Is there truth to the unintended consequences of hospitalists?

When I first learned that the U.S. was going to develop a new specialty, the hospitalist, I was very pleased.

I had long believed from study and direct observation that some of the better healthcare systems in Europe were benefited in a major way by the general separation of office and hospital medical practices and practitioners.

In the U.S., historically most patients have been taken care of by physicians practicing medicine in solo or small group practices. These same physicians usually had admitting privileges at one or more hospitals to which they admitted their patients and cared for them in the hospital while also practicing in their offices.

It was a way of life, a social construct.

The U.S. hospitalist concept was popularized after 1996 by Lee Goldman and Bob Wachter at University of California San Francisco, and took off on a quick growth slope in a market that seemed primed for separation dominance.

Add in new constraints on working hours for residents who often bore the brunt of inhouse patient care in many hospitals and the growth slope steepened to large numbers.

But how about the law of unintended consequences? Are there real downsides for patients, nonhospitalist physicians, safety, and cost control?

I hear many anecdotes of problems such as:

1. Handoffs of patients from the community physicians to the hospitalist and back being fraught with communication gaps and flaws with increasing likelihood of resulting medical errors.

2. Hospitalists having to do the “hospital’s bidding,” usurping physician autonomy and judgment to the corporate advantage of the hospital.

3. Hospitalists refusing (or being unable) to provide competent and comprehensive care to patients under their responsibility.

4. Hospitalists serving as little more than triage persons, routing every little symptom or finding to this or that specialist (headache to neurologist; tummy ache to general surgeon; heartburn to gastroenterologist; cough to pulmonologist; chest twinge to cardiologist; anxiety to psychiatrist; skin blemish to dermatologist).

Of course, the specialist likes the referral and may often run with it to his or her own special procedure, imaging, lab tests, maybe stress tests and interventional cardiology. All being billed for, no matter what the reason for admission. And all more protected from the omnipresent spectre of the looming lawyer.

Is there any truth to these stories? Are these alleged problems isolated or widespread? Or, on balance, are patients, physicians, and society truly benefited by this new animal, the hospitalist? Tell us what you have seen and heard.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    A regular community doctor still pan-consults, its not just a hospitalist thing. There will never be a perfect system, but i think once electronic records becomes perfected (maybe 2030?) and the transfer of med records becomes instantenous then there will better communications between the inpatient and outpatient docs. the fact is that now as a PMD, i get to see more patients, spend more time with them and still go home at a reasonable time. A good hospitalist program provides instantaneous access that just can’t happen in the old system

  • Anonymous

    Surge in hospitalists:   Caused by reduced fee for service … increasing office clinic workload to make ends meet … coupled with having to drive across town to see patients in the hospital for no revenue return.  Resultant gap in integrated pt care is a result of fee for service. 

  • http://www.facebook.com/rfdbbb Robert Bowman

    Real consequences include

    About 22,000 internists, 1500 pediatricians, and 1500 family physicians converted to hospitalist workforce (according to one hospitalist association) for substantial losses of primary care workforce and specific losses of primary care for the elderly at the worst time possible – 2010 to 2030 when the elderly are doubling – a population that needs 2 to 3 times more primary care. NP and PA hospitalists are also noted on the rise. In a related matter the US has lost tens of thousands of primary care NPs and PAs to teaching hospitals to cover residency work hours restrictions – along with numerous hospitalists as well. Disruption in innovation is when new designs actually make matters worse in a critical area such as primary care.

    Hospitalist care results in substantial responsibility dumped on those outside of the hospital. The US design rewards hospital, academic, and subspecialty at much higher levels and services outside of the hospital least. This has resulted in fewer professionals and less support for those delivering care outside of the hospital. Most overwhelmed in this situation – the 270,000 primary care nurses who have more and more complexity with less support. Hospitalist designs could not have targeted a problem area in a worse way. This most numerous primary care workforce has been neglected by workforce, nursing, research, and other experts and represents the key to improved health access. Hospitalist issues and increasing fragmentation is likely to drive more away.

    Primary care physicians outside of the hospital are forced by insurance to accept responsibility for patients who are not yet stabilized, including the 4 major causes of adverse hospital situations in the elderly. Patients not yet stabilized on anticoagulants, insulin, or diabetes medications are dumped outside and there is less and less an outside such as primary care that can receive them.

    Hospitalists or any specialist with poor understanding of patients and populations will error in trying too much, trying to force patients to fit guidelines, and other areas that result in too much done on the wrong patients. Benefit to risk is not just about disease and treatment. Benefit to risk where the parameters are tight is mostly about the patient and patient factors. Any of the interventions currently working to decrease readmission have substantial elements that aid in understanding the home situation.

    SMART Basic Health Access

  • http://www.zdoggmd.com ZDoggMD

    Yo, as a hospitalist at both an academic center and a community hospital, I say:
    1. Handoffs, when done thoughtfully and in conjunction with a well-functioning EMR, can be done in a safe and beneficial fashion. It’s a process issue rather than a fundamental flaw in the hospitalist model.
    2. Who in medicine these days ISN’T under pressure to serve The Man? We all have to fight to maintain our autonomy and integrity, regardless of specialty.
    3. Hospitalists refusing to provide care to certain patients? Please, teach me how to pull that one off and my life will get easier instantly! If only…
    4. Hospitalist as consulting machine IS a phenomenon at some community institutions; I think that is partly a function of having a ridiculously high census which is unmanageable without having more eyes on each patient. Solution: lower numbers of patients per hospitalist. Good luck with that one!

    In the end, we’re living the Hard Doc’s Life: http://zdoggmd.com/2011/02/hard-docs-life-hospitalist-anthem/

  • EM Prentiss

    I’d like to comment from the patient perspective! Being
    admitted means I’ve failed! Succeeding means keeping my asthma in control so no
    one put me back on roids which will screw up my diabetes & my life! Being obsessively
    compliant means by the time my PCP walks me downstairs from her office to the
    ED, I haven’t slept in days, my peak flow is in the toilet, etc. In brief, I’m
    a basket case overwhelmed at being admitted again. On paper, I probably look like
    a totally non-compliant patient cycling in and out of the hospital several
    times a year when I’m anything but.

     

    My physicians know me and trust me but the hospitalist
    doesn’t. I use an insulin pump and end up explaining it to the staff (a live
    in-service). Believe me, the most OCD staffer could not manage my diabetes or
    pump as carefully as I do. I’ve encountered some incredible hospitalists and
    some who were just awful! On my most recent hospitalization, the admitting hospitalist
    and I agreed to an insulin dosing plan. But it fell apart when the next
    physician changed everything. On enough roids to light a house, my BG was above
    what my meter would record (600). The hospitalist offered 10u of lispo and 20
    units of Lantus when I would have taken considerably more. On a previous
    hospitalization I requested a endo consult because my insulin management was so
    bad.

     

    Controlling my BG level consumes me, allowing me to ignore
    the reality that I cannot control my asthma. Intellectually, I understand
    practice models etc and that I’m not being punished or rejected for failing
    (being admitted) but at some level that what it feels like.

  • Anonymous

    My experience so far from the perspective of a referring physician … very disappointing.  Main issues:
      *  High physician turnover among the hospitalists
      *  Highly variable quality among the hospitalists
      *  Obvious handoff problems from one hospitalist shift to the next
      *  Consulted specialist may be only thread of care continuity through an inpatient stay.  (I recall a consulted renal doc acting de facto as the attending physician in one particular, very complicated case.  Thank goodness!!  He was the best doc on the case.  In monitoring the patient’s inpatient progress, we wound up ignoring the hospitalists.)

    Also, as a person living in this community, I worry about my own fate should I require services.  My own internal medicine doc now only does outpatient work.  I understand that, and would want that myself (I work in an institutional setting.)  So I wonder … what has happened to his inpatient care skill set?  And, I’m disappointed that I won’t be able to have him as my inpatient doc.

    In fact, given a choice, our family will seek inpatient services elsewhere.  If we can’t be seen by our own community doc anyway, then we might as well use a hospital with a better reputation.

  • Anonymous

    One of my concerns, as both a nurse and a family member, was that the hospitalist doesn’t really know the patient, the way the primary care physician does. How well everyone fares really depends on good communication between hospitalist and primary care provider. 

  • Anonymous

    One of my biggest issues as a home health nurse is that the hospitalists change all of the patients medicatons around- most of the time NOT to the benifit of the patient- we help them sort out the new meds and try to get them not to take their old familiar meds- most end up seeing their MD to go back on the previous meds, mean while racking up huge bills for the “new and improved meds” they were on- some times the patients get worse as they are taking the old and the new meds until we convince them this is a bad idea…I know they are doing their best but sometimes the new meds are not better just more expensive!

  • Anonymous

    A formerly responsible hospital in my city went to hospitalists, and the results were terrible.  The hospitalists were either fresh out of med school without sufficient experience for seriously ill patients, or were middle aged people who (from what I saw) couldn’t make it either financially or medically in private practice.  They were under great pressure to refer to specialists “:in the network” regardless of a patient’s former relationships with other specialists.  One had obviously not read my friend’s chart when he took credit for a treatment which she had refused.  All were quick to assign “psychological” treatments when the tests they ordered missed: colon cancer, and highly ulcerated bowel disease.  This hospital also sent a bill they thought I owed them to a collection agency when I had paid the bill in full 3 months earlier.  This hospital has obviously heard of these problems because it is now in the midst of a big advertising campaign about how many awards they’ve won.  Interesting! 

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