My book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available! Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities
Thursday, December 4, 2008
The complexity of caring for hospitalized patients, combined with the desire of many primary care doctors to limit their practice to the ambulatory setting, has led in recent years to the development of a new specialty, the “hospitalist”. Hospitalists are usually graduates of internal medicine residencies or family medicine residencies (or for children, pediatrics residencies) who choose to limit their practice to the hospital. Their practice structure tends to follow that of emergency physicians – they are either employed directly by the hospital, or by a group which contracts with the hospital for services. This system is particularly attractive to an efficiency-and-business oriented culture (the one hospital and health systems administrators are usually trained in). The primary care doctors can work all day seeing patients in the clinic, without being distracted by hospital visits, and the hospitalized patients can be cared for by people who are specialists in this field, and of course, it would seem, provide better care. In fact, this is the way care is structured in most European countries, where the general practitioners do not admit to the hospital, and specialists (usually called “internists” since in those countries virtually all primary care is done by general/family physicians) provide the hospital care.
Interestingly, the studies that have been done of quality of care by hospitalists, comparing them to doctors-who-take-care-of-their-own-patients-in-the-hospital are quite mixed, and do not reliably demonstrate higher quality. In one recent study, by the measures of care for cardiac disease used, the hospitalists had slightly better quality than the general internists and about the same as the family physicians. By the measure most dear to the heart of hospital administrators, costs follow the same pattern – none. Hospitalists are not reliably more or less cost-effective. And of course there are great differences in hospitalists and hospitalist groups – studies done of a cohort of hospitalists who have been doing that work for 10 years may not be valid when applied to a recent internal medicine residency graduate who is taking a year off before doing a cardiology or gastroenterology fellowship.
But there are other concerns. For the patient. The hospitalist is by definition not the primary care doctor, who has known you for a long time (and will be the one caring for you after discharge!). S/he meets you only in the hospital, and doesn’t really know what you were like “before”. S/he can see if you are getting better, but really doesn’t have the perspective that your primary doctor does who knew you before the episode that led you to be hospitalized. And, of course, hospitalists work shifts and “blocks”, so if you are going to be admitted to the care of the hospitalists, it works best if you can arrange to be admitted on Monday and discharged before Friday, so you will probably have (vacations aside, and nights aside – we are now finding hospitals hiring nocturnists!!) only one hospitalist. Should you, however, choose to come in Thursday and stay past the weekend, you will probably have several hospitalists doing your care even over the short stay. Besides the nocturnists! And none of them knew you before, and each of them has to learn you anew, and probably sees things just a little bit differently than the one who “had” you before.
About a year ago my sister, in California, had an abdominal problem eventually requiring surgery and had the non-surgical care provided by hospitalists (unfortunately, her problem had the bad judgment to require admission late in the week). After the surgery, she had some serious non-surgical complications, which we won’t get into here. The (newest) hospitalist indicated one day that she was a lot “better”. Perhaps, said my other sister who had flown in to be with her, she is better than yesterday, but this is no where near normal for her! The poor hospitalist, who had only met her the day before, had no basis for determining what was “normal” for her. Her “regular” doctor would have, but her regular doctor was not caring for her in the hospital. Lucky she had family there.
I think, in general, people are ok with seeing their doctor’s partner or a nurse-practitioner who works with them when they are coming to the office for a sore throat or blood pressure check and their doctor is not available. But it precisely when you are in the hospital, when you are sick and vulnerable and scared, that it is important that you see someone who knows you, who knows how you were last week and last month and will be responsible for caring for you when you leave. That may not be the surgeon who operates on your cancer, or the oncologist who prescribes the chemotherapy or the radiation oncologist who prescribes the radiotherapy, or the nephrologist who manages the kidney failure you got from the treatments – but it is the doctor who cares for you, as a person. Who recognizes you as a person, and is there to interpret all the confusing things that are happening.
Familiarity, caring, continuity of care, are wonderful things for you when you are sick, even if they seems to be costly or inefficient to those counting the beans.
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The primary sources for hospitalists are primary care physicians, nurse practitioners, and physician assistants. The rapid increase from less than 3000 to more than 40,000 comes at a critical point in time with insufficient and declining primary care capacity. There is little or no benefit and indeed some potential for harm in areas such as primary care capacity. As little as a 10% increase in salary along with better support is enough to convert NPs and PAs to specialty or hospital careers. Few seem to understand risk versus benefit over an entire nation. Also hospitalists depend upon an intact primary care capacity to follow up patients, one that no longer exists.
Robert C. Bowman, M.D.
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