The Hospitalist Movement: What Now?

After initial growth pains, the hospitalist movement is now rapidly approaching puberty. This has been a phenomenal ride with exponential growth spurts and high results. As compared to other specialties, like gastroenterology or cardiology, this was achieved on the face of some very strong adversity, mostly from the hospitalists’ own peers, worried about losing the market share, patient control, and disruption in longitudinal continuity of care, among other things. That is all in the past now.

Hospitalists are more than 20,000 strong and continue to show a bull market trend. There is now a feeling of anticlimax, which often comes after one achieves a difficult goal and asks one self: what now?

Hospitalists have brought great changes in the in-patient care. They have championed safety initiatives, mastered rapid response measures, started collaboration with pharmacies, raised the bar for quality of care, improved outcomes, reduced patients’ length of stay, decreased cost incurred on in patient care, and provided leadership and halo effect by example. The medical records compliance is better and emergency room through put has improved, to name some of the benefits and achievements of the hospitalist specialty. In recent blogs and discussions, the question has been raised: what is the next frontier?

One of things I will like to see hospitalists improve is to revive the art of physical examination. While there is no dearth of great clinicians, the majority of primary care physicians simply do not have time to do the detailed physician examination which is so vital to reach the correct diagnosis. They rely heavily on consults, laboratory tests and advanced radiological and ultrasonographic techniques. Most solo primary care physicians, who have busy office practices, cannot afford to spend time on detailed physical examinations. The situation is no better on the teaching service either. Though patients on teaching service are theoretically seen by three different physicians (intern, resident and attending) every day, nobody is able to spend enough time to do justice with physical examinations. It is a dying art which needs Prince Charming’s kiss to bring it back to life. Hospitalists could be that prince charming. There are eighteen physical signs in the examination of nails of a patient with Cirrhosis of liver.

How many of us remember them, and how many take time to look for them? I challenge the hospitalists, who spend far more time in doing history and physical, to restore this art. It will go a long way in saving un-necessary tests, save time in waiting for those tests, and most importantly, save money as well. Tests should be done to confirm the working diagnosis rather than a fishing expedition to net an elusive diagnosis.