OP-ED

The Rise of the Hospitalists

Good for Healthcare?

Sarah Jones was an anomaly in contemporary healthcare.  Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years.  Over this time, patient and physician had gotten to know each other well and had developed a fine relationship.  Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding.

When the dreaded day came that she finally needed inpatient care, however, her hopes were dashed.  Her physician explained to her that he no longer sees hospitalized patients.  Instead she would be under the care of a team of physicians known as hospitalists.  When she arrived, the hospitalist on duty introduced herself and told her that she would be the physician responsible for her care, while colleagues would be responsible during off hours.  Unlike her regular physician, who would have been on hand only once or perhaps twice per day, the hospitalists would always be in house and ready to address her needs.

Mrs. Jones was surprised and disappointed to discover that her primary physician would not be involved in her hospital care.  She had always assumed that she would be able to rely on their longstanding relationship for counsel and support.  She imagined that if she were facing some really important decision, such as whether or not to proceed with a risky operation or how to manage her own end-of-life care, it would make a huge difference to know that she could count on a physician she knew well.  Instead her hospital-based physician was a complete stranger.

Mrs. Jones’ experience is far from unique.  In the past 15 years or so, medicine has seen the birth of hospitalists, a new breed of physicians who care only for hospitalized patients.  There are now over 30,000 hospitalists in the US.  From a patient’s point of view, such physicians offer a number of advantages.  In many hospitals, a specialist in hospital medicine is always on duty, day or night.  Moreover, because such physicians work only in the hospital, they are often more familiar with the hospital’s standard procedures, information systems, and personnel.

It is not difficult to see why hospital medicine might be so attractive to young physicians.  For one thing, it provides them with a high degree of control over their working hours.  They come on and off shift at regular times, and do not bear patient care responsibilities outside these hours.  In addition, they are usually employed by the hospital, which means that they do not need to attend to a host of practice management issues that self-employed physicians confront.  They can also focus on acute-care, in-hospital medicine, avoiding the challenges associated with long-term care of chronic-disease patients.

Some non-hospitalist physicians also find the rise of hospital medicine attractive. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue.  They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges.  And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.


Hospital medicine also offers benefits to hospitals themselves.  Because hospitalists are generally hospital employees, it makes them easier to manage.  They get their paycheck from the hospital, so they tend to be more responsive to the initiatives of hospital leaders and easier to integrate with other members of the hospital’s staff, such as nursing.  In addition, the hospital has more control over the financial dimensions of this type of medical practice and can take steps to ensure that little or no potential revenue is lost because of the decisions physicians make.

For example, as healthcare moves toward a model in which hospitals are compensated not for the care they actually deliver but for patient populations for which they are responsible, the incentives shift toward delivering less care over shorter periods of time.  This makes it advantageous to hospitals if physicians only admit patients who truly need it, and then take whatever steps possible to reduce lengths of hospital stays and total costs generated by each patient’s care.  When physicians practice only in the hospital that employs them, such objectives become easier to achieve.

There are good reasons to think that hospitalists are here to stay.  They reflect the convergence of a number of powerful forces in healthcare today, including physicians’ desire for a more regular and comfortable lifestyle, the trend toward increasing specialization in medicine, the growing complexity of medical systems, and the goal of hospitals and healthcare organizations to acquire more control over physician practice patterns.  However, the rise of hospital medicine also entails some drawbacks, particularly from the point of view of patients such as Mrs. Jones.

Good for Patients?

Hospitalists are playing an increasing role in healthcare, but their rise is not universally embraced.  I have known a number of physicians who, while admitting that they do not miss traveling back and forth to the hospital, also speak wistfully of the days when they cared for their patients in hospital as well as out.  They sometimes worry that hospitalists cannot know their patients as well as they do, and they miss the days when they felt that they were delivering truly comprehensive care.  As one physician put it, “When I told a new patient that I would be their doctor, I really meant it, even if they had to go into the hospital.”

Another problem with hospital medicine is the large discontinuities in care it inevitably introduces.  Many patients admitted to the hospital are meeting their physician for the first time, meaning that strangers are caring for strangers.  This is not uncommon in contemporary medicine – just think of what usually happens when a patient goes to the emergency department.  However, it decreases the degree of familiarity between patient and physician at the same time that it increases the probability of miscommunication between multiple physicians, none of whom knows the patient as well.

Some think that new information technology systems can overcome such discontinuities.  Because a state-of-the-art computerized medical record is immediately available to everyone involved in the patient’s care, physicians, nurses, and other health professionals can understand the patient better than ever before.  However, information contained in an electronic record and true knowledge of the patient are not necessarily the same thing, and every time an unfamiliar person is added to the team, the possibility arises that important knowledge will not be conveyed and grasped.

Another pitfall of the hospitalist is the focus on short-term care.  When someone is admitted to the hospital with an acute medical condition, such as a heart attack or stroke, there are definite advantages to being cared for by an acute-care physician.  However, excellent care for many patients requires a physician who is focused on follow-up and long-term care, and who understands the patient’s life outside of the hospital.  If patients are going to thrive over the long term, they need physicians who see beyond the boundaries of the hospital stay.

A related drawback concerns trust.  Even if no important medical information were ever lost or overlooked, good medicine still requires a relationship between patient and physician.  It relies not just on biomedical knowledge, technical skills, and error-free information transmission, but on human relationships that take time and effort to build.  Patients whose physicians have known them for years are likely to feel a greater degree of trust than those who are being cared for by strangers they have never met before.

There is a problem with defining physicians by the contexts in which they practice instead of the kind of care they give.  From the patient’s point of view, where the physician happens to be based is generally much less important than the quality of their relationship with the physician.  Life-changing and even life-and-death decisions may need to be made during the course of a hospitalization, and both knowing their physician and knowing that their physician knows them makes a big difference.

The rise of hospitalists is symptomatic of larger and not always salutary changes taking place in healthcare today.  We are focusing more and more on systems – procedural systems, information systems, and financial systems – and less and less on the relationships that need to be the core of good medical care.  We make decisions based on criteria such as efficiency and cost, while neglecting the human side of the equation.  To an increasing degree, many of us no longer have someone we can call our doctor – a single physician we have known for years who will coordinate our care through the years to come.

In the first half of the 20th century, a new pediatric disease was identified.  Some infants cared for in hospital failed to grow and develop normally, despite adequate feeding.  Many eventually grew sick and died.  This disorder was more common in well-off institutions than poor ones.  What was the problem?  It turned out that these infants were not being picked up and cuddled, a practice more common in poor hospitals that could not afford fancy incubators.  Human beings need human contact in order to survive and thrive.  Now called failure to thrive, this condition was originally known as hospitalism.

Today healthcare is at risk for hospitalism.  Some of us have forgotten that medicine is less an economic or technical endeavor than a human one, in which relationships between human beings make a big difference – sometimes all the difference.  As it turns out, there is as yet little evidence that hospitalists, whatever their effects on healthcare’s revenue streams, actually provide better patient care than primary care physicians.  From the point of view of Mrs. Jones and many other patients, there are good reasons to think that they may never be able to.

Richard Gunderman, MD, PhD, is Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy at Indiana University; he was a past president of the faculty at Indiana University School of Medicine and currently serves as Vice Chair of Radiology. Gunderman is also the 2013 Spinoza professor at the University of Amsterdam, the author of over 380 scholarly articles and has published eight books, including Achieving Excellence in Medical Education, We Make a Life by What We Give,  Leadership in Healthcare and most recently, X-Ray Vision.

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Teresab;onnie arnold hayneswilliam reichertJoeline WebberSara Weedman Recent comment authors
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Teresa
Guest
Teresa

Joellen, Bonnie, and Dr. faltkof, As a patient recovering from my first hospital visit through the ER of the only hospital in Asheville, I can testify to the truth of what you shared here. I am wordering if the absence of a Primary as an overseer, and the lack of accountability that entails, the use of a hospitalist is an excuse for the hospitalist and other staff from nurses to phlebotomists , to mistreat and verbally abuse, physically and emotionally mistreat patients.You’ have a hard time convincing me I’m wrong on that! I was admitted for chest pain of the… Read more »

Sara Weedman
Guest
Sara Weedman

I think the costs of a hospitalist program are highly underestimated. The long term relationship of a physician and patient is not just based on trust but also information. The simple elimination of duplication of services and tests is one way,and the elimination of some of the ‘defensive medicine’ that protects against lawsuits are some low hanging fruit in reigning in avoidable costs. The argument that hospital costs are a small part of overall healthcare I feel is invalid as such a large percent of person’s healthcare is spent in the last 6-12 months of life. My experience is that… Read more »

Joeline Webber
Guest
Joeline Webber

Cost saving at what price? A few months ago I had the misfortune to need an AAA repair. Had a truly excellent Vascular Surgeon, but had a slightly more complex repair than expected. In the ICU I learned that I was now in the hands of a doctor I did NOT know, had never met, and most certainly did not trust. My instincts were, unfortunately, correct. The hospitalist was asked to divide a 2 mL dose of dilaudid in half and administer that dosage every 2 hours instead of the total every 4 hours. So, he did… to his mind…… Read more »

william reichert
Guest
william reichert

It is not the hospitalist’s fault that your surgeon abandoned you after surgery..
He could have remained in charge but obviously chose not to do so.

Charles Beauchamp MD, PhD
Guest
Charles Beauchamp MD, PhD

Has The Rise of the Ambulists started yet?

Charles Beauchamp MD, PhD
Guest
Charles Beauchamp MD, PhD

Excellent discussion. Here is my proposed solution to the above, given my situation as an Ambulist who practices in a rural town in a house that is three blocks from an excellent community hospital staffed by excellent hospitalists: “Follow” my patients using the capabilities of Family Health Network: http://www.familyhealthnetwork.com It is now tablet based and thus mobile. It unites the patient with: care givers, family members, care professionals (internists such as myself, specialists, hospitalists….etc), pharmacists, the public internet, medication management, self-care advice….etc It is currently being implemented in the Advanced Care Clinic at UNC-Chapel Hill. I intend to write a… Read more »

Bob Coli, MD
Guest

Thanks Dr. Gunderman for a fair and well balanced overview of the pros and cons of the hospitalist industry segment which I believe has doubled in size from about 15,000 practitioners over the last ten years. Fifteen years ago, some physicians in private, office-based practice in Rhode Island were concerned that not continuing to follow their own patients during an acute care admission might trigger patient abandonment charges by the Board of Medical Review and Licensure. It’s interesting that now even Level 3 Rhode Island PCMHs and ACOs are using hospitalists. Hopefully, with the deployment of secure and fully interoperable… Read more »

Skap
Guest

The author makes a valid point assigning extraordinary value to the physician-patient relationship in making critical decisions e.g. end-of-life decisions. However, as previous comments have suggested, not all hospital care depends on that relationship but instead on specialized, short-term, high impact care e.g. trauma after a motor vehicle accident or cholecystectomy for right upper quadrant pain. The solution is not reverting back to old days when PCPs took care of inpatients and outpatients. Instead, we need better transfer of care between the hospital setting and the primary care clinic. Moreover, PCPs can still have an impact on their patient’s care,… Read more »

Gabor Kaye
Guest
Gabor Kaye

One point that needs to be added is the increasing number of hospitalists at the expense of a decrease in the outpatient primary care workforce.

Many experienced FPs and Internists leave their office practices for “hospitalist'” opportunities. Why?
Because they pay a lot more,come with superior benefits and don’t involve the burdensome aspects dealing with insurance etc.

One can foresee the emergence of “mid level” practitioners offering the majority of outpatient primary care.

Adam Singer MD
Guest
Adam Singer MD

So many good points. I would like to take on the issue of the absent relationship. The idea that “a stranger is taking care of a stranger”. Before I had the honor of leading the largest Hospitalist group in the country and practicing as a Hospitalist years before the word had been coined and quite frankly at a time that many patients actually did suffer from “Hospitalism” (Bob’s definition of languishing in a hospital), I was a practicing Pulmonary Critical care Physician. The attraction of primary care is indeed the long term relationship but also mostly comes with impact achieved… Read more »

alan t falkoff, md, faafp
Guest

The claim that hospitalists improve care merely based on their presence is incorrect at worst and native at best. Hospitalists exist in so many hospitals for one reason and one reason alone. They make large sums of money for the hospitals they work for.

Davis Liu, MD
Guest

“We are focusing more and more on systems – procedural systems, information systems, and financial systems – and less and less on the relationships that need to be the core of good medical care. We make decisions based on criteria such as efficiency and cost, while neglecting the human side of the equation.” Why the false dichotomy? Medical care and has gotten more complex. We can save lives today that in the past were futile with better treatments and medications. Evolving from a doctor who knows it all to team-based care and specialization whether emergency medicine (decades ago) to hospital… Read more »

Curly Harrison, MD
Guest
Curly Harrison, MD

In my impression, “Hospitalist” is the name applied to folks who take care of hospitals.

I have yet to have a patient come to me who was managed by a hospitalist who did not have at least 2 unnecessary imaging studies and 2 untreated deficiencies in labs or exam findings (sic).

The “Hospitalist” is a euphemism for care and the EHR is a provocative error causer for these “stranger” doctors who never get to know the patients.

And there goes Wachter again, exaggerating the available information to make his case.

Peter Watson
Guest

Much good discussion. Our primary focus should always be the patient. Hospitalists don’t care for hospitals, they care for (and about) patients. This is our calling, it is what we are trained to do. Bob is correct, in every field there are “good” and “bad” physicians. Our hospitalist community has to be driven to expect the best. The best part of my day is taking care of a complex patient and making sure that his or her condition can be treated effectively as an outpatient. I cannot tell you how many of my outpatient colleagues are very happy to have… Read more »

Joeline Webber
Guest
Joeline Webber

AMEN! to this “In my impression, “Hospitalist” is the name applied to folks who take care of hospitals.” with an addition.. This should read “*Hospitalist is the name applied to folks who take care of hospitals, and their own pocketbooks.” I spent today trying to get a medical reason for a hospitalist to keep my elderly landlady in the hospital an extra day postop for having a wrist pinned. No one, I mean no one in that hospital was able to explain why she needed to be there for a second night. Her blood pressure had stablilized, her pain meds… Read more »

william reichert
Guest
william reichert

If the surgeon thought the patient should go home straight from the OR,
he should have and could have done so himself. He was too lazy to do so himself and so transferred the patient to the hospitalist. You are picking on the wrong guy.

Bob Wachter
Guest

Thanks to Dr. Gunderman for a mostly fair-minded piece that captures some of the benefits of the hospitalist model and some of the concerns. While I appreciated the post, the last two paragraphs on “hospitalism” represent an unfair appeal to emotions and a misstatement of the history of the word. The term “hospitalism” was used in the 19th century to describe the dismal state of patients who were confined to dirty, unsafe hospitals (largely in the UK). In fact, Webster’s defines the term thusly: “A vitiated condition of the body, due to long confinement in a hospital, or the morbid… Read more »

GlassHospital
Guest

Welby would BE a hospitalist. But maybe his loans weren’t so onerous.

b;onnie arnold haynes
Guest
b;onnie arnold haynes

i am a patient who has gone through more deaths in the past 10 years than i want to count. I am also a Patient Advocate. I do not see a difference between the hospitalist system and socialized medicine, as practiced in England and Ireland, countries in which i spent my childhood summers and much of my adulthood.. My experiences with socialized medicine were far better than hospitalists…. i have seen three ‘hospitalist’ run hospitals nearly kill my loved ones….now i no longer go to a doctor who is associated with a hospital that uses that system… hospitalists might be… Read more »

GingerR
Guest
GingerR

I’ve had HMO coverage my entire adult life and have little expectation that anybody I know will be around when I’m hospitalized. If I’m lucky they’ll be able to log into my medical records. At the least I have a sense that whoever is caring for me knows the system I’ll be released back to, and the few times I’ve been hospitalized/released I get a call from the Internist about my follow-up. Several of my parent’s peers, folks who always had fee-for-service, lived in a small town and received care under the “I have a doctor and he knows who… Read more »

Glenda RN
Guest
Glenda RN

My husband was recently hospitalized with a GI bleed from an esophageal tear post food poisoning and repeated vomiting. We saw 2 ER physicians (the shift changed) with a wait of 10 hours for admission before they were convinced he was bleeding. We then met our first hospitalist, who did not introduce himself by name, but stated “I won’t be here tomorrow morning” (it was then 2 am), I’m only admitting you.” And ordering a full diet, without knowing the cause of the bleeding. The next day we met another hospitalist, who was non-committal as to the cause of the… Read more »

m13
Guest

As with everything in medicine (and in life), there are tradeoffs. The points raises here are excellent and accurate. It speaks to hospitalist medicine, but also to the broader context in which medicine is practiced today. Checklists, electronic records, procedures and guidelines, health systems, shift, etc are now guiding care in ways that didn’t exist a few years ago. The problem isn’t that the new ways are bad or that the old ways are good (or vice versa). The issue is that dogma and being locked in a specific paradigm and thinking prevents us from acknowledging weaknesses and benefits of… Read more »