When your care involves a hospitalist

Published: December, 2006

Hospital stays can be full of surprises. One might be the doctor who shows up in place of your personal physician.

When Lydia Markham (not her real name) was admitted to the hospital one night with chest pains, she expected her primary care doctor to come by in the morning. Instead, she got a visit from a hospitalist — a physician who manages your care in the hospital, then transfers responsibility back to your personal physician when the hospital stay is over. Though surprised, Lydia was not upset because the hospitalist was attentive and assured her that he was in close contact with her doctor. Her chest pains turned out to be nothing serious, and she was out of the hospital within 24 hours. But had she been critically ill or facing a longer stay, Lydia says she's not sure how she would have felt about having her care turned over to someone she didn't know.

Who are hospitalists?

The term "hospitalist" was introduced in 1996 to describe "a new breed of physicians" that provide care only in the hospital setting (New England Journal of Medicine, Aug. 16, 1996). Though relatively new as a full-time specialty, the hospitalist concept is a variation on certain established practices, such as the rotation system, in which one member of a group practice supervises all of its hospitalized patients while his or her partners remain in the office. Hospitalists also share features with emergency room (ER) doctors, who see patients only during their ER "shifts" and are in charge of patients' care only while they're in the ER.

Hospitalists have completed medical school and postgraduate training in internal medicine, family practice, or pediatrics. A hospitalist may work directly for a hospital or as part of a managed care organization, multi-specialty practice, or hospitalist or other group. About half the hospitals in the United States employ hospitalists.

Hospitalism is the fastest growing medical specialty in the United States. According to a survey by the Society of Hospital Medicine, the number of hospitalists has grown from about 800 in the mid-1990s to more than 15,000 in 2006. Demand for this specialty was initially fueled by managed care efforts to bolster efficiency, cut costs, and improve care. Today, patients admitted to the hospital tend to be more severely ill. (Certain conditions that once required hospitalization are now handled on an outpatient basis; also, more older people are in the hospital with chronic age-related illnesses.) Hospital-based doctors can better attend to such patients, respond to their problems, and navigate hospitals' increasingly complex systems.

Some clinicians worry that this arrangement disrupts the physician-patient relationship just when a patient needs it most. But the concept sits well with other primary care doctors and internists, who find that they can use their time more efficiently, focusing on patients in the office, when they have fewer patients to visit in the hospital. Anyway, in today's fast-paced, highly specialized hospital environment, the physician-patient relationship regularly expands to include a range of other professionals. One point of consensus is that close communication between hospitalist and primary care doctor is crucial. (For more about this, see "A doctor talks about: Working with a hospitalist.")

A doctor talks about: Working with a hospitalist

Celeste Robb-Nicholson, M.D.

Some HWHW readers have asked whether having a hospitalist direct their hospital treatment, rather than their internist or primary care physician, could compromise their health. Like most very good questions, this one doesn't have a simple correct answer.

A hospitalist may be the best person to make decisions about your hospital care because he or she is there — physically in the hospital — and concentrating mainly on inpatient treatment. The hospitalist can see patients several times a day and respond more quickly to test results or to a patient's changing condition than an internist who works in an office across town. That can result in more efficient decision making about your hospital care.

Some internists prefer to leave inpatient care to hospitalists because, with a crowded outpatient schedule, they find it challenging to effectively manage the rapid pace of hospital care without being there. Others feel that hospitalists have better inpatient skills and instincts because of their familiarity with hospitals. In such cases, the internist may feel that a hospitalist will enhance the patient's care.

On the other hand, many patients and doctors believe that the doctor who best understands a patient's unique health situation should make decisions about hospital care. A hospitalist who doesn't know the patient's full medical history, emotional state, or personal preferences might order more or less aggressive tests or interventions than the patient's personal physician would recommend. And most patients feel frightened and vulnerable while they're in the hospital. At such times, receiving care from a physician who knows you well can be especially reassuring. It also reduces the likelihood of a gap in communication between hospital physicians and the internist who will continue your outpatient care.

There's no single right or wrong approach. But if you feel it's important for your internist to follow you during a hospitalization, it might be worth finding one who will. Of course, you would need to make the switch well before a hospitalization, so that your new clinician can get to know you and your health history.

A hospitalist is likely to provide up-to-date and efficient treatment, but ensuring communication and continuity of care takes extra effort — by everyone. You can do some of the legwork yourself. Keep your internist's contact information with you, so you or your hospitalist can call with updates during your hospital stay. You (or a close friend or family member) can keep track of events during your hospitalization, recording major procedures, such as cardiac catheterization or liver biopsy; surgeries; complications, such as a stay in an intensive care unit or an episode of delirium; and medication reactions (not just allergies, but also medications you couldn't tolerate). At discharge, get a list of all of your medications, and, if available, a discharge summary to give to your internist. Touch base with your internist's office after a hospital stay to update your list of medications, especially those that have changed, and to ask for a follow-up appointment.

What if I'm assigned a hospitalist?

If you know you'll be going to the hospital, ask your primary care physician if she or he will be in charge or a hospitalist. Your physician might think it's better for you to have a hospitalist, for several reasons: She may find it difficult to visit if her office is far from the hospital or she has a full in-office schedule; the hospital or your health plan might encourage the use of hospitalists; or your doctor may want to focus on office-based patient care.

Your physician will share your records and other information so the hospitalist will know your medical history, health condition, and preferences. Once you're admitted, the hospitalist will examine you, coordinate all your tests and treatments, and visit you daily. He or she should be available throughout your stay to address your questions and concerns. When you're discharged, the hospitalist is responsible for prescribing the medicines you'll need to take when you leave the hospital and sending a summary of your hospital records and treatments to your primary care doctor. Your care then shifts back to your primary care doctor.

How do they measure up?

In the mid-1990s, proponents predicted that the use of hospitalists would reduce the length of hospitalizations and lower medical costs without compromising quality of care or causing patient dissatisfaction. Preliminary research suggests they may be largely right. But most of these studies have focused on single hospitals or small groups of hospitalists. And most were conducted early in the hospitalist movement, so their findings may not apply today.

Reviews in the Journal of the American Medical Association (Jan. 23/30, 2002) and Health Care Manager (July–September 2004) found that in hospitals with hospitalist care, costs fell by an average of 13% and the length of stays by an average of 17%. Most of the studies didn't address patient satisfaction, but the few that did found no difference. The impact on quality of care was not easy to determine, because different studies used very different measures. Some relied on readmission rates, others on mortality rates or use of outside consultants. There's no evidence so far that quality of care has suffered, but larger-scale and longer-term studies are needed to weigh the impact on patient care and the patient-doctor relationship.

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