I had missed this original MedPage Today column by George Lundberg back in November and so was pleased to catch it as a re-run over at Kevin, MD. George asks the question, "Are Hospitalists a Boon or a Bane, and for Whom?"
A hospitalist, you will recall, is an internist who is the surrogate for your primary care doctor when you have been admitted to the hospital. Before the hospitalist movement started in the mid-1990s-- thanks in great measure to Lee Goldman and Bob Wachter at University of California San Francisco -- your PCP would be in charge of your care at the hospital. S/he would visit early in the morning before taking office appointments and then again in the evening to check in on you. If important issues came up during the day, someone at the hospital would call the PCP to determine the course of action.
The idea of hospital medicine is that these trained doctors are there full-time to check up on you and intervene as necessary in your care. Being on staff, they would know the in's and out's of the hospital, the flows with radiology, physical therapy, laboratories, and the like. They could also explain things to you and members of your family when it was convenient for you, rather than outside of normal business hours.
George notes, however:
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).
I was really taken aback by this. Maybe my sample is biased, but the experience I have leads me to have the highest regard for hospitalists and for their role in taking care of patients and families. Far from triage persons, they have the time to get to know patients and avoid the need for more costly specialty care. I have found them to be the leaders, too, in process improvement designed to reduce harm and ensure safety. Here's an example from BIDMC, where hospitalist Melissa Mattison developed a protocol for reducing the likelihood of falls among elder patients. And here is hospitalist Julius Yang explaining the fundamentals of Lean process improvement.
Indeed, primary care doctors can no longer carry out those tasks. (The exception is concierge doctors who limit their panel of patients to just a few hundred people.) PCPs are overwhelmed by the demands of their office practices. Were they to try to visit their admitted patients, they would have little time for in-depth assessments. Also, they would find themselves left behind on the latest clinical processes in the hospitals. And they certainly would not be effective in implementing process improvement in the complex hospital environment if they could only be present for a few hours.
But let me pose the question to this audience. The comments on George's initial article and on Kevin's reprint tended to be negative about hospitalists. What has been your experience? If it has been negative, please answer this: How well do you think your PCP could have taken care of you in the absence of the hospitalists? Do you think you would have had a better experience?