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.