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

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Are hospitalists a threat to the identity of internists?

If internists don't see patients in the hospital, what will distinguish them from other specialties?

From the February 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Deborah Gesensway

SAN FRANCISCO—The idea of having an internist in the hospital full-time to look after the hospitalized patients of other doctors is taking off. But concerns persist about its effect on patient care, the consequences for the doctor-patient relationship and even what it means for the future of general internal medicine.

Proponents and skeptics of the "hospitalist" movement gathered last month to discuss these concerns and to share experiences of how they're facing up to potential pitfalls in this model of health care delivery.

"This is a purposeful discontinuity in care," said Robert M. Wachter, FACP, associate professor of medicine and epidemiology at the University of California, San Francisco and co-author of a 1996 article in the New England Journal of Medicine that coined the label "hospitalist." "One has to believe the advantages exceed the obvious disadvantages."

For Dr. Wachter, who organized the conference on "The Emerging Role of Hospitalists in American Health Care," the advantages stack up this way:

  • Patients are in the hospital because they are very sick or have a rare disease, so they need their doctors to have better inpatient skills. On the flip side, outpatient doctors are seeing sicker patients—and more of them—and need to focus on improving their outpatient availability and skills. This is more easily done if outpatient medicine is a doctor's entire focus.
  • Asking primary care physicians to be responsible for quality improvement in the hospital is unfair because they are in the hospital only 5% to 10% of the time currently.
  • The hospitalists practicing today—there are about 1,500 in active practice in the United States, including some in nearly every state—are showing they can reduce lengths of stay for hospitalized patients and not worsen patient satisfaction. (Dr. Wachter cautioned that these experiences are anecdotal, and emphasized that there is a dire need for good studies with randomized patients, adjusted for severity of illness.)
  • Hospitalism is a good career opportunity for general internists, who until now had only one choice to make: Those who wanted to be generalists could become primary care physicians, while those who wanted to be intensivists could become subspecialists.

"In many ways, the hospitalist is an acute generalist," Dr. Wachter said. Added Mark Smith, ACP Member, president and CEO of the California Healthcare Foundation, "This is finally a way to make general internal medicine sexy. ... You can say, 'I am a general internist' and at the same time, say 'stat.' "

This advantage, however, can also be understood as a potential disadvantage, Dr. Smith said. While general internists are attracted to jobs as hospitalists because they get a chance to use technology and do all the high intensity things possible in a hospital today, patients might find themselves with no one interested in caring for them the low-tech way—talking to them and their families—when they are at their sickest and neediest, particularly at the end of life.

Steven A. Schroeder, MACP, president of the Robert Wood Johnson Foundation, said he worries that over time, the general internists who choose hospitalism may be only interested in high technology-types of medicine and not in caring for patients as people. Already, he said, it appears to be a line of work that is particularly attractive to one kind of internal medicine trainee—young, male chief residents. "Is this a flight from primary care?" Dr. Schroeder asked. "Is it a flight from treating patients over time?"

ACP President-elect Harold C. Sox, FACP, a professor of general internal medicine at Dartmouth Medical School in New Hampshire, said that the importance of continuity in medical care shouldn't be downplayed, especially for patients who are "looking for an old friend" when they are in the hospital. "I believe continuity of care is good for patients and good for internists," he said. "It transforms our work into being a calling from being simply a job."

While Dr. Sox said that there is a "kernel of a good idea in the hospitalist model," he expressed great concern about the involuntary model of hospitalist care, where primary care physicians have no choice but to refer their hospitalized patients to a hospitalist. "It abrogates the right of a patient to choose his or her physician and the right of a qualified physician to use his or her skills," he said.

Such involuntary models of hospitalism also threaten the identity of internal medicine, Dr. Sox said, because being able to take care of patients in all settings is at the heart of what it means to be an internist.

Without some kind of inpatient role, Dr. Sox said, internists become indistinguishable from other primary care physicians. "Internists barred from inpatient care will become 'outpatient internists,' which will confuse patients and give health plans less reason to impanel internists," he said. There also will be less reason for medical students to choose internal medicine, he added.

The identity of internal medicine is "blurred now," Dr. Sox said, "and with a mandatory hospitalist model, it will become even more blurred." He added that he has fewer concerns with a system that makes hospitalists available to doctors and patients who voluntarily choose to use them.

Finally, speakers at the meeting said, internists who are attracted to hospitalism should keep in mind that the number of general, acute care hospitals is shrinking, and that fewer patients are being hospitalized for fewer days at a time. As Dr. Smith from the California Healthcare Foundation explained, as the nature of hospitals change, so too will the nature of hospitalists.

The debate will continue at the first national meeting of the new National Association of Inpatient Physicians—ACP's first affiliate member organization—April 1 in San Diego, the day before ACP's Annual Session. To register, call 800-523-1546, ext. 2600.

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