• The Hospitalist and How They Have Improved/Worsened (pick one) Medical Care

    The Hospitalist and How They Have Improved/Worsened (pick one) Medical Care

    By Dr. Kenneth Rothaus

    What is a hospitalist?  Basically, the hospitalist is a physician who practices exclusively in a hospital, in-patient setting. Although this specialty is a relatively young one of 20-25 years, hospitalists now represent one of the largest specialties of internal medicine numbering in excess of 50,000 physicians.  What created the need for this specialty, and what led to such a rapid growth?

    During the last quarter of a century, economic factors have driven much care that formerly was practiced in the hospital to an outpatient setting.  At the same time, advancements in medicine allowed more critically ill patients to be treated and survive, thus filling these empty hospital beds.  Treatment of these more acutely ill patients required more visits than the traditional morning and evening rounds by the attending physician.  In addition, insurance- and government-driven reimbursement and outcome-based regulations forced hospitals to focus on length of stay, complications, hospital mortality and readmissions.  Concurrently, the availability of much of the low cost, hospital-based, physician labor force (e.g., interns and residents) traditionally used by hospitals to care for the critically ill patient was reduced as laws were passed to limit the work hours of this group.

    Thus, a specialty of hospital-based, acute care, inpatient physicians was not only born but has thrived.  As two articles in this week’s New England Journal of Medicine document, the hospitalist has its cheerleaders and its naysayers. The former point to an improvement in the quality of care, hospital systems, and implementation of bedside procedures and innovative patient and family centered models of care.

    The critics on the other hand point out that studies of improvement in hospital-based care do not look at the long-term effect on the health and longevity of those discharged under this system.  They decry the loss of the continuity of the physician-patient relationship. As the hospitalists are given primary responsibility for admitted patients, fewer community based physicians make hospital rounds or even keep their hospital privileges. The patients, thus, lose the continuity of care with the physicians who know them best.

    Another risk of the rise of the hospitalist based in-patient care according to this article, is that it also eliminates the cross-fertilization of care and ideas between the outpatient and in-patient setting.  The hospitalist specialty predominantly grows its ranks from physicians directly out of their residency.  These doctors have had little to no experience with outpatient or traditional practice based medicine.  Combining that with the decline in hospital visits by the patient’s community based generalist and specialist radically alters the traditional teaching models and continuity of care between the hospital and community based care of the patient.

    The supporters and critics of the hospitalist model each have valid points.  Critically ill patients require and deserve frequent, experienced physician attention during their hospitalizations. The continuity of care provided in the community by their primary care physicians or internist is also paramount.  Clearly, a better blending of both of these models is required.

    Have you eperienced care by a hospitalist? What was your experience like? We look forward to your comments in the box below.

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