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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