The Hospitalist Movement is Here to Stay
Once, when patients were hospitalized, their own doctors would follow and coordinate the care provided by whatever specialist was needed. But economics, the desire to reduce the length of hospital stays, and the unique challenges of providing hospitalized care led to the development of the "hospitalist," that is physicians who specialize in treating patients in the hospital.
I have nothing intrinsically against the concept, except that in today's health care system increasingly challenged by utilitarian pressures, I have worried that hospitalists-- being employees or contractors with the hospitals rather than specifically the patient's own physician--could come to unconsciously represent the hospital's bottom line and culture rather than the needs and values of the sickest patients. I am especially concerned about this potential paradigm in futile care theory cases in which hospitalists who want to terminate wanted care could unduly sway ethics committees. And, not being a patient's usual doctor and with no history with the patient or family, I have also been concerned that communication with families in catastrophic situations could be difficult or become hostile. On the other hand, I have seen the work of hospitalists in my local hospital and have, so far, been quite impressed.
My concerns aside, it is pretty clear that the hospitalist movement has succeeded and is moving quickly from the experimental stage to becoming the norm. This is clear from the conclusion of an article in the current New England Journal of Medicine (no link) entitled, "The Hospitalist Movement--Time to Move On," by Laurence F. McMahon, Jr., M.D., M.P.H.. He concludes:
The hospitalist movement has arrived, and it has transformed the care of hospitalized patients. Investigations similar to the early studies of hospitalist practice, which were focused on cost and comparing outcomes with those of other providers, should begin to wane. New investigations should focus on quality improvement, comparative effectiveness, clinical informatics, the safety of patients, and the translation of new medical advances to clinical practice. Academic medical centers must make strategic investments to provide opportunities in research training for hospitalist physicians and to support the research infrastructure. The academic focus and role models in the training environment will enhance the pipeline for hospitalists, but the underlying payment structure for evaluation and management needs to be dramatically enhanced if this field is to be sustained. Hospitalists are now an integral component of our delivery system; we must take advantage of these skilled physicians and take the next steps to enhance the care of hospitalized patients. It is time to move on.Like it or not, this is clearly the future of medicine.
Labels: Hospitalists
posted by Wesley J. Smith @ 10:10 AM
3 Comments
3 Comments:
On the other hand, having doctors who focus on hospital care can be useful because they're more aware of the kinds of problems specific to a hospital, like handling infections. With all the problems of, I believe it's staph infections of late, having a group of people who focus only on how to care for you in the hospital can be useful. Yes, it can be abused, but I can see potential good there.
I agree. I think it can be terrific. But I also think it can be impersonal.
It's sort of like going back to the womb for Internal Medicine and some Family Physician docs: A return to the world of the teaching hospital, with a focus on inpatients and none of the distractions.
The hospital practice for a private doc pays less and less, requires travel to and from the hospital and takes time from the office practice with phone calls and paper work - or home life, if you want to have one.
Add in running out in the middle of night to deliver babies, care for the troubled neonate or the admissions from up to 5 ER "hit lists" (getting patients you've never seen before and who don't have a primary care doctor, often because they don't have the money to pay a doctor or are completely non-compliant), the mandatory committee and staff meetings and sometimes fees that come with hospital privileges and it's no wonder so many of my FP colleagues gladly give up hospital practice.
We used to scrub in on our own patient's surgeries until Medicare decided not to pay enough to justify our taking a couple of hours away from scheduling patients. I loved walking out to the family in the waiting room with the surgeon. And I actually knew what I was talking about when describing the surgery. The surgeons all use their own Physician Assistants or RNs these days. Somehow that fee is enough and justifyanle to Medicare and insurance companies.
The hospitalist has been and will be further driven by pressure from the requirements of hospitals and insurance companies - - all of which are really run by Medicare and JHACO, anyway.
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