resident has to call that doctor's office and find out what it is. Sometimes they have two different ideas for the patient's discharge planning. When this happens, moving the patient along to the right level of care without the hospitalist is harder. The hospitalist listens to the whole team and everyone's recommendations and moves the patient along in a more succinct way," Lyman says.
"Many primary care physicians used to go into the hospital at 6 a.m. to visit patients," Howie explains. They'd be there until 9 a.m. and then go to their office and see patients. They'd see more patients until about 3 p.m. or so, and return to the hospital in the afternoon. On top of that, they'd usually be on call every third night. This schedule made for a very long day."
Now, primary care physicians can opt to have hospitalists care for their patients. In these cases, the hospitalist assumes the role of attending physician, and the primary care provider acts as a consultant in the patient's care.
At UCSF/Stanford, Howie explains that as soon as the patient arrives in the hospital she calls the primary care provider. "We're much better at communicating this way since the hospitalists came on board."
Howie coordinates the patient's care, making sure that a social worker is called, for example, or that the patient is taught about his medications. Then, when the patient is ready for discharge, she calls the primary care physician and discusses the patient's course of care, medications, and any unresolved issues. A copy of the discharge summary goes to the primary care provider.
Coordinating care has been much easier with hospitalists on board, she says. "It's very helpful to have a member of the medical team available in the hospital. The hospitalist doesn't add another layer of communication, he provides the continuity of care to enable the patient to get through the hospital system smoothly."
From Lyman's perspective, as one who does utilization and discharge planning, hospitalists have helped a lot. "Now we have an attending physician who's visible every day whom I can talk to about utilization issues. It's fantastic because I can go right to the source," she explains.
Like most new developments in healthcare, the trend of hospitalists providing care isn't without controversy. For example, some primary care physicians worry about losing control over patient care. This issue is especially controversial now, because in some cases managed care organizations have dictated that primary care physicians must hand over care of their hospitalized patients to hospitalists.
This topic is especially hot in Florida. In a transition beginning in mid-March and finishing mid-June, Prudential HealthCare-South Florida is requiring all of its 3,000 physicians to transfer the care of their acutely ill patients to hospitalists. This mandated use of hospitalists is one of the largest in the country, according to the ACP-ASIM Observer (a publication of the American College of Physicians and American Society of Internal Medicine).
But this example isn't an isolated one. Humana Inc. has mandated a similar plan in 11 markets, and Cigna Corp. has also introduced mandatory hospitalist policies. In addition, a smattering of individual hospital systems nationwide have done the same, the article reports.
In April, 24 physician groups voiced their concern about mandatory hospitalist programs when they sent several large insurance companies and the American Association of Health Plans a letter stating that mandatory hospitalist programs were "bad public policy" and "bad for individual patients," according to the article.
Some primary care physicians are also concerned that patients, especially elderly ones, won't interact as well with a hospitalist. That's because the patients develop a close relationship with their primary care physicians and won't share all of their thoughts with an unknown caretaker.
"The downside," says Lyman, "is that the hospitalist doesn't know the patient any better than we do initially." Howie agrees: "Sometimes it's hard to explain to these patients that someone else will care for them."
But Lyman hasn't caught wind of any problems. "I haven't heard patients complain that they want to see their primary care physician when they're under the care of a hospitalist," she says.
Naturally, most hospitals don't want to ruffle the feathers of the primary care physicians associated with their facilities. At UCSF/Stanford, Howie and colleagues include the recommendations of primary care providers. And some providers still choose to visit their hospitalized patients daily. "Each primary care provider sees the role in the hospital differently," Howie says. "We try to honor their recommendations and the relationship they have with their patients."
Whether hospitalists provide less expensive or better care is still under study. In the meantime, the hospitalist movement continues to grow. And that's had a positive impact from Lyman's and Howie's viewpoint.
As long as good communication remains a mainstay of the hospitalist-led team, Howie sees a bright future. "People don't get better because of the medicines they take, and it's not because of their physician or nurse. It's the overall care they get," she says.
"People who are sick need to be taken care of by more than one person. And if a group of people who care for a patient communicate well, then the patient will get the best of care."