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Hospitalists: A New Medical Specialty

Have you ever wondered why some primary care physicians don’t provide your care when you are admitted to the hospital? A new specialty has developed that allows for your care within the hospital setting to which you may not be aware. These specialists are called Hospitalists.

WHAT IS A HOSPITALIST?

The term “hospitalist” first appeared in 1996 in an article in the New England Journal of Medicine. A hospitalist is a doctor that cares for hospitalized patients when their Primary Care Physician (PCP) no longer admits patients to the hospital. The hospitalist practices only within the boundaries of the hospital and when that patient is discharged, they will go back to their PCP for their medical care. The term PCP generally refers to General Practitioners, Family Physicians, Internists, and Pediatricians. More and more PCP’s in America are focusing on their ambulatory (office) practice and no longer round on their patients when they are hospitalized. This might seem counter-intuitive at first glance when you, the patient asks: why isn’t my doctor – who knows the most about me – not going to treat me when I need him/her most? This is a perfectly logical question but the answer is not so simple. Let’s explore the factors that led to this very rapidly growing new specialty that currently boasts 20,000 physicians.

The soaring cost of medical care and the national burden posed by an aging population have forced many changes in our approach to medical care in America. Physicians, particularly PCP’s, have seen their salaries decline significantly over the past ten years while administrative costs and burdens have bludgeoned. The results of these changes are that many PCP’s simply can no longer afford the time nor cost of spending a few hours in the hospital every day. For many, allowing hospitalists to care for their in-patients is the only way to survive these challenging times. Another factor is the high cost of hospitalized care which can, to varying degrees, be reduced when hospitalists are introduced.

WHO ARE HOSPITALISTS?

The preponderance of hospitalists is physicians with a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree. Roughly 70% of practicing hospitalists are trained in general internal medicine and another 10% are family medicine specialists. Internal Medicine subspecialists, mostly pulmonologists or intensive care specialists, make up another 4%. Pediatricians account for about 8% of hospitalists.

Finally, a small percentage is non-physician providers, usually physician assistants (P.A.’s) or nurse practitioners (N.P.’s). Residencies are starting to develop hospitalist tracks with a more customized education approach slanted toward inpatient care. At this time, however, most hospitalists are not specifically trained for this role – they simply limit their practice to the in-patient setting.

DO HOSPITALISTS ADD VALUE? ARE THEY A GOOD THING OR A BAD THING?

As in most things in life, this depends upon your perspective. Let’s look at so-called “quality of care” and the costs associated with hospitalized care. One recent study by the Society of Hospital Medicine (SHM – online at www.hospitalmedicine.org) looked at outcomes for 284 hospitalists. It revealed that patients cared for by hospitalists, rather than their personal PCP, resulted in a modestly shorter hospital stay by about 1/3 of a day and slightly lower cost for that stay as well. Most other parameters studied such as readmission rates and complications during the stay were the same for both groups. These relatively minimal savings do add up, however, and both hospitals and insurance companies can save millions of dollars annually when hospitalists are employed.

Hospitalists tend to free up office-based PCP’s by serving on various hospital committees that these PCP’s just don’t have the time to do. Also, some argue, medical students and residents benefit from hospitalists who are not rushing to get back to their office to accommodate a packed waiting room of patients.

Finally, there is the issue of the quality of care versus the patient’s desire to see their personal physician while hospitalized. This one is not measured so easily. Proponents of hospitalists argue that they treat in-patients 100% of their time, and they spend much more time at the hospital, rendering them the more skilled practitioner for hospitalized patients. PCP opponents of hospitalists say that their unique knowledge of the patient and often the family provides them an advantage that results in better care for the patient. This debate is further addressed in the “Future of Hospitalists” section below. All PCP’s agree that if hospitalists are used, it is important that they keep in contact with the PCP during the hospital stay to ensure proper communication.

WHO DOES THE HOSPITALIST WORK FOR?

There are quite a few models for hospitalist practices. They include hospitalist groups employed directly by hospitals and others owned by managed care organizations or HMO’s. Remember that as stated earlier, both hospitals and insurance companies benefit from at least some cost

savings when hospitalists are employed. According to the American Hospital Association (AHA), larger hospitals and HMO’s are more likely to hire hospitalists than smaller ones. Currently, one half of all US hospitals have hospitalists on staff and 70% of larger ones do, according to Ken Terry writing for Medical Economics, a hugely popular magazine for doctors. He goes on to state that one third of all hospitalists are now employed by a hospital. Even when hospitals do not fully employ them, they subsidize their salaries. Sometimes, larger PCP groups will hire their own full time hospitalists, although this trend is on the decline.

These arrangements are diverse and each has its advantages and disadvantages with no clearly ideal model. Around the nation, regional variations in the use of hospitalists are the rule. In Minnesota, most hospitalists work for large multispecialty groups; in Florida they tend to be independent; and in Virginia they barely exist at all. Here in Michigan more and more hospitals are hiring them; at Beaumont nearly one half of the PCP’s have hospitalists care for their patients when they are hospitalized. This national disparity shouldn’t be surprising since the entire field of hospitalists is only ten years old and still in the fits of growing pains.

THE FUTURE OF HOSPITALISTS

A recent article in the March 2008 edition of Medical Economics covered the current state of hospitalists in America. The debate rages on amongst PCP’s as to whether the net benefits from hospitalists outstrip the net detriments. Family doctor Omar Khan doesn’t understand why so many PCP’s are willing to surrender inpatient care. Internist Mark Tucci of Fox Lake, IL, agrees. “I suspect that I’d earn more if I didn’t see patients in the hospital, and instead just devoted the time to seeing patient in the offices,” he told Medical Economics.

On the other side is Jeffrey K. Pearson, a family physician in San Marco, CA. He says “I love hospital work, but I got to the point where I just didn’t have time… I was just getting beaten down.” Another family doctor and proponent of hospitalists is Joel Dickerman of Cascade, CO related a similar story in this recent article. Although many PCP’s believe that delegating their inpatient care to hospitalists will cause their clinical skills to deteriorate, the inevitability of their growth due to economic factors will likely win out.

WHAT DO YOU, THE PATIENT, NEED TO KNOW ABOUT HOSPITALISTS?

For now, perhaps the most important factor isn’t so much whether your doctor admits you to the hospital or his / her hospitalist does but rather how well your doctors are communicating with each other. I serve on the Primary Care Council at the William Beaumont hospitals and this issue of proper, timely, and coordinated communication between all the treating doctors is a top priority of ours.

As a patient, I advise you to ask your doctor whether or not he / she will be the one to admit you should you require hospital care-and if the answer is a hospitalist will, inquire about their communication protocols.

Marc Weisman, DO, FAAFP is a board certified family and geriatric medicine (AMA) staff physician at Royal Oak and Troy Beaumont hospitals. He received his undergraduate degree in Microbiology and Public Health B.S. at Michigan State University. He earned his Doctor of Osteopathic Medicine degree at the University of Osteopathic Medicine and Health Sciences. He completed his residency and post-residency training at William Beaumont Hospital. He is in private practice in Madison Heights, MI.