Correspondence
Growth in Care Provided by Hospitalists
N Engl J Med 2009; 360:2789-2791June 25, 2009
- Article
To the Editor:
The analysis by Kuo et al. (March 12 issue)1 quantifies the unprecedented growth in care provided by hospitalists in recent years. It appears that hospitalists will soon care for the majority of U.S. inpatients, surpassing even the ambitious predictions we made 13 years ago.2 In their editorial, Hamel et al. agree, concluding that “hospitalists are here to stay.”3
This is why I was surprised that the editorialists argue for an alternative model, the “rotating primary care physician” model.4 Although this model has the advantage of on-site presence, it suffers from a glaring liability: the primary care physician who spends 1 week in 7 on hospital rotation accrues no more overall hospital experience than the primary care physician who comes to the hospital for 40 minutes every morning. With so little hospital time, the rotating primary care physician is unlikely to achieve the efficiency or quality advantages of a true hospitalist or to match the hospitalist's commitment to improvement of hospital systems.4,5
Because of this, I believe the model of rotating primary care physicians will join the traditional model of inpatient care provided by primary care physicians in accounting for an ever-dwindling proportion of hospital care. The data reported by Kuo et al. support this prediction.
5 ReferencesRobert M. Wachter, M.D.
University of California, San Francisco, San Francisco, CA 94131
bobw@medicine.ucsf. edu 1
Kuo Y-F ,Sharma G ,Freeman JL ,Goodwin JS . Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009;360:1102-1112
Full Text | Web of Science | Medline2
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 | Medline3
Hamel MB ,Drazen JM ,Epstein AM . The growth of hospitalists and the changing face of primary care. N Engl J Med 2009;360:1141-1143
Full Text | Web of Science | Medline4
Wachter RM . An introduction to the hospitalist model. Ann Intern Med 1999;130:338-342
Web of Science | Medline5
Wachter RM ,Goldman L . The hospitalist movement 5 years later. JAMA 2002;287:487-494
CrossRef | Web of Science | Medline
To the Editor:
Kuo and associates do not adequately stress the fact that continuous contact and cooperation between the primary care physician and the hospitalist is the fundamental basis for success. Patients who are in the hospital at a time when their primary care physician is unavailable are grateful when a competent physician takes over and relieves their anxiety. To be successful, however, the hospitalist must be completely informed of the patient's condition, including details of his or her history.
It is discouraging in such situations to find the hospitalist trying to catch up by reading the patient's chart. All too often, the absence of the primary care physician leaves a gap, correctly referred to as “the weekend gap,” which cannot be filled unless the hospitalist is fully informed of the patient's condition. Personal contact is the key to success. Therefore, the hospitalist should see the patient together with the primary care physician at least once before the primary care physician's absence. Looking over the patient's chart is no substitute for personal contact.
Richard J. Bing, M.D.
Huntington Medical Research Institute, Pasadena, CA 91101Author/Editor Response
We thank Wachter and Bing for their comments. The economic viability of hospitalists depends on subsidization from hospitals.1,2 We expect that the number of hospitalists will continue to grow as long as they are perceived by hospitals as lowering costs.
Bing refers to “the weekend gap,” when a hospitalist is providing temporary coverage for patients who are followed in the hospital by their primary care physician. We examined how commonly that occurred by examining hospitalizations in 2006 of Medicare patients who had an identifiable primary care physician. Among these hospitalized patients, we identified those who were seen at least once by a hospitalist. Only 11% of the patients in this group were also billed for services by their primary care physician. While they were in the hospital, the great majority of patients received all their medical care from hospitalists or all from nonhospitalists.
However, we agree with Bing's larger point about the threats to continuity of care during hospitalization. In another report,3 we noted that continuity from outpatient to inpatient care declined steadily from the mid-1990s through 2006. By 2006, only 39.8% of hospitalized Medicare patients received care in the hospital by a physician who had provided care for them in an outpatient setting in the prior year. Efforts to test and implement processes that are intended to lessen the negative effect of such discontinuity should be a high priority.
3 ReferencesYong Fang Kuo, Ph.D.
James S. Goodwin, M.D.
University of Texas Medical Branch, Galveston, TX 77555
yokuo@utmb.edu 1
2008 SHM survey: the authoritative source on the state of hospital medicine: highlights/executive summary. Philadelphia: Society of Hospital Medicine, 2008.
2
Kralovec PD ,Miller JA ,Wellikson L ,Huddleston JM . The status of hospital medicine groups in the United States. J Hosp Med 2006;1:75-80
CrossRef | Web of Science | Medline3
Sharma G ,Fletcher KE ,Zhang D ,Kuo YF ,Freeman JL ,Goodwin JS . Continuity of outpatient and inpatient care by primary care physician for hospitalized older adults. JAMA 2009;301:1671-1680
CrossRef | Web of Science | Medline
Author/Editor Response
As Wachter points out, primary care physicians who rotate responsibility for the care of their practices' inpatients may treat fewer hospitalized patients each year than most hospitalists. Therefore, as we note in our editorial, a rotating approach requires sufficient patient volume for physicians to maintain their skills, and it is not viable for all practices. When it is feasible, we think it might offer the best of both worlds because physicians would have more knowledge about the patients and could provide better continuity and coordination of care. It is not known how much time physicians must devote to inpatient medicine to maintain their competence in providing inpatient care, but no amount of inpatient experience can compensate for lack of familiarity with patients. This is the issue in the balance.
Because of logistical challenges and preferences, a growing number of primary care physicians are choosing to refer their patients to hospitalists, and this number may continue to increase; whether this is in the patients' best interests is not known.
We share Bing's view that optimal communication among the clinicians caring for patients is crucial. Primary care physicians and hospitalists should work together to improve care coordination and communication.
Mary Beth Hamel, M.D., M.P.H.
Jeffrey M. Drazen, M.D.
Arnold M. Epstein, M.D.- Citing Articles (1)
Citing Articles
1
Mark B. Reid, Gregory J. Misky, Rebecca A. Harrison, Brad Sharpe, Andrew Auerbach, Jeffrey J. Glasheen. (2012) Mentorship, Productivity, and Promotion Among Academic Hospitalists. Journal of General Internal Medicine 27:1, 23-27
CrossRef
