Correspondence
The Role of “Hospitalists” in the Health Care System
N Engl J Med 1997; 336:444-446February 6, 1997
- Article
To the Editor:
In their Sounding Board article on the emerging role of “hospitalists” in the American health care system (Aug. 15 issue),1 Drs. Wachter and Goldman express their view that developing a hospitalist specialty to care for inpatients is desirable and inevitable. I do not agree that separating patients from the doctor who knows them best, at perhaps the patient's moment of greatest need, is desirable. Nor is it clear that such separations save money. Often hospital-based physicians keep patients hospitalized longer and order more aggressive interventions than primary care physicians caring for patients with comparable conditions and outcomes, just as patients seen in emergency departments are often kept longer for more aggressive testing and treatment than comparable patients treated in a doctor's office. The reasons are similar: physicians are (rightly) more uncomfortable with unfamiliar patients and families and cannot rely on knowing their history and their ability to make follow-up visits. This is particularly true in my specialty, pediatrics.
I agree, however, that the rise of a hospitalist specialty is inevitable. The reason: because of the lack of comprehensive health insurance, too many patients have no primary physician. For years, in many hospitals, these patients have received inpatient care from rotating panels of physicians in the appropriate specialties. However, there is no advantage to that arrangement over one using hospital-based physicians, in either cost or quality of care. As long as the American health care system continues to insist that health care is a privilege, not a right, this need will continue to exist.
1 ReferencesDavid Epstein, M.D.
Pediatric Associates, Newark, DE 197021
Wachter RM ,Goldman L . The emerging role of “hospitalists“ in the American health care system. N Engl J Med 1996;335:514-517
Full Text | Web of Science | Medline
To the Editor:
I have practiced primary care medicine in a traditional rural setting since 1979. In addition to a busy outpatient schedule, I have full privileges in the hospital that include the nursery for newborns, pediatric and adult medical admissions, the intensive care unit and coronary care unit, and an occasional surgical consultation. My hospital provides a broad range of medical and surgical services and has recently hired a team of medical hospitalists.
Therefore, I have given considerable thought to the issues raised by Drs. Wachter and Goldman. Should I abandon my full-service practice and give way to the newer notion of restricting myself to outpatient care while the hospitalists handle admissions? Many of my colleagues are about to join the forces of modernization by dropping their hospital duties. They say that the change will make their lives easier and may enhance their incomes.
Nonetheless, I plan to stay the course, providing both outpatient and inpatient care to patients ranging from newborns to senior citizens. Does this plan make sense? I think so, for several reasons. If I were to simply camp out at the office, I would be unable to learn from other doctors and nurses at the hospital. An office setting would isolate me from my colleagues, and my work would become quite boring. I would lose the ability to understand the personalities and abilities of the various specialists.
My patients like to know that I am bringing information I have gathered about them as outpatients to the more intensive setting of the hospital. There, they are often worried and not themselves. Their families are confused and unfamiliar with the many intensivists and surgeons they encounter. And when untoward events occur, families are more likely to litigate against physicians whom they have just met, and have met under unfavorable circumstances. When the familiar family doctor carries out his or her inpatient duties, however, many of these difficulties are less pronounced. Finally, I am confident that I can provide the most cost-effective, comprehensive, and enjoyable care to patients in my office after discharging them from my hospital service.
Sanford Guttler, M.D.
1 Trade St., Granite Falls, NC 28630To the Editor:
The essay by Wachter and Goldman adds credence to my theory that patients are regarded as objects. Under the system they propose, patients who have been seeing their own physicians for years would be cared for by strangers. Patients ill enough to be in the hospital are those who need their regular physicians the most. This is especially true if the patients have incurable diseases, in the context of which the usual buzzwords of “efficiency” and “outcomes” have little meaning. It is sad, but the most important part of medicine, the relationship between the doctor and the patient, is being forgotten. It is especially sad that physicians are beginning to think like M.B.A.s.
William F. Nakashima, M.D.
414 G St., Marysville, CA 95901To the Editor:
I worked for 20 years in an urban teaching hospital in Canada where hospitalists reigned. The conditions Wachter and Goldman describe were very evident — discontinuity of care, increased costs, and dissatisfaction among patients. In 1991, we converted a 30-bed ward to one where family physicians admitted and attended their own patients in a teaching unit staffed with trainees in family medicine. A recent hospital-accreditation survey confirmed that our patients' lengths of stay were shorter than the national average, that continuity of care had improved because of the doctors' knowledge of patients, families, and community resources, and that patients were very satisfied. From my experience, beware of the hospitalists.
Warren Rubenstein, M.D.
Mount Sinai Hospital, Toronto, ON M5G 1X5, CanadaTo the Editor:
Drs. Wachter and Goldman correctly identify many of the forces promoting change in the care of hospitalized medical patients. We would identify one additional factor: severity of illness. Patients admitted to hospital medical services are much sicker than was once the case. They no longer “lie in” while awaiting diagnostic tests or adjustments to medication, or while convalescing. Such patients are now either sent home with close follow-up as outpatients or transferred to rehabilitation or skilled-nursing facilities. Today's more typical hospitalized patient is likely to require intense monitoring and intervention for an acute or critical illness, an illness that often requires rapid and skilled response.
These changes will make it even more challenging to provide efficient, high-quality inpatient care for patients throughout the hospital. We agree that this role is best filled by hospitalists. However, a physician of this type would best be trained as an internist and an intensivist — a physician with knowledge and skill in general medicine and critical care. Such skills would make the physician more valuable not only as the “primary care provider” for medical inpatients, but also as a consultant to surgical colleagues. The successful hospitalist would be competent at all levels of in-hospital care, thereby reducing both the fragmentation that can occur as patients move in and out of intensive care units and the need for subspecialty consultants.
M. Iain Smith, M.D.
Paul Bellamy, M.D.
Jan Tillisch, M.D.
UCLA School of Medicine, Los Angeles, CA 90095Author/Editor Response
The authors reply:
To the Editor: Our description of the emerging role of hospitalists is based not on an assertion that the hospital model is the only way to provide in-hospital care, but rather on irrefutable evidence that both teaching and nonteaching hospitals are adopting the model. Instead of denying the potential attractiveness of this option, we suggest that as many physicians consider changing to the new approach, dialogue should focus on preserving what is valuable in the current system.
In the hospitalist model, internists who spend most or all of their time in the hospital provide inpatient care, accepting patients who are “handed off” by primary care providers and returned to the providers' care at discharge. Drs. Epstein, Guttler, Nakashima, and Rubenstein remind us that the potential benefits of this model (greater expertise with inpatient care, greater availability of both inpatient and outpatient physicians, and improved efficiency) must be weighed against two potentially detrimental effects: patients' dissatisfaction at not seeing their primary care provider at the hospital, and a “voltage drop” in information at the hospital threshold. We believe that high-quality providers and systems will develop protocols based on contact by telephone, e-mail, and fax to guarantee continuity of care at admission, during hospitalization, and at discharge. Moreover, there is no reason that primary care providers could (or should) not make periodic phone calls or “social visits” to their hospitalized patients, both to maintain contact and to facilitate communication with hospitalists. Such visits take a fraction of the time that would be required to serve as the physician of record to a severely ill hospitalized patient.
Dr. Smith and colleagues would have intensivists serve as hospitalists, caring for patients both inside and outside the intensive care unit. The ideal hospitalist will be skilled in providing high-quality, satisfying care to patients in all hospital settings, while deftly and efficiently integrating inpatient and outpatient care. Although in some settings it may indeed be intensivists who possess these skills, in most cases we believe this role will be filled by nonintensivist internists who will work closely with consultants in the intensive care unit while their patients are critically ill.
We do not believe the debate about hospitalists is served by anecdotal claims about greater satisfaction among patients and providers. Real data are required, and we are the first to acknowledge that different models suit different settings. We recommend that the shape of our health care system be guided by measuring clinical outcomes, costs, and satisfaction rather than by following passion or tradition.
Robert M. Wachter, M.D.
Lee Goldman, M.D.
University of California, San Francisco, San Francisco, CA 94143-0120- Citing Articles (2)
