Zero to 50,000 – The 20th Anniversary of the Hospitalist

Patients often ask which hospital they should go to in an emergency. I tell them they can go to whichever one they prefer, since my group no longer rounds at the hospital. Our patients are taken care of by the hospital-based doctors. Let’s discuss why this came about and how you can advocate for yourself if you require admission.

The field of ‘hospitalists’ is defined by a location, unlike all prior specialties that were defined by a body part (I am a lung specialist; others might take care of your heart, GI tract, etc), or an age group (pediatrics, adolescent medicine, geriatrics). Care in the hospital is now provided by hospitalists – a specialty that didn’t exist when I was in training. There are now 50,000 of them, more than in any other subspecialty. The entire field of internists is comprised of 109,000 docs.

Many developments in medicine and changes in insurance payments contributed to this change over the past few decades. Payments to hospitals based on ‘DRGs’, or diagnosis-related-groups, provided a lump sum for a particular diagnosis, regardless of how many days the patient stayed. Hospitals needed to figure out the most efficient way to manage patients without sacrificing quality. By employing doctors whose focus was in-patients, they could avoid the issues of private docs like myself rounding once a day, not seeing test results the same day, and perhaps allowing workups to take an extra day or two.

At the same time, elective admissions of a not-so-sick person coming in to have multiple tests done just for convenience, were vanishing. Hospitals were no longer reimbursed for those admissions, so the work-ups needed to be done on an out-patient basis. Therefore, the remaining admissions ended up being acutely ill patients needing rapid attention when they arrived, and multiple visits during each day of their stay. A doctor based in an office outside of the hospital couldn’t possibly accomplish that. Plus, poor re-imbursement to the doctors for those visits couldn’t make up for time away from office hours. Alternatively, rounding before or after office hours made for very long days.

About that time, articles were published showing that hospitalists accomplished workups in less time than private doctors. So hospitals opted to hire them. They received the same DRG payment whether the workup is accomplished in 3 days or 5 – so they should aim for 3. Then some health care organizations came on board, hiring hospitalists to provide quicker care and save them money through decreased hospital bills for shorter stays.

You may recall that about the same time, a few decades ago, medical training programs limited the number of hours a resident could work per day or per week in order to limit physician fatigue and improve patient safety. Since the number of residents wasn’t increased substantially, if resident shifts were decreased, someone else’s hours had to be increased. The answer was again to hire hospitalists.

There was a large pool of internists who, for the most part, were trained in acute in-patient settings. If you’ve been in a university hospital, you’d recognize the young people running around in SHORT white coats. We only graduate to the LONG white coats as a fellow or attending. These hospital-trained residents always have SOME out-patient training but may be more comfortable with the short-term acute care of in-patients. So here was a ready supply of labor for this new field. Doctors who are considering which sub-specialty to go into or who have moved to a new area to be with family, could work as a hospitalist for a year or two until they decide about their future practice.

The increased use of electronic health records also contributed, in that it was easier for hospitalists to prepare templates for their orders and notes compared with many private physicians struggling with each nuance of the computer systems, potentially with a different system at each hospital where they had privileges.

So, clearly there were many interrelated factors, making the field of hospitalists worthwhile on many fronts. Advancing from general hospitalists, there are now pediatric hospitalists, surgical, OB and others. In the intensive care unit, there’s a subset of “intensivists” who are critical care specialists, mostly with backgrounds in internal medicine, pulmonary or anesthesia.

Since there are now penalties to hospitals if their patients are re-admitted after a few days, the latest field is ‘post-acute care’ physicians, often funded by the hospital to take care of patients if their private physicians can’t see them within a few days of discharge. If they can help a patient avoid a re-admission for relapse of the condition by seeing them soon after hospital discharge, it’s better for the patient and for the hospital.

This all makes good business sense – private docs spend more time in their offices and less time commuting to hospitals, and hospitalists are based in the hospital all day to take care of patients. How does that translate into patient care? It can be a perfect model if it works as intended. The key is good communication.

On the down side, many patients have told me that they’ve gotten used to us taking them through every emergency that has come up, and they miss the comfort of seeing us when they are hospitalized. There are the very basic but ESSENTIAL issues many of you have posed – how will they know my history and how will YOU know what went on when I return to your care?

Here are some tips to try to avoid potential pitfalls:

—Many of my colleagues and I send summary information with you or fax it to the ER or appropriate floor. You need to let the hospitalist know to look for it. You MUST be your own advocate in this case. It is common for the information to NOT make it to the admitting physician.
—Make sure the hospitalist knows who your primary care and sub-specialists are, e.g. cardiology, neurology, etc, so if they’re needed and available they will help provide continuity for those parts of your care.
— Even if your PCP or specialists don’t have privileges at that particular hospital, the hospitalist can call them to discuss your care. This can help avoid duplication of tests that were already done as an outpatient and can improve care based on prior history.
—While in the hospital, try to keep track of the tests that have been done and at least the general results.
— Try to keep a list of tests that need to be followed up, either immediately after discharge or in 3 or 6 months. This may include test results that are still pending at the time of discharge.
—Make sure the discharge summary goes to your primary care provider (PCP). The version that goes home with the patient is rarely adequate for your physician. There’s an online system in place now, CRISP (Chesapeake Regional Information System for our Patients), whereby your doctor should be able to obtain that information, but having it sent to them makes it easier.
—Ask about any changes to your medication list before you leave the hospital, but then review it with your PCP after discharge. One source of errors is that sometimes your brand of medication is not available in the hospital, an alternative is given, and then you go home with BOTH meds on your list.
—Make an appointment to see your PCP soon after discharge and bring a TOTAL list of your meds with you. This serves to both verify that the changes are reasonable and that your PCP is up to date with what you are taking.

According to the New England Journal of Medicine, about 75% of all US hospitals, including all highly ranked academic health centers, have hospitalists. In our area, it’s difficult to find an internist who still rounds at the hospital on a regular basis. One of the aspects we all agree on is that we miss seeing each other in the lounge or in the nursing stations, and collaborating on patient care. But over time, the medical system led to the development of the hospitalist field and the field in turn influences the clinical practice of medicine. It’s a good, efficient system when we all consider ourselves part of an effective team – private docs, hospitalists and intensivists, and patients. It does take some extra effort to keep all the parts moving in sync. In the interest of having a good outcome, you need to be aware of how the system works and take an active role in optimizing communication.

Let us know your thoughts.

REFERENCE:
Wächter, R., Goldman, L Zero to 50,000 – The 20th Anniversary of the Hospitalist. NEJM 375;11, 1009-1011.