American College of Physicians: Internal Medicine — Doctors for Adults ®

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Internists in the hospital—only

'Hospitalists' idea taking off, but will continuity of care suffer?

From the May 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Deborah Gesensway

The medical journal's classified ad announces "opportunities available—100% hospital-based." An e-mail posted on an Internet chat site seeks information about any group practice's experience with having their inpatients managed by a dedicated hospital physician.

These ads concern hospitalists, a new type of doctor for a new direction in inpatient care. The idea is to give hospitalized patients better care by making one physician—who is physically in the hospital full-time—responsible for most of their care, and to maximize the use of office-based physicians' time by allowing them to focus on their outpatients.

The theory of having general internists who practice only in the hospital isn't new—think of Great Britain or Canada—but the practice in the United States has snowballed just in the last year. "Hospitalists"—a tag coined only last summer by University of California, San Francisco, internists Robert M. Wachter, FACP, and Lee Goldman, FACP, in the pages of the New England Journal of Medicine—can now be found practicing in such disparate workplaces and medical marketplaces as Sacramento, Calif. and Springfield, Mass. A new medical society, the "National Association of Inpatient Physicians," has been formed and is planing a national conference for December. Among the meeting's topics: What are the implications for internal medicine and should hospitalists have their own specialty?

But the growing popularity of hospitalists is raising other questions, like whether the current system of patient care—a system that has worked well for decades, and one that both doctors and patients have liked—should be changed at all. After all, skeptics ask, isn't it better to see your doctor—the one who knows you in health as well as sickness—in the hospital when you are most vulnerable? There are also questions about how splitting outpatient and inpatient management between different primary care physicians will affect patient health.

Critics distrust any further fragmentation of the health care delivery system and insist on the need for real continuity of care, particularly for complicated, ill patients. And others wonder how the move to hospitalists will affect internists, who traditionally get much of their identify from the ability to expertly treat difficult conditions that may require hospitalization.

"It does not seem best for patients to be seen by an internist in the office, have a diagnosis made and a therapy advised, then be admitted to the hospital and have their care turned over to somebody else," said ACP Regent James J. Bergin, FACP. "A new rapport has to occur and confidence developed in this new individual who is taking care of them at a difficult time."

Dr. Bergin recently received a letter from Humana Health Care Plans announcing the start this winter of a hospital inpatient management program at his Kansas City hospital. Humana, the letter explains, will require all primary care physicians participating with the HMO to turn over primary care of their hospitalized Humana patients to an inpatient doctor who will then transfer responsibility back upon discharge.

When people have serious health problems or advanced disease and are nearing the end of their lives, Dr. Bergin explained, "a special kind of bonding occurs between the physician and the patient. I don't see how that's a good thing to be changed." ACP has begun studying the trend and its effect on patient care and internists' careers, and the American Board of Internal Medicine (ABIM) is watching the trend.

John R. Nelson, ACP Member, a Gainesville, Fla., internist who discovered a niche in hospital care soon after finishing his residency, worries about these issues as well. "You've put another cook in the kitchen, and that is potentially bad," he said. Of particular concern, he said, are issues of continuity of care and transferring information between health care sites.

"But I think these risks can be more than made up for by the fact that the patient is seeing what essentially amounts to a specialist in hospital care," Dr. Nelson said. "This is what I do all the time. In my nine years as a full-time hospitalist, I've taken care of X number of patients with sepsis, while a doctor in traditional internal medicine practice has taken care of only a tenth to a third of that many. What doctor do you want to see when you have sepsis? Most people choose the specialist."

Advocates also point to the realities of today's system of health care delivery. The old system of primary care physicians following their own patients in and out of the hospital is already obsolete in most communities in the country. After all, supporters point out, how many internists today take all their own call and always follow their own patients every evening and weekend? How many referrals do outpatient physicians give to critical care specialists because they are too busy in the office to provide the care themselves? The horse, so to speak, is already out of the barn, and patients don't seem to mind.

Being honest

When a group of general internists and family physicians at Park Nicollet Clinic in suburban Minneapolis began setting up a hospitalist service in 1994 to care for all the group's admissions at Methodist Hospital, they started by "being honest with ourselves about how good our continuity was in the first place," explained Richard B. Freese, ACP Member, a general internist at the time and now senior vice president for clinical services for HealthSystem Minnesota, an integrated system that includes the clinic and hospital.

"The truth of the matter is that with the doctors increasingly taking call for each other, the continuity wasn't very good to begin with," Dr. Freese said. "Thursday evening I might have one of my patients admitted by one of my partners. I might see him on Friday, but if he deteriorated Friday night, somebody else who was taking call for me was taking care of him. Saturday, somebody else would be rounding on him." Since the group instituted a system where six doctors with no outpatient responsibilities work full time in the hospital taking care of a daily average of 100 patients for 78 primary care doctors, Dr. Freese said, patients now report noticing fewer hand-offs.

Studies conducted by Park Nicollet, meanwhile, have shown no difference in patients' perceptions of the quality of their care. And the benefits, Dr. Freese said, include reports from outpatients of reduced waiting time. In addition, the hospital has reported half-day decreases in the average length of stay per patient and a 25% drop in the average cost per patient. Other organizations have found similar cost-savings when they've hired full-time hospitalists.

For Dr. Freese in Minnesota, however, the cost-savings were a bonus, and not the reason the clinic started the program. The original idea came from internists looking to improve call schedules, he said, not from bean counters at a health system. In fact, many committed hospitalists, such as Dr. Nelson, admit that they're not sure whether hospitalists produce significant long-term savings exist. They admit that there may simply be a shift from hospital costs to physician costs.

For most hospitalists, however, the benefits have more to do with improving the quality of inpatient medicine and making work schedules more predictable and lifestyles less hectic. "For most primary care doctors, the hospital is nothing but middle-of-the-night surprises when you are asleep or middle-of-the-day surprises when you are busy in your office," explained Winthrop Whitcomb, MD, a full-time internist-hospitalist at Mercy Hospital in Springfield, Mass. His inpatient service was formed in 1993 specifically to address the problem of community doctors who left the hospital's medical staff because they felt their inpatient duties were taking up too much time.

"We also found that there are more and more doctors who just don't want to do inpatient work anymore," Dr. Whitcomb said, a reaction he attributes to the hospital becoming more daunting for outpatient providers "given technology and the acuity of the patients' illness."

Different models

Since hospitalism has largely been a grassroots effort, a response to particular economic or workforce conditions, there is no one model of hospitalist. Such a physician can be self-employed, a member of medical groups oracademic faculty or employee of a hospital, HMO or management services organization. Some give up all outpatient medicine; others rotate into hospital-only practice for a week or a month at a time. They are primarily general internists, but also subspecialists—particularly pulmonologists/critical care specialists—and also occasionally family physicians.

In highly capitated markets such as California, much of the interest in hospitalists comes from to their money-saving potential. "The old system had many things to speak for it," said San Francisco's Dr. Wachter, who helped coin the term hospitalist. "But that system really only works very well when there is no need for systems improvement or quality improvement in the hospital, or when it really doesn't matter whether the patient is in the hospital for four days or six days, or when patients in the hospital aren't all that sick, or when the average primary care physician at any given time has six or eight patients in the hospital so they have a lot of experience. These obviously aren't the case anymore."

At UCSF, Dr. Wachter has spearheaded a hospitalist system with a particularly academic flavor. Its hospitalists are hired specifically to spend three to six months each year working full time on the wards. For the months they are on hospital duty, they work 28 days a month and their beeper is never turned off. During the other months, the hospitalists teach medical students and residents, do research, work on hospital quality improvement projects and precept in the outpatient clinic. "We felt that maintaining some outpatient connection would make them better hospitalists," Dr. Wachter said.

For him, the definition of a hospitalist is "physicians who spend more than 25% of their time based in a hospital setting, where they serve as the physicians of record after accepting 'hand-offs' of hospitalized patients from primary care physicians, returning these patients to the care of the primary care physicians at the time of hospital discharge." The important parts of that definition, he said, are the idea of a hand-off and the assumption that there is some minimum amount of time a hospitalist has to practice his craft to be invested in hospital care.

"I don't think it has to be 100%," Dr. Wachter said. "I am not wedded to this idea that tomorrow you are either an outpatient doctor or you are an inpatient doctor and never the twain will meet."

Others say full-time hospital practice is the only way to go. Dr. Nelson from Gainesville is part of a five-person private practice that does only hospital care for patients at two community hospitals. His patients are a combination of unassigned patients admitted through the emergency room, referrals from a core group of about 15 to 25 primary care physicians who never or rarely do any inpatient medicine, and referrals from primary care physicians in rural areas a long drive away from the hospital. "There are a lot of internists now looking for jobs that are strictly outpatient, and we enable them to have that job," Dr. Nelson said.

Although he and his partners typically work shifts of two to four seven-day weeks with a week or so off (their way of dealing with the continuity concern), Dr. Nelson says he has a more rational lifestyle than he might otherwise as a traditional internist. "I don't operate an office. I don't have any employees. I have a beeper and a billing person and my malpractice insurance. My overhead is less than 10% [of earnings] every year," he said. "So when I take a vacation, I don't make any money, but I didn't really spend anything either to keep my practice alive when I was gone."

Bradley Flansbaum, ACP Member, a full-time hospitalist at Long Island Jewish Medical Center in New York since last summer, works a different kind of schedule, one he hopes will allow him to avoid burning out, a major concern of many hospitalists. He works two months on inpatient medicine followed by a month off. In the off months, he is precepting in the medical clinic, pursuing research and teaching medical students. His department instituted the hospitalist program in part because it wanted to improve resident education by having attendings who were committed to inpatient care.

Yet a different kind of hospitalist is Kenneth P. Patrick, MD, a family practitioner who did a critical care fellowship and now works as a full-time hospitalist at Chestnut Hill Hospital in Philadelphia. His other hospitalist colleagues are pulmonologists, and their business has boomed in the last three or four years as more and more primary care physicians have chosen to stay in their offices.

Turf battles

To no one's surprise, turf battles are already brewing in this developing—and potentially lucrative—field of work. Some organizations representing pulmonologists, for instance, are talking about recasting their subspecialty as the obvious hospitalists. General internists certainly see this as their bailiwick. The American Academy of Family Physicians, meanwhile, has been outspoken in its concern about hospitalists, noting that some family physicians have been forced out of hospitals by institutions and insurance companies promoting inpatient specialists.

Dr. Patrick from Philadelphia said his referrals took off, for instance, when the large HMO, US Healthcare, began asking its participating primary care physicians to declare whether or not they would always follow their patients in the hospital. For those who chose not to—there was no financial penalty or incentive to make either decision—US Healthcare selected a physician or two at each hospital to care for these doctors' US Healthcare patients. Dr. Patrick was that doctor in his hospital, and he now works five days a week plus every third weekend and has no outpatient practice at all.

The hospitalist trend may make sense in terms of economics and in terms of addressing physicians' lifestyle and practice needs, but what about for the quality of patient care? There is no real evidence for or against hospitalists, suggesting the need for research.

John M. Eisenberg, MACP, the newly appointed administrator of the federal Agency for Health Care Policy and Research, is calling for careful evaluation before the nation embraces hospitalists. He sees real problems with a hospitalist model of care unless it is occurs in well integrated systems of care that have overcome the communication problems inherent in having different physicians responsible for the same patient in different settings. Teams and electronic medical records may be part of the answer.

"I believe in continuity of care across space as well as across time," Dr. Eisenberg said. "You can't imagine a hospital stay as six days of illness circumscribed by a year of health. People have diseases that get exacerbated and require hospitalization and then they get discharged and they continue their rehabilitation at home, and I don't think there's anybody who understands the kind of life that a patient is going to go back to better than the patient's principle primary care physician." An example, he said, might be the diabetic whose glucose can be controlled perfectly in the hospital, "but if you don't understand that patient's lifestyle and family and diet once the patient goes home, then the hospitalization is wasted."

Some hospitalists in private practice, meanwhile, say they worry about what may be lost by cutting themselves off from outpatient practice. This may be less of a problem today than some time in the future when internists may be asked to focus their training exclusively for either office or hospital jobs.

And if the system truly moves more in the direction of separate inpatient and outpatient doctors, many worry that the role of the outpatient internist is called into question. If general internists don't treat patients in the hospital, what distinguishes them from the family physician or even the physician assistant? Florida's Dr. Nelson said he suspects this fear is what's driving some of the nervousness in the internal medicine community about hospitalists.

"But there are now a lot of awfully sick people in the outpatient setting that we didn't use to have to deal with because they were in the hospital," Dr. Nelson said. "And I think we need people in the medical community to express a willingness to take care of those people. That's the role I see for the internist. Outpatient internists now have to know how to give outpatient IV antibiotics. They have to be able to do expensive work-ups for metastatic cancer all as an outpatient."

According to Mark A. Kelley, FACP, chair-elect of the ABIM and vice dean for clinical affairs at the University of Pennsylvania Health System, it is hard to envision hospitalist internal medicine—or, for that matter, outpatient-oriented internal medicine—becoming their own specialties. Nonetheless, he said, the ABIM is watching the trend closely as "an evolutionary phase of internal medicine" driven more by economics than actual changes in the intellectual discipline.

"I think this is going to be locally driven," he said. "If you have a fee-for-service environment, this may not happen. But in areas that are heavily managed care, where there's a surplus of physicians, where the primary care physicians do not see it as essential or even desirable to take care of inpatients, I see the role of hospitalists evolving. It's all driven by economics."

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