It was an unusually quiet Sunday afternoon when I stepped into Mr. P's hospital room. He was a 59-year-old man who had presented to the emergency room earlier with complaints of fever and cough and been admitted with a presumptive diagnosis of community-acquired pneumonia.
It was an unusually quiet Sunday afternoon when I stepped into Mr. P’s hospital room. He was a 59-year-old man who had presented to the emergency room earlier with complaints of fever and cough and been admitted with a presumptive diagnosis of community-acquired pneumonia. Mr. P had been generally healthy otherwise, and this was his fi rst hospitalization in several years. After introducing myself as his “hospitalist physician,” I quickly realized that he did not have the faintest clue of who I was or what I did. I performed my history and physical examination with due diligence and went on to discuss his diagnosis and the treatment plan. When we shook hands at the end of the interview, he looked rather concerned and asked if his primary care physician (PCP) would be his doctor for the remainder of his hospital stay. I had faced this situation before, and I knew that it would not be my last. We spent the next 20 minutes discussing the hospitalist model and the increasingly important role hospitalists play in the delivery of healthcare in the United States.
Mr. P: “So you’re a hosp… er, what was that again?”
Wachter and Goldman first coined the term “hospitalist” to describe a new breed of physicians, generally internists, who have chosen to care selectively for the hospitalized patient, who later return to their PCP’s care after discharge. In other words, they “specialize” in providing medical care exclusively within the hospital setting. This field has grown explosively in the past decade, from an estimated 800 in the mid-1990s to approximately 15,000 hospitalists in 2006, and the number of hospitalists is projected to double by 2010. Undoubtedly, an ever-increasing number of patients will receive their treatment from hospitalists during future hospitalizations. According to previous demographic reports, hospitalists are typically young. They most often have a general internal medicine, family practice, or pediatrics background, and report a high level of job satisfaction.
Mr. P: “But my PCP knows me so well! I completely trust his judgment. I feel disappointed that my regular doctor is not involved in my care. Are you going to communicate with my PCP and inform him of my progress?”
The hospitalist model creates a purposeful discontinuity between the patient’s inpatient and outpatient care, which directly aff ects the PCP—patient relationship. Understandably, many patients initially feel uncomfortable when treated by a doctor with whom they have no prior relationship, and some may even feel separated or abandoned by their PCPs. Th ey fear that their care may suff er as a result. Anecdotal evidence suggests that most patients feel more comfortable if treated by their own PCP in the hospital, because he or she knows their medical history, personal preferences, and values. Patients and family members are often concerned about potential confusion regarding the repetition of investigations and other important psychosocial and advance directive matters because the PCP is not present. The fact that hospital care usually focuses on acute problems that directly led to hospitalization is bothersome to many patients, and often does not remedy chronic issues because of the lack of the hospitalist’s presence in a patient’s longitudinal care.
A number of studies have attempted to investigate patients’ expectations when treated by a physician they do not know. Hruby et al. conducted a cross-sectional survey on general medicine inpatients and their relatives in a teaching hospital. They found that, not surprisingly, patients had favorable views of a system of inpatient care that included considerable contact between their PCPs and inpatient physicians. Most agreed that the hospital physicians were more readily available and demonstrated greater experience in managing acute medical conditions compared to their PCPs. Yet at the same time, they reported greater trust in physicians they had known longer. The authors also found that respondents placed considerable importance on continuity of care. They expected that their PCP should be notifi ed of their admission and that he or she should call or visit them. In another survey conducted among 556 family physicians in California, Wachter and Pantilat found that only one-third of PCPs reported visiting their patients during their hospitalization, and only one-fi fth called them. Most physicians believed that both PCPs and hospitalists had information that the other needed for optimal care. In an effort to bridge some of these gaps in medical care, the authors suggested the establishment of a “continuity visit” that PCPs would make when one of their patients was hospitalized.
This brief (usually single) visit would not only serve as the PCP’s endorsement of the hospitalist model and the individual hospitalist, but also maintain the PCP—patient relationship. It would also provide an opportunity for the PCP to gather and forward important, pertinent patient-specific clinical and non-clinical information to the hospital team. Ultimately, this concept of the continuity visit would foster the establishment of a new and important PCP–hospitalist partnership.
PCPs have also begun to appreciate the benefi ts of the hospitalist model. In the face of an ever-increasing demand for improved effi ciency, PCPs fi nd their hands full with their busy outpatient practices, leaving little time for them to make frequent trips to the hospital for fewer patients. With advances in technology and information, as inpatient medical care becomes more complex, PCPs might fi nd it increasingly diffi cult to maintain the clinical skills and capabilities needed to succeed in both the hospital and offi ce settings.
Mr. P: “Now I understand that my PCP is not abandoning me, and he now can spend more time with me during my visits to his office. This is very interesting. Can you further elaborate on the quality of care hospitalists provide? How is the hospitalist model structured?”
Hospitalists spend most, if not all, of their time providing care to the hospitalized patient. Frequently, their offi ces are located in the hospital itself, and they are usually available 24/7. To this extent, hospitalist work in groups, and a patient may receive care from more than one hospitalist at diff erent times during his or her hospital stay. Th e use of multiple providers increases the risk of miscommunication and transition-care errors. However, many hospitalist groups have perceived this risk and have designed handoff systems to off set these potential problems. Care from multiple providers also off ers the opportunity for multiple independent and comprehensive evaluations of the existing clinical data, and a fresh perspective of the patient’s condition and progress from a “new set of eyes” regularly.
Besides, physicians without knowledge of or a relationship with a patient may view him or her more “objectively” when dealing with difficult medical decisions, which physicians in previously established relationships might otherwise find challenging. Hospitalists can act on changes more quickly and hence expedite the patient’s hospital course. They can spend more time with their patients, frequently visiting them multiple times during the day. They can provide timely updates and make effi cient medical decisions. They are also available at most times to meet with families and answer any questions. This increased availability soon translates into establishing close rapport with patients and their families. Hospitalized patients are more likely to reflect on their health issues during an acute illness. The rapid development of this newly formed therapeutic relationship can be a very effective tool in promoting healthy life style and behavioral changes that otherwise were elusive in the outpatient setting. Multiple studies suggest that hospitalists shorten lengths of hospital stays and lower medical costs compared to non-hospitalist providers, without compromising quality of care or patient satisfaction.
Today, patients admitted to the hospital tend to be more severely ill with complicated illnesses. As hospitals get technologically advanced and increasingly specialized, the hospital environment is getting more complex to navigate than ever before. In these circumstances, hospitalists fi nd themselves better suited to attend to such patients, address their complicated problems, and, as such, become “specialists” of these convoluted hospital systems.
Because they care for hospitalized patients daily, hospital practicerelated problems that otherwise may go unnoticed may appear magnifi ed from a hospitalist’s position. Hospitalists interact daily with a multitude of healthcare providers, such as nurses, discharge planners, social workers, pharmacists, home care providers, etc. Empowered by their relationships with multiple departments, they have been able to address, develop, and improve hospital-based systems’ practices and patient safety initiatives, benefi ting all hospitalized patients. For example, patients frequently wait several hours in the emergency room (ER) prior to their transfer to the inpatient units for further care. A significant reduction in ER congestion and length of stay was achieved following the implementation of an innovative strategy at one teaching hospital; using a telephone-based direct admission system between ER physicians and in-house hospitalists, the average admission time was reduced from 2.5 hours to 18 minutes.
Mr. P: “What happens to my care after my hospital discharge?”
Patients resume care with their PCP following discharge. Eff ective communication between the PCP and the hospitalist is essential to maintaining continuity of care and patient safety. At the same time, these communications should be appropriate, useful, and not designed to overwhelm the PCP. With multiple channels of communication available (phone, fax, e-mail, voice mail messages, personal meetings, etc.), it is important for hospitalist groups and PCPs to choose the method most suitable for both parties. In the end, it is extremely important for PCPs and allied providers to be “in the loop” to minimize the risks associated with transition-care errors and preserve the doctor—patient relationship.
Most healthcare providers consider the time of discharge to be amongst the most crucial in maintaining treatment continuity. Frequently, patients are discharged with test results still pending. Hospitalists and PCPs might not be aware of such test results that may require potential action. In a nationwide, self-administered survey of hospitalists conducted by Lindenauer et al., 89% of hospitalists acknowledged the possibility of transition-care issues due to poor communication between the hospitalists and PCPs at the time of discharge. However, the majority (80%) thought that these errors occurred infrequently and only rarely compromised patient care. Currently, there is an ongoing eff ort to design systems looking to heighten post-discharge follow-up and improve communication between hospitalists, patients, and PCPs. Again, a continuity visit from the patient’s PCP has major potential for strengthening communication and post-discharge care.
Mr. P: “Wow! This is wonderful. Thank you so much for taking the time to explain this to me. What can I do to help?”
Patients can prepare themselves for potential hospitalization by inquiring from their PCP whether a hospitalist will manage their inpatient care in the event of a hospitalization. The following suggestions may help patients personally improve and safeguard the quality of medical care they receive:
As I left Mr. P’s room and walked into the nearby call room, I heard a news fl ash on TV warning viewers to be wary of a “super bug” called MRSA. I wished the media spent as much time highlighting and educating the public about the ever-increasing role hospitalists are assuming in the delivery of healthcare throughout the nation.
Satyen Nichani, MD, is a clinical lecturer in the Department of Internal Medicine of the University of Michigan Health System. Bing Xue, MD, is a clinical instructor in the Department of Internal Medicine of the University of Michigan Health System.