The hospitalist model of care -- in which a generalist physician cares for (and coordinates the care of) hospitalized patients, returning the patients to their primary physicians at the time of hospital discharge -- has become the fastest growing medical specialty in history. Early hospitalist growth was catalyzed by evidence that hospitalists markedly improved hospital efficiency and may improve quality. More recently, hospitalists have assumed key roles in academic centers (replacing housestaff whose hours have been capped), as co-managers of non-medical patients, and as leaders of systems improvement work in quality, safety, medical education, and information technology.Robert Wachter. The Hospitalist Model of Care: The Fastest Growing Specialty In Medical History [internet]. Versão 20. Knol. 2009 jul 14.
The Hospitalist Model of Care
The Fastest Growing Specialty In Medical History
Introduction
Since I coined the term “hospitalist” (along with Dr. Lee Goldman) in a 1996 New England Journal of Medicine article [1], the hospitalist field has grown from a few hundred physicians to more than 20,000, making it the fastest growing physician specialty in medical history. This post will describe the hospitalist model, provide a history of the movement, describe some of the key issues facing the field today and in the future, give patients and family members some information that may help them work effectively with hospitalists, and then answer a question that medical students, residents or practicing physicians may be grappling with: should I consider a career as a hospitalist?
Since I coined the term “hospitalist” (along with Dr. Lee Goldman) in a 1996 New England Journal of Medicine article [1], the hospitalist field has grown from a few hundred physicians to more than 20,000, making it the fastest growing physician specialty in medical history. This post will describe the hospitalist model, provide a history of the movement, describe some of the key issues facing the field today and in the future, give patients and family members some information that may help them work effectively with hospitalists, and then answer a question that medical students, residents or practicing physicians may be grappling with: should I consider a career as a hospitalist?
What is a hospitalist?
A hospitalist is a physician who specializes in the care of hospitalized patients. The field that describes the practice of hospitalists is called “Hospital Medicine.”
A hospitalist is a physician who specializes in the care of hospitalized patients. The field that describes the practice of hospitalists is called “Hospital Medicine.”
If you are healthy, you are unlikely to encounter a hospitalist, since few participate in outpatient practice. But if you were hospitalized (let’s say for heart failure, a severe infection, or a complication of diabetes) in the United States today, there is a better-than-even chance that the doctor responsible for your care in the hospital would be a hospitalist.
How are hospitalists trained?
Most hospitalists are trained in internal medicine (80%), family medicine (5%), or pediatrics (10%). A few have pursued subspecialty training in fields like infectious diseases or pulmonary disease. Internal medicine training adequately prepares hospitalists for the clinical issues they will face in hospital care: diagnosing patients, treating them with the right medicine, doing basic procedures, working with medical specialists. New training programs for hospitalists focus on areas that have traditionally not been well taught in medical school and residency, including: improving the systems of care to improve quality and safety, working effectively with other providers (such as nurses and pharmacists) and non-providers (such as hospital administrators), co-managing the care of specialized patients (such as patients admitted to the hospital for neurosurgery or hip fractures), and communication skills [2]. Moreover, most patients in the U.S. die in hospitals, so improving hospitalists’ abilities to provide high quality, compassionate end-of-life care (“palliative care”) has become a “core competency” for the field. The Society of Hospital Medicine, the professional society representing hospitalists, has published the Core Competencies of the field, which reflect this breadth [3].
Most hospitalists are trained in internal medicine (80%), family medicine (5%), or pediatrics (10%). A few have pursued subspecialty training in fields like infectious diseases or pulmonary disease. Internal medicine training adequately prepares hospitalists for the clinical issues they will face in hospital care: diagnosing patients, treating them with the right medicine, doing basic procedures, working with medical specialists. New training programs for hospitalists focus on areas that have traditionally not been well taught in medical school and residency, including: improving the systems of care to improve quality and safety, working effectively with other providers (such as nurses and pharmacists) and non-providers (such as hospital administrators), co-managing the care of specialized patients (such as patients admitted to the hospital for neurosurgery or hip fractures), and communication skills [2]. Moreover, most patients in the U.S. die in hospitals, so improving hospitalists’ abilities to provide high quality, compassionate end-of-life care (“palliative care”) has become a “core competency” for the field. The Society of Hospital Medicine, the professional society representing hospitalists, has published the Core Competencies of the field, which reflect this breadth [3].
Some future hospitalists will obtain advanced training in Hospital Medicine, such as through a Hospital Medicine fellowship offered at UCSF Hospital Medicine fellowships and a handful of other institutions [4]. During the fellowship, physicians generally hone their clinical skills, but spend most of their time improving their skills in leadership, quality improvement, patient safety, medical education, and hospital-based research.
The History of Hospital Medicine
In order to appreciate the emergence and rapid growth of hospitalists, we first must consider the organization of and reimbursement for hospital care in the United States. Hospitals began as charitable institutions, evolving out of the “almshouses” of the 19th century [5]. By the mid-20th century, these charitable roots collided with the need for a sufficient revenue stream to employ hundreds, even thousands of employees, build expensive operating rooms, buy up-to-date technologies, and market their services to patients. “No money, no mission” became a familiar refrain. Germane to the history of American hospitals is that as they grew into today’s behemoths, most hospitals employed nurses, pharmacists, respiratory therapists, administrators – but not physicians, who for the most part remained individual (or small group) entrepreneurs. Since they “brought in the business,” hospital administrators seeking patients spent considerable time and money courting community-based physicians. Another interesting aspect of American hospital care was that the system called for patients’ outpatient physicians – mostly general internists or family physicians for adults, and pediatricians for children – to serve as the physician-of-record when their patients were hospitalized. Even for procedures that would be taken care of by a specialist (such as heart surgery or childbirth), the expectation was that the patient’s “regular doctor” would be there, managing the day-to-day medical care. For hospitalizations for more purely medical problems – complications of diabetes, heart attacks, stroke, or severe infections – the patient’s outpatient doctor was in charge, calling in consultants for advice or procedures as needed. While this system seemed natural to American patients and physicians, it was distinctly unusual. In most other developed countries, general practitioners were not expected to come to the hospital; rather, a hospital-based specialist (usually a subspecialist such as a gastroenterologist or cardiologist) would assume the responsibility for hospital care, according to the nature of the patient’s main clinical problem (i.e., the patient with a complication of liver failure would be cared for by a gastroenterologist in the hospital). But in an America hospital, an armada of primary care doctors could be seen in the doctor’s lounge at 7:45 am, and most would remain on hospital rounds until mid-morning, often returning at the end of their day (after seeing patients in the office from, let’s say, 10:30am to 5pm) to follow-up on test results or consultant recommendations. This system worked reasonably well for several decades. Patients presumably liked having their regular doctor care for them in the hospital. Primary care physicians enjoyed rubbing shoulders with their colleagues (particularly important since the average American primary care doctor works in an office with only 1-3 colleagues). And since, on the average day, each doctor had 10-12 patients in the hospital, the “wasted” commute time between office and hospital was no big deal. Moreover, the pace of hospitalization was relatively leisurely; patients might stay for weeks after a heart attack, and there was no pressure to discharge patients promptly, since insurance companies (including government insurers like Medicare) paid hospitals and doctors a daily fee. Beginning in the early 1980s, everything began to change, for a variety of reasons. First, in 1983, Medicare (the government program that pays for care for the elderly) changed the way it reimbursed hospital care, moving to a system of “diagnosis-related groups” (DRGs) that paid the hospital by the diagnosis rather than per day. In other words, a hospital might now receive $8000 for a hospitalization for congestive heart failure, $15,000 for septic shock, and so on. Suddenly, hospitals came under intense pressure to shorten hospital lengths of stay and lower hospital costs, since their reimbursement was fixed. Unsurprisingly, patients who might previously have stayed for 2 weeks might now be discharged after 4 days. Interestingly, Medicare chose to disconnect physician reimbursement for hospital care from the DRG system for hospital payments. Physicians continued to be paid for each day of service, creating tension between their financial interests (keeping the patients in the hospital for extra days) and those of the hospital (discharging patients promptly). In economist lingo, the hospitals’ and physicians’ financial incentives were no longer aligned. Notwithstanding this conflict between hospital and physician incentives, the overall trend was to more rapid hospital discharges and a higher threshold for hospitalization. This trend was abetted by changes in technology and medical science. A patient who in 1970 might have been admitted for a week of diagnostic tests to “rule out cancer” could now rapidly have that workup as an outpatient by getting a CAT scan. Better antibiotics and intravenous pump systems made it possible to treat patients with infections in nursing facilities or even at home. Medical researchers began studying length of stay, and generally found that lengths of stay could be safely shaved. For example, studies demonstrated that the heart attack patient who previously might have spent a month in the hospital could be safely discharged (if he or she met certain criteria) after 3 days. The impact of these forces meant that, by the early 1990s, the average hospital census of a primary care doctor was 1-3 patients, not 8-12. The primary care doctor, rather than coming to the hospital from 7:30-10:30am, now came from 7:30-8:15am, with his first office patient scheduled at 8:30am (and others to be seen every 15 minutes until 5:30pm). The few patients remaining in the hospital were extremely ill, and pressure to expedite their discharge was intense. Meanwhile, the patients who might have been hospitalized a decade earlier had not gone away – the primary care doctor was caring for them out of her office. Slowly, without fanfare, the nature of hospital care had completely changed, and with these changes, the ability of primary care doctors to remain the physician-of-record for their hospitalized patients became far more challenging. Why? The hospital patients had many tests to follow-up on and consultants’ recommendations to coordinate but the primary care doctor was not there to do so, creating tremendous fragmentation; primary care doctors became less comfortable with clinical and organization aspects of hospital care; patients in the office now expected their physician to see them on time; and economically, the commute, a trivial inefficiency in a prior era, now loomed larger since a physician might waste an hour of the day only to see 1-2 patients. Beginning in the early 1990s, particularly in large group practices in environments in which there was significant pressure to decrease hospital costs, some practices looked at this landscape and saw the need for a new kind of physician: a generalist analog to the primary care physician, but one who would spend all the day in the hospital, managing the patients, coordinating care, and returning patients back to their primary doctor at the time of discharge. The hospitalist concept was born. Interestingly, although this story felt unique at the time, it actually followed a predictable pattern. Specialties in medicine were traditionally organized around four dimensions:
• Specialists who focused on disorders and diseases of specific organs (cardiologists, nephrologists, dermatologists)
• Specialists who focused on populations of patients (geriatricians, pediatricians)
• Specialists who focused on procedures or technologies (radiologists, interventional cardiologists)
• Specialists who focused on particularly complex disease-types (oncologists, infectious disease specialists)
This schema was augmented in the 1960s and 1970s by 2 specialties that emerged around sites of care: emergency medicine and critical care medicine. In both cases, new environments had been created, largely to pool nursing expertise and technology, without physician-specialists to man them. In emergency rooms, patients were first seen by nurses, and primary care physicians were then called from their office practices to come into the ER to see them. As Intensive Care Units emerged around technologies like mechanical ventilation, specialized nurses were hired to staff them, but again, the outpatient physicians remained the care providers. In both cases, it was ultimately recognized that there needed to be a separate group of physicians who became expert in the care delivered in these complex settings, working closely with the on-site nurses, and who were immediately available for emergencies. The specialties of emergency medicine and critical care medicine were born: “site-defined generalist specialties,” and a purposeful discontinuity was built into the system, as a different doctor – heretofore a stranger to the patient – assumed care in these settings. The emergence of hospital medicine is the next expansion of this trend for specialists, in a site of care at which the care has become increasingly complex. In this way, the hospitalist field is evolutionary, not revolutionary.
What Does it Feel Like to be Cared for by a Hospitalist?
Ideally, the primary care doctor in the outpatient setting will explain to her patients that she works with hospitalists to provide hospital care. When that communication has occured, when hospitalized the patient is not left to wonder where his primary care doctor is, and will be primed to trust this new physician and system. Whether the patient is told about the hospitalist model in advance of the hospitalization or by the hospitalist at the time of admission, it is critical that certain messages are clear:
• The hospitalist is a specialist in hospital care
• He or she can be around the ward throughout the day, a level of access that primary care doctors can’t possibly replicate
• The hospitalist and primary care doctors work as colleagues and partners, communicating at the time of admission and discharge, at the very least, to be sure that no “information is dropped” at the time of transitions
• Although the hospitalist system does require an inpatient-outpatient discontinuity, the presence of a hospitalist improves the continuity of hospital care; for example, the hospitalist can act as an orchestra conductor, coordinating the care when the patient is being evaluated by multiple hospital specialists
• The primary care doctor remains the care provider after the patient leaves the hospital
What are the Results of Hospitalist Care?
More than 20 studies have examined the results of hospitalist care [6]. Virtually all of them have shown that hospitalists decrease lengths of hospital stay and cut hospital costs, saving hospitals (when they are paid under DRGs; i.e., a fixed sum per hospitalization) billions of dollars each year. Few would support the hospitalist model if these savings came at the expense of quality of care or patient safety. They don’t. No study has shown a decrease in any measure of quality of care or an increase in medical errors, and a few studies have shown improvements in mortality rates or fewer hospital readmissions [7][8]. Other measures of quality, such as whether patients receive the right medicines for heart failure or pneumonia, have generally remained stable or improved modestly [9]. In academic center hospitals, hospitalists have become the main teachers of inpatient medicine. Several studies have studied the impact of this change, and all have found striking improvements in resident and medical student education, probably due to the hospitalists’ focus on staying abreast of the literature and their availability to trainees [10]. Although patients often have legitimate concerns about the hospitalist model – perhaps wondering why their doctor is no longer coming in to the hospital to care for them – surveys of patients cared for by hospitalists have shown high levels of satisfaction and comfort [6]. Patients appear willing to trade off the familiarity of their regular doctor for the extra availability and specialized focus offered by the hospitalist. Similarly, although early surveys of primary care doctors illustrated significant concerns about the model, later ones have found that these doctors generally believe the model improves the efficiency and even the quality of care for their patients [11]. Many primary care physicians were initially worried that they would be “kicked out of the hospital” – in the vast majority of case, hospitalist programs were made voluntary, with primary care doctors free to choose to use, or not use, hospitalists for their hospital care.
The Explosive Growth of Hospital Medicine
By all accounts, the hospitalist field is the fastest growing specialty in the history of American medicine. When I first introduced the term “hospitalist” in 1996 [1], there were probably a few hundred of these physicians in the U.S. By 2007, there were 20,000, and today there are undoubtedly several thousand more than that (Figure; Source: Society of Hospital Medicine). While in the early days of the field’s development the main challenge was establishing the specialty’s legitimacy and demonstrating its value, many programs today find that their main challenge is recruiting and retaining quality physicians – in other words, meeting an ever-increasing demand for growth.
The Evolving Roles of Hospitalists
In the early years of the hospitalist field, hospitalists mostly assumed the roles that primary care physicians previously had carried out: caring for the medical illnesses of their hospitalized patients. Over the past decade, 3 important trends have helped fuel the unprecedented growth of the field, and have augmented the ability of hospitalists to improve hospital care.
Quality and Patient Safety
Prior to the past decade, physicians generally saw their roles as individual practitioners caring for individual patients – supported by staff who carried out the “doctor’s orders.” The Institute of Medicine’s reports on patient safety in 2000 [12] and quality in 2001 [13] led to twin revolutions in American medicine – catalyzed by a new understanding that the quality and safety of American health care were highly variable and often poor. With this understanding came a recognition that improving quality and safety depended on a new style of practice: with much better teamwork, the use of checklists and other systems to standardize and build in redundancies for safety, and the implementation of information technology – in short, the doctor was no longer a virtuoso individually responsible only for his own performance, but needed to be a member and leader of a high functioning team. While many physicians bristled at the shift in roles and mindsets, the twin revolutions began at a remarkable time for hospitalists. At the time of the IOM reports, the field was just entering its period of explosive growth, but it suffered from a public relations problem: no physician wanted to be known as a specialist in getting people out of the hospital quickly and cheaply. The quality and safety movements provided an opportunity for a change in focus and a “re-branding” of the hospitalist field, as the physician specialty most focused on improving the quality and safety of hospital care [14]. It should be no surprise, perhaps, that my group at the University of California, San Francisco (UCSF) has published more than 100 articles and 3 books on quality and safety, or that we are the key teachers of this new content to our trainees, and that we now chair many of our hospital’s committees concerned with improving quality and safety. In fact, many hospitalists, at UCSF and elsewhere, have embraced this mantra: “I have two sick patients, one a person in a bed with an illness, and the other this dysfunctional organization called the hospital that I work in. My job is to make both of them better; ultimately, I can’t really do one without the other.”
Limitations on Housestaff Work Hours
Partly driven by the safety movement, in 2003 the Accreditation Council for Graduate Medical Education (ACGME, the organization that regulates the nation’s more than 100,000 trainees) limited the duty hours of residents to no more than 24 in a row or 80 in a week. Though these numbers may still seem absurdly high to laypeople, they actually represented a 10-30% decrease in duty hours in many specialties of medicine. While teaching hospitals have employed a wide range of maneuvers to provide patient care previously provided by overworked residents, the most popular replacement strategy has involved hospitalists. At UCSF Medical Center, for example, while the hospitalists’ core work remains caring for patients while working with trainees, nearly half of our patient encounters now occur without a resident.
Surgical Co-Management
As the hospitalist field matured, many began to wonder whether hospitalists should broaden their focus from just medical-type patients to include the management of surgical patients as well. By this, I don’t mean actually performing surgery. Rather, surgical care involves a complex set of activities during the pre-operative and post-operative period, some of which are more “medical” than surgical. Preoperatively, patients with chronic medical illnesses need to have their conditions “tuned” to the degree possible, and a determination sometimes is needed as to whether the patient is stable enough to tolerate surgery. Post-operatively, in addition to obvious issues like wound care and pain control, patients often need their diabetes or blood pressure managed, their infections treated, and a variety of strategies implemented to increase their probability of recovery (for example, prevention of post-operative blood clots). Just as the primary care doctor’s busy office practice meant that he or she could not be physically present to coordinate hospital care, so to does the surgeon’s busy operating room schedule. Moreover, although surgeons have superb training in the technical aspects of their trade and the pre- and postoperative surgical aspects of care, their training (and often their interests) are less focused on medical management. So once hospitalists were present in the majority of U.S. hospitals, the stage was set for hospitalists to expand their patient population to “co-management” of surgical patients. The organization of co-management services varies widely. Issues that need to be worked out between hospitalists and surgeons include who is responsible for pain control, how to manage blood thinners (which might be needed to prevent clot but could increase the risk of bleeding into the surgical site), who communicates with the patient and family regarding big picture issues, and so on. Early data on surgical co-management is generally supportive of its value but has not yet demonstrated striking improvements in quality [15]. Nevertheless, I believe these arrangements make great sense and are likely to grow rapidly during the hospitalist field’s second decade.
The Economics of Hospitalist Care
The American health care system tends to reimburse procedures quite well, but pays for diagnosing patients and coordinating their care extremely poorly. This dynamic has created shocking workforce imbalances, with trainees flocking to highly reimbursed, “lifestyle” fields like dermatology and radiology, and away from fields like primary care [16]. Reimbursement for hospital care is, like most cognitive and coordinative care, also reimbursed relatively poorly by insurance companies and government payers. In fact, in most circumstances, a hospitalist would need to manage at least 25 hospitalized patients each day in order to generate a typical internist’s salary; a patient load that would create burnout and obviate the hospitalists’ efficiency advantages (because it is hard to get a patient home promptly when you can’t get around to seeing them until late in the day). It would appear that, on purely economic grounds, the hospitalist field would be dead in the water. But recall the discussion above about the organization of hospital care and the DRG system. In an environment in which the hospital is paid a fixed sum for hospital care, it has a tremendous incentive to embrace models of care that might safely decrease its costs and length of stay. Moreover, in a new environment, in which hospital quality and safety are under tremendous scrutiny, the hospital is also intensely interested in any arrangement that would engage physicians in efforts to improve quality and safety. This set of conditions enhanced the viability of hospital medicine: in about 90% of hospitalist groups, significant support (up to 50% of salaries) comes from the hospital rather than directly from insurance companies. This hospital support is needed to create properly supported jobs for hospitalists, but it has a further advantage: it “aligns the incentives” between hospitalists and hospitals. The hospitalist who knows that he is receiving one-third of his paycheck from the hospital is likely to care about the hospital’s agenda, whether it is improving the quality of care for patients with sepsis or safely decreasing the length of stay for patients with heart failure. Of course, this is a tough way to run a specialty, and inevitable tension surfaces each year around budget time. But many hospitals have become completely dependent on their hospitalists, and most want to keep their cadre of high quality hospitalists. Since hospitalists don’t have an office practice, it is quite easy for the dissatisfied hospitalist to quit a job on Friday and be working across town on Monday. This dynamic has generally meant that hospital support has remained at reasonable levels for most hospitalist groups. Ultimately, of course, a fair reimbursement system would pay all physicians at a level commensurate with the value they bring, but it seems unlikely that we will see such a reimbursement system in the U.S. any time soon.
Is Hospital Medicine a Specialty?
At this point, the field of Hospital Medicine has most of the attributes of more traditional specialties: a distinctive group consciousness among its practitioners, a thriving professional society, a core curriculum [3], training programs (mostly at the fellowship level) [4], a journal, textbooks (here and here), and certainly large numbers of practitioners. That said, most people who come to Hospital Medicine have not received additional training beyond their medicine or pediatrics residencies. Specialty boards – particularly the American Board of Internal Medicine (ABIM) (on which I sit), have been working toward recognizing the unique focus of hospitalists and the expertise they accrue outside of a formal training program like a residency or fellowship. Although a pathway toward a hospitalist certification is still in its development stage, the ABIM has endorsed such a concept (“Recognition of Focused Practice”). If the tentative plan is approved, this would not change initial board certification (for example, in internal medicine) but rather would provide an option within the Maintenance of Certification process – in which a physician might declare that he or she is a hospitalist, demonstrate a high volume of hospital patients, engage in quality improvement activities in the hospital, and take a test that is more focused on hospital than ambulatory care [17]. Stay tuned…
The Expansion of the Hospitalist Concept to Other Specialties
Having a physician who focuses on hospital care and is available there throughout the day (and often the night) leads to a trend of good things happening; consequently, the model has spread beyond adult medicine to a variety of other specialties.
Pediatric hospitalists
Data from the Society of Hospital Medicine indicate that about 10% of U.S. hospitalists are pediatricians. Because of the need for critical mass (it is difficult to sustain a hospialist program without having at least 10-20 patients in the hospital), pediatric hospitalists are generally found in very large hospitals, particularly in Childrens’ Hospitals. The motivations, focus, and economics of a pediatric hospitalist program fairly closely mirror those in adult programs; if anything, because so few children are hospitalized, general pediatricians may be less comfortable with hospital care than general internists, and thus even more likely to embrace the model [18].
Surgical hospitalists
These are surgeons who take on the role of hospitalists; to be distinguished from the idea of surgical co-management by internist-hospitalists described earlier. Here, the idea is that – rather than a dozen surgeons on call for the emergency room every day, each also seeing patients in the office and perhaps booked in the operating room – a smaller group of surgeons agrees to do only hospital care for a finite period – perhaps a week at a time. The surgical hospitalist becomes “first call” for ER consults, permitting rapid availability that cannot be replicated by the more traditional system. The surgical hospitalist triages patients in the emergency department; when surgery is needed, he or she may perform it or refer the patient to a colleague according to the rules of engagement that are established by the organization. Early data on these programs indicate tremendous increases in responsiveness and satisfaction by emergency department staff [19]. Whether the model improves surgical outcomes is as yet unknown.
Neurohospitalists
Here, a neurologist – often a stroke specialist – assumes the hospital work, allowing other neurologists to predictably engage in their office practice (where the bulk of neurology practice is centered) [20]. Only a handful of these programs exist, and outcome data are not yet available.
Obstetrical hospitalists
The motivation for obstetrical hospitalists (often called "laborists" [21]) is a bit different, owing more to the vagaries of the malpractice system than other traditional considerations. Consider the example of an obstetrical practice of 7 physicians: a generation ago, every pregnant woman might have expected that her own obstetrician would deliver her baby. This meant that each OB was on call every night. For obvious reasons, many practices shifted to a rotating model, in which only one of the providers was on call for the entire practice each night. This rotational model remains the most common in obstetrical practice. (Interestingly, many primary care groups went through a similar stage before settling on the idea of a full-time hospitalist. I don’t consider these rotational systems “hospitalist” programs, because – although they do provide the full-time hospital availability – they lack the professional focus. Each member of the outpatient-based group is spending about the same amount of aggregate time in the hospital as before; it is just that he or she is doing it in blocks, rather than a little bit every day. On the other hand, hospitalists rapidly accrue far more hospital experience than rotating physicians.) But the malpractice premiums in obstetrics are the highest in medicine; it is not unusual for a U.S. obstetrician to pay $200,000 a year in premiums, largely owing to obstetrics work (the premiums are far lower for gynecology services). Given this, some groups have determined that it is economically advantageous for only 1 of their members to become a full-time OB hospitalist (and pay the full OB malpractice premium), while the other 6 stay in the office delivering prenatal care and practicing gynecology (paying a far lower premium). Some groups rotate this obstetrical hospitalist role each year. Again, there are no data yet on the outcomes of these models or patient satisfaction with them, but many OB patients have already become accustomed to the notion that someone other than their regular obstetrician may be delivering them. In that setting, the shift to a hospitalist model may not feel like a great change from the rotating model so common today.
Hospitalists Outside the United States
When the American hospitalist field began, I frequently heard “that’s nothing new – they’ve had a hospitalist model in England forever.” Well, yes and no. As I mentioned earlier, many other countries have long had a discontinuity from the general practitioner to the hospital physician. On the other hand, no other country has had a tradition of generalist-hospitalists, such as we now have in the U.S. Rather, systems like that of the United Kingdom and Singapore relied on hospital-based subspecialists to provide hospital care. The patient with a gastrointestinal bleed was referred to the gastroenterologist, the one with congestive heart failure to the cardiologist, and so on. The problem with these models is that patients often don’t have just a single thing wrong when they are admitted to the hospital, they have 5. The specialists, quite naturally, focus intensely on their area of expertise, sometimes at the cost of relative neglect of the other problems. Because of this, many countries are presently trying to adopt a version of the American hospitalist model. In the past 5 years, I have visited or been visited by representatives of England, Brazil, Argentina, China, and Singapore, all interested in shifting their system toward the American model.
I’m a Doctor or Medical Student: Should I Become a Hospitalist?
The hospitalist field is extraordinarily exciting, because it combines the virtues of generalism (seeing a wide variety of patients and diseases) and acuity (the pace is fast and patients are complicated and very ill). It also marries direct patient care with lots of opportunities for systems improvement work and, in hospitals with trainees, teaching. Hospitalists have a remarkable number of interactions with all sorts of people: patients and families, hospital administrators, nurses, pharmacists, quality improvement and infection control professionals, and more. And they are all over the building: on the ward, in the ICU, in the emergency department, in radiology, sometimes in the surgical recovery room. There is no job in medicine that combines all of these attributes. The physician with a generalist bent will need to determine whether all of these advantages outweigh the loss of the patient continuity that comes with an outpatient practice. Although some patients are admitted frequently and one gets to know them over time, most contacts are intense but episodic, and relationships – though often deep and profound – are not long-lasting. In this way, hospital medicine occupies an intermediate place, between the very short (minutes to hours) encounters of the Emergency Medicine physician and the longitudinal relationships (years to decades) of the primary care physician. Witnessing the breathtaking evolution and growth of the field in the past decade, it is also clear that a satisfied hospitalist will need to be comfortable with change. This is likely to be a field that continues to evolve over time – a situation that might be off-putting for some but a major attraction for others. The perfect hospitalist loves diagnostic dilemmas (think the TV doctor Geoffrey House, who has been dubbed the first TV hospitalist), prizes the gratification of caring for a very sick person and making a difference, enjoys the relationships with a wide variety of hospital staff, takes pleasure from allaying the anxiety and gaining the trust of patients and families at times of great needs, and gets great satisfaction from the fact that, even when he cannot cure, he can comfort patients and families at the end of life. For the right person, it is a terrific career path.
I’m a Patient: How Should I Interact with a Hospitalist?
First of all, don’t be surprised if your hospital physician is, in fact, a hospitalist. Having read this, you hopefully understand what a hospitalist is, how they are trained, and why they are there instead of your regular doctor. But this person is a stranger to you, and it is reasonable to have questions and concerns. Speak up. Ask the hospitalist how he or she will communicate with your regular doctor to ensure that there are no fumbled handoffs. Inquire about his or her background – where did she go to medical school and do her residency. Make a connection – ask how she likes being a hospitalist. Tell the hospitalist about any preferences you have or special needs – not just your medical history, but any unusual reactions you have to certain medicines, or that you get very anxious in tight places (like MRI scanners), or that you want the hospitalist to update your son in Philly on your condition each day. The hospitalist may ask you about your preferences for cardiopulmonary resuscitation and intensive care – this is a conversation we have with most patients, and doesn’t imply that she thinks things will go badly. Rather, our default setting is to be very aggressive (CPR, ICU care, mechanical ventilation if any of these become clinically necessary), and it is important that the hospitalist knows if your preferences would be to focus on relieving symptoms rather than extending life, if the need arose. Even if you’ve previously filled out an advance directive, I highly recommend having this conversation with your hospitalist; I try to have it with my patients early in the course of virtually every admission. Many patients have told me that they were scared when a hospitalist first approached them; it is natural to want to see the familiar face of your regular doctor at a time of high anxiety. By the second day of hospitalization, most people “get it” – they see that the hospitalist can be available to them in a way that their primary care doctor cannot be, that he or she has spoken to their regular doctor to update him on the situation, and that their care is being coordinated in a way that cannot be replicated under other organizational arrangements. At moments like these, being a hospitalist is an extremely gratifying job.
Useful Websites
Society of Hospital Medicine
The professional society representing hospitalists -- SHM does a terrific job in education, resources, research, and advocacy. All hospitalists should be members. The Society publishes a newsletter and a journal.
The UCSF Hospitalist Program
Our program is generally considered the nation's leading academic program. We are always looking for excellent academic hospitalists to join our faculty -- if interested, please contact me. Our fall CME conference ("Management of the Hospitalized Patient") is the nation's most popular university-based clinical conference in hospital medicine, drawing about 600 hospitalists every year. In 2009, it takes place September 24-26 in San Francisco, preceded by a 3-day, hands-on "Hospitalist Mini-College".
My blog, Wachter's World
I cover issues of interest to hospitalists and hospital leaders, including quality, safety, IT, medical education, and major policy developments. The blog is one of the nation's most popular healthcare blogs, with approximately 1500 unique visitors each day.
References
1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996; 335:514-7. http://content.nejm.org/cgi/content/extract/335/7/514
2. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med 2001;111:247-254. http://www.ncbi.nlm.nih.gov/pubmed/11530039?dopt=Abstract
3. McKean SC, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use the core competencies in hospital medicine: a framework for curricular development. J Hosp Med 2006; 1 Suppl:57-67. http://www.ncbi.nlm.nih.gov/pubmed/17219574
4. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med 2006; 119:72.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/16431196
5. Rosenberg CE. The care of strangers: The rise of America's hospital system. Baltimore: Hopkins University Press: 1995. http://www.amazon.com/Care-Strangers-Americas-Hospital-System/dp/0801850827/ref=pd_sim_b_title_2
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487-94. http://www.ncbi.nlm.nih.gov/pubmed/11798371
7. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med 2002; 137:859-65. http://www.ncbi.nlm.nih.gov/pubmed/12458985
8. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service; results of a trial of hospitalists. Ann Intern Med 2002; 137:866-74. http://www.ncbi.nlm.nih.gov/pubmed/12458986
9. Roytman MM, Thomas SM, Jiang CS. Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure. J Hosp Med 2008; 3:35-41. http://www.ncbi.nlm.nih.gov/pubmed/18257099
10. Hauer KE, Wachter RM, McCullouch CE, Woo GA, Auerbach AD. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med 2004; 164:1866-71. http://www.ncbi.nlm.nih.gov/pubmed/15451761
11. Auerbach AD, Aronson MD, Davis RB, Phillips RS. How physicians perceive hospitalist services after implementation: anticipation vs. reality. Arch Intern Med 2003; 163:2330-6. http://www.ncbi.nlm.nih.gov/pubmed/14581253
12. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press, 2000. http://www.nap.edu/openbook.php?isbn=0309068371
13. Committee on Healthcare in America, IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press, 2001. http://www.nap.edu/catalog.php?record_id=10027
14. Wachter RM. Reflections: The hospitalist movement a decade later. J Hosp Med 2006; 1:248-52. http://www.ncbi.nlm.nih.gov/pubmed/17219506
15. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip arthoplasty. A randomized, controlled trial. Ann Intern Med 2004; 141;28-38. http://www.annals.org/cgi/content/abstract/141/1/28
16. Bodenheimer T. Primary care -- will it survive? N Engl J Med 2006; 355:861-4. http://www.ncbi.nlm.nih.gov/pubmed/16943396
17. Wachter RM. What will board certification be -- and mean -- for hospitalists? J Hosp Med 2007; 2:102-4. http://www.ncbi.nlm.nih.gov/pubmed/17427981
18. Bellet PS, Wachter RM. The hospitalist movement and its implications for the care of hospitalized children. Pediatrics 1999; 103;473-7. http://pediatrics.aappublications.org/cgi/content/extract/103/2/473
19. Maa J, Gosnell JE, Carter JT, Wachter RM, Harris HW. The surgical hospitalist: a new solution for emergency surgical care? Bull Am Coll Surg 2007; 92;8-17. http://www.ncbi.nlm.nih.gov/pubmed/18041231
20. Josephson SA, Engstrom JW, Wachter RM. Neurohospitalists: an emerging model for inpatient neurological care. Ann Neurol 2008; 63:135-40. http://www.ncbi.nlm.nih.gov/pubmed/18306369
21. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol 2003; 188:310-2. http://www.ncbi.nlm.nih.gov/pubmed/12592231
In order to appreciate the emergence and rapid growth of hospitalists, we first must consider the organization of and reimbursement for hospital care in the United States. Hospitals began as charitable institutions, evolving out of the “almshouses” of the 19th century [5]. By the mid-20th century, these charitable roots collided with the need for a sufficient revenue stream to employ hundreds, even thousands of employees, build expensive operating rooms, buy up-to-date technologies, and market their services to patients. “No money, no mission” became a familiar refrain. Germane to the history of American hospitals is that as they grew into today’s behemoths, most hospitals employed nurses, pharmacists, respiratory therapists, administrators – but not physicians, who for the most part remained individual (or small group) entrepreneurs. Since they “brought in the business,” hospital administrators seeking patients spent considerable time and money courting community-based physicians. Another interesting aspect of American hospital care was that the system called for patients’ outpatient physicians – mostly general internists or family physicians for adults, and pediatricians for children – to serve as the physician-of-record when their patients were hospitalized. Even for procedures that would be taken care of by a specialist (such as heart surgery or childbirth), the expectation was that the patient’s “regular doctor” would be there, managing the day-to-day medical care. For hospitalizations for more purely medical problems – complications of diabetes, heart attacks, stroke, or severe infections – the patient’s outpatient doctor was in charge, calling in consultants for advice or procedures as needed. While this system seemed natural to American patients and physicians, it was distinctly unusual. In most other developed countries, general practitioners were not expected to come to the hospital; rather, a hospital-based specialist (usually a subspecialist such as a gastroenterologist or cardiologist) would assume the responsibility for hospital care, according to the nature of the patient’s main clinical problem (i.e., the patient with a complication of liver failure would be cared for by a gastroenterologist in the hospital). But in an America hospital, an armada of primary care doctors could be seen in the doctor’s lounge at 7:45 am, and most would remain on hospital rounds until mid-morning, often returning at the end of their day (after seeing patients in the office from, let’s say, 10:30am to 5pm) to follow-up on test results or consultant recommendations. This system worked reasonably well for several decades. Patients presumably liked having their regular doctor care for them in the hospital. Primary care physicians enjoyed rubbing shoulders with their colleagues (particularly important since the average American primary care doctor works in an office with only 1-3 colleagues). And since, on the average day, each doctor had 10-12 patients in the hospital, the “wasted” commute time between office and hospital was no big deal. Moreover, the pace of hospitalization was relatively leisurely; patients might stay for weeks after a heart attack, and there was no pressure to discharge patients promptly, since insurance companies (including government insurers like Medicare) paid hospitals and doctors a daily fee. Beginning in the early 1980s, everything began to change, for a variety of reasons. First, in 1983, Medicare (the government program that pays for care for the elderly) changed the way it reimbursed hospital care, moving to a system of “diagnosis-related groups” (DRGs) that paid the hospital by the diagnosis rather than per day. In other words, a hospital might now receive $8000 for a hospitalization for congestive heart failure, $15,000 for septic shock, and so on. Suddenly, hospitals came under intense pressure to shorten hospital lengths of stay and lower hospital costs, since their reimbursement was fixed. Unsurprisingly, patients who might previously have stayed for 2 weeks might now be discharged after 4 days. Interestingly, Medicare chose to disconnect physician reimbursement for hospital care from the DRG system for hospital payments. Physicians continued to be paid for each day of service, creating tension between their financial interests (keeping the patients in the hospital for extra days) and those of the hospital (discharging patients promptly). In economist lingo, the hospitals’ and physicians’ financial incentives were no longer aligned. Notwithstanding this conflict between hospital and physician incentives, the overall trend was to more rapid hospital discharges and a higher threshold for hospitalization. This trend was abetted by changes in technology and medical science. A patient who in 1970 might have been admitted for a week of diagnostic tests to “rule out cancer” could now rapidly have that workup as an outpatient by getting a CAT scan. Better antibiotics and intravenous pump systems made it possible to treat patients with infections in nursing facilities or even at home. Medical researchers began studying length of stay, and generally found that lengths of stay could be safely shaved. For example, studies demonstrated that the heart attack patient who previously might have spent a month in the hospital could be safely discharged (if he or she met certain criteria) after 3 days. The impact of these forces meant that, by the early 1990s, the average hospital census of a primary care doctor was 1-3 patients, not 8-12. The primary care doctor, rather than coming to the hospital from 7:30-10:30am, now came from 7:30-8:15am, with his first office patient scheduled at 8:30am (and others to be seen every 15 minutes until 5:30pm). The few patients remaining in the hospital were extremely ill, and pressure to expedite their discharge was intense. Meanwhile, the patients who might have been hospitalized a decade earlier had not gone away – the primary care doctor was caring for them out of her office. Slowly, without fanfare, the nature of hospital care had completely changed, and with these changes, the ability of primary care doctors to remain the physician-of-record for their hospitalized patients became far more challenging. Why? The hospital patients had many tests to follow-up on and consultants’ recommendations to coordinate but the primary care doctor was not there to do so, creating tremendous fragmentation; primary care doctors became less comfortable with clinical and organization aspects of hospital care; patients in the office now expected their physician to see them on time; and economically, the commute, a trivial inefficiency in a prior era, now loomed larger since a physician might waste an hour of the day only to see 1-2 patients. Beginning in the early 1990s, particularly in large group practices in environments in which there was significant pressure to decrease hospital costs, some practices looked at this landscape and saw the need for a new kind of physician: a generalist analog to the primary care physician, but one who would spend all the day in the hospital, managing the patients, coordinating care, and returning patients back to their primary doctor at the time of discharge. The hospitalist concept was born. Interestingly, although this story felt unique at the time, it actually followed a predictable pattern. Specialties in medicine were traditionally organized around four dimensions:
• Specialists who focused on disorders and diseases of specific organs (cardiologists, nephrologists, dermatologists)
• Specialists who focused on populations of patients (geriatricians, pediatricians)
• Specialists who focused on procedures or technologies (radiologists, interventional cardiologists)
• Specialists who focused on particularly complex disease-types (oncologists, infectious disease specialists)
This schema was augmented in the 1960s and 1970s by 2 specialties that emerged around sites of care: emergency medicine and critical care medicine. In both cases, new environments had been created, largely to pool nursing expertise and technology, without physician-specialists to man them. In emergency rooms, patients were first seen by nurses, and primary care physicians were then called from their office practices to come into the ER to see them. As Intensive Care Units emerged around technologies like mechanical ventilation, specialized nurses were hired to staff them, but again, the outpatient physicians remained the care providers. In both cases, it was ultimately recognized that there needed to be a separate group of physicians who became expert in the care delivered in these complex settings, working closely with the on-site nurses, and who were immediately available for emergencies. The specialties of emergency medicine and critical care medicine were born: “site-defined generalist specialties,” and a purposeful discontinuity was built into the system, as a different doctor – heretofore a stranger to the patient – assumed care in these settings. The emergence of hospital medicine is the next expansion of this trend for specialists, in a site of care at which the care has become increasingly complex. In this way, the hospitalist field is evolutionary, not revolutionary.
What Does it Feel Like to be Cared for by a Hospitalist?
Ideally, the primary care doctor in the outpatient setting will explain to her patients that she works with hospitalists to provide hospital care. When that communication has occured, when hospitalized the patient is not left to wonder where his primary care doctor is, and will be primed to trust this new physician and system. Whether the patient is told about the hospitalist model in advance of the hospitalization or by the hospitalist at the time of admission, it is critical that certain messages are clear:
• The hospitalist is a specialist in hospital care
• He or she can be around the ward throughout the day, a level of access that primary care doctors can’t possibly replicate
• The hospitalist and primary care doctors work as colleagues and partners, communicating at the time of admission and discharge, at the very least, to be sure that no “information is dropped” at the time of transitions
• Although the hospitalist system does require an inpatient-outpatient discontinuity, the presence of a hospitalist improves the continuity of hospital care; for example, the hospitalist can act as an orchestra conductor, coordinating the care when the patient is being evaluated by multiple hospital specialists
• The primary care doctor remains the care provider after the patient leaves the hospital
What are the Results of Hospitalist Care?
More than 20 studies have examined the results of hospitalist care [6]. Virtually all of them have shown that hospitalists decrease lengths of hospital stay and cut hospital costs, saving hospitals (when they are paid under DRGs; i.e., a fixed sum per hospitalization) billions of dollars each year. Few would support the hospitalist model if these savings came at the expense of quality of care or patient safety. They don’t. No study has shown a decrease in any measure of quality of care or an increase in medical errors, and a few studies have shown improvements in mortality rates or fewer hospital readmissions [7][8]. Other measures of quality, such as whether patients receive the right medicines for heart failure or pneumonia, have generally remained stable or improved modestly [9]. In academic center hospitals, hospitalists have become the main teachers of inpatient medicine. Several studies have studied the impact of this change, and all have found striking improvements in resident and medical student education, probably due to the hospitalists’ focus on staying abreast of the literature and their availability to trainees [10]. Although patients often have legitimate concerns about the hospitalist model – perhaps wondering why their doctor is no longer coming in to the hospital to care for them – surveys of patients cared for by hospitalists have shown high levels of satisfaction and comfort [6]. Patients appear willing to trade off the familiarity of their regular doctor for the extra availability and specialized focus offered by the hospitalist. Similarly, although early surveys of primary care doctors illustrated significant concerns about the model, later ones have found that these doctors generally believe the model improves the efficiency and even the quality of care for their patients [11]. Many primary care physicians were initially worried that they would be “kicked out of the hospital” – in the vast majority of case, hospitalist programs were made voluntary, with primary care doctors free to choose to use, or not use, hospitalists for their hospital care.
The Explosive Growth of Hospital Medicine
By all accounts, the hospitalist field is the fastest growing specialty in the history of American medicine. When I first introduced the term “hospitalist” in 1996 [1], there were probably a few hundred of these physicians in the U.S. By 2007, there were 20,000, and today there are undoubtedly several thousand more than that (Figure; Source: Society of Hospital Medicine). While in the early days of the field’s development the main challenge was establishing the specialty’s legitimacy and demonstrating its value, many programs today find that their main challenge is recruiting and retaining quality physicians – in other words, meeting an ever-increasing demand for growth.
The Evolving Roles of Hospitalists
In the early years of the hospitalist field, hospitalists mostly assumed the roles that primary care physicians previously had carried out: caring for the medical illnesses of their hospitalized patients. Over the past decade, 3 important trends have helped fuel the unprecedented growth of the field, and have augmented the ability of hospitalists to improve hospital care.
Quality and Patient Safety
Prior to the past decade, physicians generally saw their roles as individual practitioners caring for individual patients – supported by staff who carried out the “doctor’s orders.” The Institute of Medicine’s reports on patient safety in 2000 [12] and quality in 2001 [13] led to twin revolutions in American medicine – catalyzed by a new understanding that the quality and safety of American health care were highly variable and often poor. With this understanding came a recognition that improving quality and safety depended on a new style of practice: with much better teamwork, the use of checklists and other systems to standardize and build in redundancies for safety, and the implementation of information technology – in short, the doctor was no longer a virtuoso individually responsible only for his own performance, but needed to be a member and leader of a high functioning team. While many physicians bristled at the shift in roles and mindsets, the twin revolutions began at a remarkable time for hospitalists. At the time of the IOM reports, the field was just entering its period of explosive growth, but it suffered from a public relations problem: no physician wanted to be known as a specialist in getting people out of the hospital quickly and cheaply. The quality and safety movements provided an opportunity for a change in focus and a “re-branding” of the hospitalist field, as the physician specialty most focused on improving the quality and safety of hospital care [14]. It should be no surprise, perhaps, that my group at the University of California, San Francisco (UCSF) has published more than 100 articles and 3 books on quality and safety, or that we are the key teachers of this new content to our trainees, and that we now chair many of our hospital’s committees concerned with improving quality and safety. In fact, many hospitalists, at UCSF and elsewhere, have embraced this mantra: “I have two sick patients, one a person in a bed with an illness, and the other this dysfunctional organization called the hospital that I work in. My job is to make both of them better; ultimately, I can’t really do one without the other.”
Limitations on Housestaff Work Hours
Partly driven by the safety movement, in 2003 the Accreditation Council for Graduate Medical Education (ACGME, the organization that regulates the nation’s more than 100,000 trainees) limited the duty hours of residents to no more than 24 in a row or 80 in a week. Though these numbers may still seem absurdly high to laypeople, they actually represented a 10-30% decrease in duty hours in many specialties of medicine. While teaching hospitals have employed a wide range of maneuvers to provide patient care previously provided by overworked residents, the most popular replacement strategy has involved hospitalists. At UCSF Medical Center, for example, while the hospitalists’ core work remains caring for patients while working with trainees, nearly half of our patient encounters now occur without a resident.
Surgical Co-Management
As the hospitalist field matured, many began to wonder whether hospitalists should broaden their focus from just medical-type patients to include the management of surgical patients as well. By this, I don’t mean actually performing surgery. Rather, surgical care involves a complex set of activities during the pre-operative and post-operative period, some of which are more “medical” than surgical. Preoperatively, patients with chronic medical illnesses need to have their conditions “tuned” to the degree possible, and a determination sometimes is needed as to whether the patient is stable enough to tolerate surgery. Post-operatively, in addition to obvious issues like wound care and pain control, patients often need their diabetes or blood pressure managed, their infections treated, and a variety of strategies implemented to increase their probability of recovery (for example, prevention of post-operative blood clots). Just as the primary care doctor’s busy office practice meant that he or she could not be physically present to coordinate hospital care, so to does the surgeon’s busy operating room schedule. Moreover, although surgeons have superb training in the technical aspects of their trade and the pre- and postoperative surgical aspects of care, their training (and often their interests) are less focused on medical management. So once hospitalists were present in the majority of U.S. hospitals, the stage was set for hospitalists to expand their patient population to “co-management” of surgical patients. The organization of co-management services varies widely. Issues that need to be worked out between hospitalists and surgeons include who is responsible for pain control, how to manage blood thinners (which might be needed to prevent clot but could increase the risk of bleeding into the surgical site), who communicates with the patient and family regarding big picture issues, and so on. Early data on surgical co-management is generally supportive of its value but has not yet demonstrated striking improvements in quality [15]. Nevertheless, I believe these arrangements make great sense and are likely to grow rapidly during the hospitalist field’s second decade.
The Economics of Hospitalist Care
The American health care system tends to reimburse procedures quite well, but pays for diagnosing patients and coordinating their care extremely poorly. This dynamic has created shocking workforce imbalances, with trainees flocking to highly reimbursed, “lifestyle” fields like dermatology and radiology, and away from fields like primary care [16]. Reimbursement for hospital care is, like most cognitive and coordinative care, also reimbursed relatively poorly by insurance companies and government payers. In fact, in most circumstances, a hospitalist would need to manage at least 25 hospitalized patients each day in order to generate a typical internist’s salary; a patient load that would create burnout and obviate the hospitalists’ efficiency advantages (because it is hard to get a patient home promptly when you can’t get around to seeing them until late in the day). It would appear that, on purely economic grounds, the hospitalist field would be dead in the water. But recall the discussion above about the organization of hospital care and the DRG system. In an environment in which the hospital is paid a fixed sum for hospital care, it has a tremendous incentive to embrace models of care that might safely decrease its costs and length of stay. Moreover, in a new environment, in which hospital quality and safety are under tremendous scrutiny, the hospital is also intensely interested in any arrangement that would engage physicians in efforts to improve quality and safety. This set of conditions enhanced the viability of hospital medicine: in about 90% of hospitalist groups, significant support (up to 50% of salaries) comes from the hospital rather than directly from insurance companies. This hospital support is needed to create properly supported jobs for hospitalists, but it has a further advantage: it “aligns the incentives” between hospitalists and hospitals. The hospitalist who knows that he is receiving one-third of his paycheck from the hospital is likely to care about the hospital’s agenda, whether it is improving the quality of care for patients with sepsis or safely decreasing the length of stay for patients with heart failure. Of course, this is a tough way to run a specialty, and inevitable tension surfaces each year around budget time. But many hospitals have become completely dependent on their hospitalists, and most want to keep their cadre of high quality hospitalists. Since hospitalists don’t have an office practice, it is quite easy for the dissatisfied hospitalist to quit a job on Friday and be working across town on Monday. This dynamic has generally meant that hospital support has remained at reasonable levels for most hospitalist groups. Ultimately, of course, a fair reimbursement system would pay all physicians at a level commensurate with the value they bring, but it seems unlikely that we will see such a reimbursement system in the U.S. any time soon.
Is Hospital Medicine a Specialty?
At this point, the field of Hospital Medicine has most of the attributes of more traditional specialties: a distinctive group consciousness among its practitioners, a thriving professional society, a core curriculum [3], training programs (mostly at the fellowship level) [4], a journal, textbooks (here and here), and certainly large numbers of practitioners. That said, most people who come to Hospital Medicine have not received additional training beyond their medicine or pediatrics residencies. Specialty boards – particularly the American Board of Internal Medicine (ABIM) (on which I sit), have been working toward recognizing the unique focus of hospitalists and the expertise they accrue outside of a formal training program like a residency or fellowship. Although a pathway toward a hospitalist certification is still in its development stage, the ABIM has endorsed such a concept (“Recognition of Focused Practice”). If the tentative plan is approved, this would not change initial board certification (for example, in internal medicine) but rather would provide an option within the Maintenance of Certification process – in which a physician might declare that he or she is a hospitalist, demonstrate a high volume of hospital patients, engage in quality improvement activities in the hospital, and take a test that is more focused on hospital than ambulatory care [17]. Stay tuned…
The Expansion of the Hospitalist Concept to Other Specialties
Having a physician who focuses on hospital care and is available there throughout the day (and often the night) leads to a trend of good things happening; consequently, the model has spread beyond adult medicine to a variety of other specialties.
Pediatric hospitalists
Data from the Society of Hospital Medicine indicate that about 10% of U.S. hospitalists are pediatricians. Because of the need for critical mass (it is difficult to sustain a hospialist program without having at least 10-20 patients in the hospital), pediatric hospitalists are generally found in very large hospitals, particularly in Childrens’ Hospitals. The motivations, focus, and economics of a pediatric hospitalist program fairly closely mirror those in adult programs; if anything, because so few children are hospitalized, general pediatricians may be less comfortable with hospital care than general internists, and thus even more likely to embrace the model [18].
Surgical hospitalists
These are surgeons who take on the role of hospitalists; to be distinguished from the idea of surgical co-management by internist-hospitalists described earlier. Here, the idea is that – rather than a dozen surgeons on call for the emergency room every day, each also seeing patients in the office and perhaps booked in the operating room – a smaller group of surgeons agrees to do only hospital care for a finite period – perhaps a week at a time. The surgical hospitalist becomes “first call” for ER consults, permitting rapid availability that cannot be replicated by the more traditional system. The surgical hospitalist triages patients in the emergency department; when surgery is needed, he or she may perform it or refer the patient to a colleague according to the rules of engagement that are established by the organization. Early data on these programs indicate tremendous increases in responsiveness and satisfaction by emergency department staff [19]. Whether the model improves surgical outcomes is as yet unknown.
Neurohospitalists
Here, a neurologist – often a stroke specialist – assumes the hospital work, allowing other neurologists to predictably engage in their office practice (where the bulk of neurology practice is centered) [20]. Only a handful of these programs exist, and outcome data are not yet available.
Obstetrical hospitalists
The motivation for obstetrical hospitalists (often called "laborists" [21]) is a bit different, owing more to the vagaries of the malpractice system than other traditional considerations. Consider the example of an obstetrical practice of 7 physicians: a generation ago, every pregnant woman might have expected that her own obstetrician would deliver her baby. This meant that each OB was on call every night. For obvious reasons, many practices shifted to a rotating model, in which only one of the providers was on call for the entire practice each night. This rotational model remains the most common in obstetrical practice. (Interestingly, many primary care groups went through a similar stage before settling on the idea of a full-time hospitalist. I don’t consider these rotational systems “hospitalist” programs, because – although they do provide the full-time hospital availability – they lack the professional focus. Each member of the outpatient-based group is spending about the same amount of aggregate time in the hospital as before; it is just that he or she is doing it in blocks, rather than a little bit every day. On the other hand, hospitalists rapidly accrue far more hospital experience than rotating physicians.) But the malpractice premiums in obstetrics are the highest in medicine; it is not unusual for a U.S. obstetrician to pay $200,000 a year in premiums, largely owing to obstetrics work (the premiums are far lower for gynecology services). Given this, some groups have determined that it is economically advantageous for only 1 of their members to become a full-time OB hospitalist (and pay the full OB malpractice premium), while the other 6 stay in the office delivering prenatal care and practicing gynecology (paying a far lower premium). Some groups rotate this obstetrical hospitalist role each year. Again, there are no data yet on the outcomes of these models or patient satisfaction with them, but many OB patients have already become accustomed to the notion that someone other than their regular obstetrician may be delivering them. In that setting, the shift to a hospitalist model may not feel like a great change from the rotating model so common today.
Hospitalists Outside the United States
When the American hospitalist field began, I frequently heard “that’s nothing new – they’ve had a hospitalist model in England forever.” Well, yes and no. As I mentioned earlier, many other countries have long had a discontinuity from the general practitioner to the hospital physician. On the other hand, no other country has had a tradition of generalist-hospitalists, such as we now have in the U.S. Rather, systems like that of the United Kingdom and Singapore relied on hospital-based subspecialists to provide hospital care. The patient with a gastrointestinal bleed was referred to the gastroenterologist, the one with congestive heart failure to the cardiologist, and so on. The problem with these models is that patients often don’t have just a single thing wrong when they are admitted to the hospital, they have 5. The specialists, quite naturally, focus intensely on their area of expertise, sometimes at the cost of relative neglect of the other problems. Because of this, many countries are presently trying to adopt a version of the American hospitalist model. In the past 5 years, I have visited or been visited by representatives of England, Brazil, Argentina, China, and Singapore, all interested in shifting their system toward the American model.
I’m a Doctor or Medical Student: Should I Become a Hospitalist?
The hospitalist field is extraordinarily exciting, because it combines the virtues of generalism (seeing a wide variety of patients and diseases) and acuity (the pace is fast and patients are complicated and very ill). It also marries direct patient care with lots of opportunities for systems improvement work and, in hospitals with trainees, teaching. Hospitalists have a remarkable number of interactions with all sorts of people: patients and families, hospital administrators, nurses, pharmacists, quality improvement and infection control professionals, and more. And they are all over the building: on the ward, in the ICU, in the emergency department, in radiology, sometimes in the surgical recovery room. There is no job in medicine that combines all of these attributes. The physician with a generalist bent will need to determine whether all of these advantages outweigh the loss of the patient continuity that comes with an outpatient practice. Although some patients are admitted frequently and one gets to know them over time, most contacts are intense but episodic, and relationships – though often deep and profound – are not long-lasting. In this way, hospital medicine occupies an intermediate place, between the very short (minutes to hours) encounters of the Emergency Medicine physician and the longitudinal relationships (years to decades) of the primary care physician. Witnessing the breathtaking evolution and growth of the field in the past decade, it is also clear that a satisfied hospitalist will need to be comfortable with change. This is likely to be a field that continues to evolve over time – a situation that might be off-putting for some but a major attraction for others. The perfect hospitalist loves diagnostic dilemmas (think the TV doctor Geoffrey House, who has been dubbed the first TV hospitalist), prizes the gratification of caring for a very sick person and making a difference, enjoys the relationships with a wide variety of hospital staff, takes pleasure from allaying the anxiety and gaining the trust of patients and families at times of great needs, and gets great satisfaction from the fact that, even when he cannot cure, he can comfort patients and families at the end of life. For the right person, it is a terrific career path.
I’m a Patient: How Should I Interact with a Hospitalist?
First of all, don’t be surprised if your hospital physician is, in fact, a hospitalist. Having read this, you hopefully understand what a hospitalist is, how they are trained, and why they are there instead of your regular doctor. But this person is a stranger to you, and it is reasonable to have questions and concerns. Speak up. Ask the hospitalist how he or she will communicate with your regular doctor to ensure that there are no fumbled handoffs. Inquire about his or her background – where did she go to medical school and do her residency. Make a connection – ask how she likes being a hospitalist. Tell the hospitalist about any preferences you have or special needs – not just your medical history, but any unusual reactions you have to certain medicines, or that you get very anxious in tight places (like MRI scanners), or that you want the hospitalist to update your son in Philly on your condition each day. The hospitalist may ask you about your preferences for cardiopulmonary resuscitation and intensive care – this is a conversation we have with most patients, and doesn’t imply that she thinks things will go badly. Rather, our default setting is to be very aggressive (CPR, ICU care, mechanical ventilation if any of these become clinically necessary), and it is important that the hospitalist knows if your preferences would be to focus on relieving symptoms rather than extending life, if the need arose. Even if you’ve previously filled out an advance directive, I highly recommend having this conversation with your hospitalist; I try to have it with my patients early in the course of virtually every admission. Many patients have told me that they were scared when a hospitalist first approached them; it is natural to want to see the familiar face of your regular doctor at a time of high anxiety. By the second day of hospitalization, most people “get it” – they see that the hospitalist can be available to them in a way that their primary care doctor cannot be, that he or she has spoken to their regular doctor to update him on the situation, and that their care is being coordinated in a way that cannot be replicated under other organizational arrangements. At moments like these, being a hospitalist is an extremely gratifying job.
Useful Websites
Society of Hospital Medicine
The professional society representing hospitalists -- SHM does a terrific job in education, resources, research, and advocacy. All hospitalists should be members. The Society publishes a newsletter and a journal.
The UCSF Hospitalist Program
Our program is generally considered the nation's leading academic program. We are always looking for excellent academic hospitalists to join our faculty -- if interested, please contact me. Our fall CME conference ("Management of the Hospitalized Patient") is the nation's most popular university-based clinical conference in hospital medicine, drawing about 600 hospitalists every year. In 2009, it takes place September 24-26 in San Francisco, preceded by a 3-day, hands-on "Hospitalist Mini-College".
My blog, Wachter's World
I cover issues of interest to hospitalists and hospital leaders, including quality, safety, IT, medical education, and major policy developments. The blog is one of the nation's most popular healthcare blogs, with approximately 1500 unique visitors each day.
References
1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996; 335:514-7. http://content.nejm.org/cgi/content/extract/335/7/514
2. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med 2001;111:247-254. http://www.ncbi.nlm.nih.gov/pubmed/11530039?dopt=Abstract
3. McKean SC, Budnitz TL, Dressler DD, Amin AN, Pistoria MJ. How to use the core competencies in hospital medicine: a framework for curricular development. J Hosp Med 2006; 1 Suppl:57-67. http://www.ncbi.nlm.nih.gov/pubmed/17219574
4. Ranji SR, Rosenman DJ, Amin AN, Kripalani S. Hospital medicine fellowships: works in progress. Am J Med 2006; 119:72.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/16431196
5. Rosenberg CE. The care of strangers: The rise of America's hospital system. Baltimore: Hopkins University Press: 1995. http://www.amazon.com/Care-Strangers-Americas-Hospital-System/dp/0801850827/ref=pd_sim_b_title_2
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487-94. http://www.ncbi.nlm.nih.gov/pubmed/11798371
7. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med 2002; 137:859-65. http://www.ncbi.nlm.nih.gov/pubmed/12458985
8. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service; results of a trial of hospitalists. Ann Intern Med 2002; 137:866-74. http://www.ncbi.nlm.nih.gov/pubmed/12458986
9. Roytman MM, Thomas SM, Jiang CS. Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure. J Hosp Med 2008; 3:35-41. http://www.ncbi.nlm.nih.gov/pubmed/18257099
10. Hauer KE, Wachter RM, McCullouch CE, Woo GA, Auerbach AD. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med 2004; 164:1866-71. http://www.ncbi.nlm.nih.gov/pubmed/15451761
11. Auerbach AD, Aronson MD, Davis RB, Phillips RS. How physicians perceive hospitalist services after implementation: anticipation vs. reality. Arch Intern Med 2003; 163:2330-6. http://www.ncbi.nlm.nih.gov/pubmed/14581253
12. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press, 2000. http://www.nap.edu/openbook.php?isbn=0309068371
13. Committee on Healthcare in America, IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press, 2001. http://www.nap.edu/catalog.php?record_id=10027
14. Wachter RM. Reflections: The hospitalist movement a decade later. J Hosp Med 2006; 1:248-52. http://www.ncbi.nlm.nih.gov/pubmed/17219506
15. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip arthoplasty. A randomized, controlled trial. Ann Intern Med 2004; 141;28-38. http://www.annals.org/cgi/content/abstract/141/1/28
16. Bodenheimer T. Primary care -- will it survive? N Engl J Med 2006; 355:861-4. http://www.ncbi.nlm.nih.gov/pubmed/16943396
17. Wachter RM. What will board certification be -- and mean -- for hospitalists? J Hosp Med 2007; 2:102-4. http://www.ncbi.nlm.nih.gov/pubmed/17427981
18. Bellet PS, Wachter RM. The hospitalist movement and its implications for the care of hospitalized children. Pediatrics 1999; 103;473-7. http://pediatrics.aappublications.org/cgi/content/extract/103/2/473
19. Maa J, Gosnell JE, Carter JT, Wachter RM, Harris HW. The surgical hospitalist: a new solution for emergency surgical care? Bull Am Coll Surg 2007; 92;8-17. http://www.ncbi.nlm.nih.gov/pubmed/18041231
20. Josephson SA, Engstrom JW, Wachter RM. Neurohospitalists: an emerging model for inpatient neurological care. Ann Neurol 2008; 63:135-40. http://www.ncbi.nlm.nih.gov/pubmed/18306369
21. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol 2003; 188:310-2. http://www.ncbi.nlm.nih.gov/pubmed/12592231
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