Several months ago, when Lloyd A. Coombs, 61, a retired machinist from Springfield, was rushed to the hospital with congestive heart failure, he was surprised to find the person in charge of his care would not be his primary doctor but one he’d never heard of with a title he’d never come across: hospitalist.
Actually, he says “it was fine.” The hospitalist, Dr. Winthrop F. Whitcomb, director of inpatient medical service at Mercy Hospital in Springfield, kept his regular doctor informed, and best of all, was on the scene whenever Coombs needed him.’
“I liked it because I could see him every day, sometimes twice, three times a day. He corresponded with my family and everything,” says an enthusiastic Coombs, who now feels well.
In the old days, when care wasn’t so “managed” and patients stayed in the hospital longer, a primary care physician would often stop by to see his hospitalized patients early in the morning and maybe later as well. In between, he’d try to coordinate things as best he could from his office.
The plus was the continuity of the bond between patient and doctor. The negatives were the hours wasted as the primary doctor and hospital specialists chased each other by phone, not to mention the primary doctor’s disgruntled patients waiting to be seen in the office.
Now, hospital stays are so short that a doctor who might once have had 10 hospitalized patients a day may now have only two or three, sometimes even at different locations, making it less efficient to drive all over town to visit them while trying to take care of office patients as well.
In theory, the answer to that dilemma is hospitalists – a term coined in 1996 to refer to internists who, instead of seeing private patients of their own, spend all day in the hospital overseeing the care of other doctors’ patients.
There are now 3,500 such physicians in American hospitals, say Whitcomb and Dr. John Nelson, a hospitalist at the North Florida Regional Medical Center in Gainsville, who co-founded the National Association of Inpatient Physicians in 1997. The group now has 800 members and is gaining 100 new ones a month.
Though the hospitalist movement is growing fastest in California and the Southeast, hospitalists now practice in many Massachusetts hospitals, adds Whitcomb.
There’s not enough evidence yet to say how well hospitalist programs are working, but there is some:
- A 1998 study of nearly 10,000 Pennsylvania patients published in the Annals of Internal Medicine found that costs were about 15 percent less for patients seen by hospitalists compared to those whose hospital care was managed by their primary care doctors. Although length of stay decreased in all comparison groups, the decline was greatest in the hospitalist model. Hospitalists’ patients also needed fewer readmissions.
- A 1998 study of 1,623 California patients published in the Journal of the American Medical Association showed that a hospitalist model reduced length of stay and did not affect mortality or readmission rates or patient satisfaction.
- Hospitalists also cut length of stay and costs at the Park Nicollet Clinic in St. Louis Park, Minn., according to an observational analysis in the February 16, 1999 issue of Annals.
- On the other hand, an analysis of 16 Kaiser Permanente hospitals in California, also published in the February 16 Annals, found that although length of stay decreased, costs increased with hospitalist care. Researchers couldn’t explain this trend but speculate that patients may have been sicker.
Still, some observers say the advantages are many.
At Brigham and Women’s Hospital in Boston, for instance, a survey showed that patient satisfaction with hospitalists is as good or better as with traditional care, says Dr. Andrew Halpert, who runs one of the Brigham’s two hospitalist programs and heads inpatient care for Harvard Vanguard Medical Associates, a group practice in Boston.
And 30-day readmission rates dropped about 25 percent among patients seen by Harvard Vanguard hospitalists, he says.
Because patients in the hospital are sicker than those seen in office settings, hospitalists may be better at managing complex cases, proponents say.
“You get good at what you do all the time, and a hospitalist does inpatient care all the time,” says Nelson. “Last year, I cared for nearly 1,000 hospitalized patients. A doctor with my same training who practices mostly in the office and a little in the hospital has done hospital care a lot less.”
Still, there’s so little data that “we’re flying blind,” cautions Dr. John Eisenberg, administrator of the Agency for Health Care Policy and Research, the lead government agency for researching medical cost and quality issues.
“I like the idea of voluntary hospitalists – if I’m a doctor and I need to have someone [ else] care for a patient in the hospital and the patient agrees,” he says. “What I don’t like is mandatory hospitalists, if I think I could provide better care and I’m not allowed to.”
Dr. Harold Sox, chairman of the department of medicine at Dartmouth-Hitchcock Medical Center, agrees, noting in an Annals article that mandatory “hand-offs” of patients to hospitalists “threatens the internist’s identity as the physician who can care for the sickest patients in any venue. . .”
In Texas and Florida, the issue of mandatory versus voluntary hospitalists is becoming a legislative battle; managed care companies are urging laws to mandate the practice and doctors are generally opposed to it. The hospitalists’ association sides with primary care doctors, saying that the hospitalist system should be voluntary.
“I’m not sure this model is for everybody,” concedes Whitcomb of Springfield. “Some patients really want to see their doctor when they’re in the hospital, and some physicians want to retain their hospital responsibilities.”
But so far, “patients are telling us it’s okay,” says Nelson of Florida. “They’re willing to trade a familiar doctor and in turn get a more available doctor.”
The idea may increasingly appeal to more primary care doctors. So long as a doctor is kept in the loop, having someone else in the hospital all day to chat with patients and make sure lab tests get read is a boon, adds Nelson.
“And it eliminates the need to practice telephone medicine.”
Information
For more information on hospitalists, contact:
- The National Association of Inpatient Physicians at 1-800-843-3360 or on the Web at www.naiponline.org
- You can also read the February 16, 1999 supplement to the journal, “Annals of Internal Medicine.”