In a “Viewpoint”
article in JAMA, April 25, 2012, John
Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists:
analyzing an emerging phenomenon”.[1]
They describe the progression of the hospitalist model – doctors who just care
for patients in the hospital, rather than seeing them also in the office from
general medical care to specialty care. They note that in recent years hospitals
have hired physicians in a variety of specialties, including neurology,
orthopedics, obstetrics/gynecology and others, to take care of patients,
particularly at night or in emergency situations, so that other doctors to not
have to come in to do so.
An argument in favor
of this arrangement is that these physicians are present for urgent events
(e.g., the neurology stroke specialist who is there right away to care for a
person who comes to the emergency room with an acute stroke) and that they may
have specialized knowledge that a more “general specialist” doesn’t. In a
useful “box”, the authors summarize the criteria that might be applied to
deciding if a specialty hospitalist is a good idea. These include the number of
inpatients who might require their services, the urgency of the need for those
services (is it a matter of minutes that may save a life?), whether the other
specialists are so tied up in the operating room or office that they could not
respond promptly, and if there so much “sub-specialization” that many doctors
in that specialty would not be capable of addressing the needs that arise in
the hospital.
I have previously
written about “generalist” hospitalists, (Hospitalists,
Dec 4, 2008) and expressed my concerns about this movement from the point of
view of the patient. The advantage for hospitals and health systems that employ
physicians is obvious – they can have some doctors that work in the ambulatory
setting, and some that work in the hospital, and each can be most “productive”
in that setting and not have to leave to go to the other, decreasing
efficiency. In theory, at least, the
hospitalists are very good at
managing the problems of people in the hospital, so quality may improve. And, to
be sure, doctors often like it also – it makes their
lives easier, or more controllable – they are only responsible for outpatient
medicine, and don’t have to travel to the hospital to see their patients, or if
they are hospitalists, don’t have to go to the office. While not one of those
listed by Nelson et al. as a benefit of having hospitalists, this advantage for
doctors is real.They can work set shifts, like many of the most popular
specialties such as emergency medicine and anesthesiology and intensive care –
and then be off.
This, of course, leaves the patients. While hospitalized
patients certainly want to be cared for by a physician or physicians who are
skilled in addressing the problems that they have, it is also often a very
scary time, and a good time to have the involvement of someone who knows you, who knew what you were like
before you got so ill that you had to be hospitalized. Your primary care
doctor, if you are lucky enough to have one. The technical skills of the
hospitalist may be fine, but they do not know what you were like before, and
will not be involved in your care after, your hospitalization. Plus the same
attractions that lead to hospitalists in the first place now have led to a
sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily
even have the same hospitalist making decisions about your care, even during
the day, for the duration of your stay.
In addition, the skill sets of hospitalists vary. Dr.
Wachter is one of the founders of the hospitalist movement and heads a
long-standing hospitalist service at the University of California San Francisco
(UCSF). His 1996 article, The
emerging role of "hospitalists"
in the American health care system,[2]
written with Lee Goldman, is one of the seminal articles in the field. But the
results that are achieved by teams of experienced career hospitalist groups
such as his, in terms of both quality and cost, may well not be replicated by hospitalists
who are just out of their residency training and spending a year working in
this role prior to subspecialty fellowships in cardiology or gastroenterology.
Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction
with hospitalist care is equal to that provided by primary care doctors,[3]
but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now
not seeing them from those who do not.
That said, I do not have a problem with most specialty
hospitalists. Specialists are not generalists, unlike primary care providers, we
don’t think that every person should have one of each. The person who comes in
to the Emergency Department with an acute stroke and benefits from having a
stroke neurologist right there is not likely to have a general neurologist. The
same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery,
among others, or for people who need emergency intervention for an acute heart
attack. The case of “laborists” is somewhat different; the women having a baby (arguably
the most common reason for people being glad
to be in the hospital) who has been followed by an obstetrician or family
doctor might well want and expect to be delivered by that doctor (a point acknowledged
by Nelson). While many primary care doctors would like to provide this
continuity to their patients, they may be unable to in the system they work in.
And if it is not their “fault”, it is a pretty guilt-free way to enjoy the
benefit.
If
the hospitals and health systems make more money and operate more “efficiently”
with separate hospitalist and “ambulists” (yes, this term is being used by
some!), and if the doctors are happy with the arrangement because it makes their
lives more controllable, the boat on generalist hospitalists and “laborists” has
probably already sailed, at least in communities large enough for this to be
feasible.
Anyone who has flown in and out of the Kansas City
International Airport (KCI) knows what a pleasure it is compared to other
airports in even relatively big cities. Built on only one level in 3
almost-circular terminals, there are only a few gates for each security
checkpoint so the lines are relatively short (compared to, say, the nightmare
at Denver International). Once you come in you get off your
plane, walk right out into the hall where your baggage carousel is nearby, and
then you walk right out to the street (even sooner if you have no checked bag),
where you can be picked up or go to your car in the garage right there. It is a
true pleasure for the traveler.
But it is not so desirable for the airport and airlines. I
have heard that this setup requires more security people than any airport
except Heathrow. There are rumblings about redesigning, maybe rebuilding, the
airport to make it more “efficient”. Sure, it will be worse for the traveler,
but that’s the way it goes.
So maybe you want to ask your doctor if s/he will see you in
the hospital. And let the hospital and health system know that you think it is
important, too. It is unreasonable to ask your primary care doctor to work a
full day in the office and also care for patients in the hospital; that time
needs to be built into their schedules by their employers. It could work; you
never know. What’s good for people sometimes actually happens.
And if you haven’t flown in and out of KCI, you should do it
soon before it becomes Denver.
[1] Nelson
JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging
phenomenon. JAMA. 2012 Apr
25;307(16):1699-700.
[2] Wachter
RM, Goldman L., The emerging role of "hospitalists" in the American
health care system, N Engl J Med.
1996 Aug 15;335(7):514-7.
[3] Seiler
A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care
provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.
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