Hospitals may not be for all doctors
Like most people, I’m picky about the doctors I choose for myself and my family. Ideally, they should be pleasant, wary without being alarmist, empathetic and professional. Their office should be no more than 10 minutes from my home and have plenty of street parking (or at least an inexpensive self-park lot). And, of course, they should be covered by my insurance plan.
When push comes to shove, however, I’m willing to overlook almost any character flaw, inconvenience or expense for the best doctor.
Ultimately, what I want is a physician with unparalleled diagnostic and clinical skills -- one who will pluck me from death’s grip should I fall seriously ill. In choosing this doctor, I allow the worst-case scenario to drive my decision-making. The final question I always ask myself is: “Is this the doctor I want by my hospital bedside?”
But the answer to that question may soon be irrelevant. These days, there’s a good chance that my personal physician wouldn’t care for me if I were hospitalized. In some cases, primary care physicians are opting to stay out of the hospital; in others, hospitals simply insist that such care be handled by a hospital-based physician, or hospitalist.
These doctors work in collaboration with (or sometimes for) the hospital. They forgo the practice of outpatient medicine, choosing to care exclusively for acutely ill, hospitalized patients. The vast majority are trained in internal medicine, although some have a background in family practice or pediatrics.
Use of hospitalists has grown increasingly popular over the last 15 years; in fact, hospital medicine is now the fastest-growing medical specialty in the United States, says the Society of Hospital Medicine. In 1996, there were only a few hundred hospitalists scattered across the country; currently, the organization estimates that there are more than 30,000. This trend could ultimately free up more primary care physicians to do what they do best -- keep us out of the hospital -- while streamlining the hospital-care experience.
Different skills
Traditionally, primary care physicians such as internists and family practitioners have tended to their patients both inside and outside of the hospital. Delivering care in two settings, and doing both well, isn’t easy. Commuting between the office and the hospital creates obvious logistical problems, and working out of two locations makes it impossible for primary care doctors to be available to their hospitalized patients all of the time. Because they often aren’t on hand when problems crop up, emergencies may have to be dealt with over the telephone or handled by doctors-in-training who staff the hospital.
As medical care has become increasingly more complex, some doctors have found they can’t keep up. Caring for patients in both the in-patient and out-patient settings simply requires knowing too much. “The skill set is very different,” says Dr. Janet Nagamine, a hospitalist and chair of the Quality and Safety Committee for the Society of Hospital Medicine. “It’s not realistic to think that you can be good at both.”
The shift toward hospital medicine began, at least in part, as a response to these types of difficulties. Unquestionably, it solves many of them. Hospitalists are on site round-the-clock and are readily available to patients.
Because they focus exclusively on caring for the sickest patients, hospitalists are expert at it. It’s a case of practice makes perfect. “We do these things every day,” says Nagamine. “We could do it in our sleep.”
This new model of care offers certain clear benefits. For starters, hospitalists help reduce medical costs by modestly shortening hospital stays. A study published in the New England Journal of Medicine in 2007 showed that patients overseen by hospitalists were discharged about half a day sooner than those cared for by family physicians and internists.
A number of studies show that hospitalists adhere to established treatment guidelines more closely than their primary care counterparts. Patients suffering from a heart attack, for instance, are more likely to receive aspirin when they’re admitted to the hospital and be discharged on medications called beta-blockers. Both these interventions have been shown to improve outcomes following a heart attack and are widely recognized as the standard of care.
Whether or not patients treated by hospitalists actually fare better, however, is less clear-cut. “The evidence tips towards the fact that hospitalists improve quality,” says Dr. Bob Wachter, chief of the Division of Hospital Medicine at UC San Francisco. But the effect isn’t overwhelming. In fact, most studies show little difference in clinical outcomes between patients overseen by hospitalists and those cared for by their primary care doctors.
Transitions between the hospital and home are perhaps the Achilles’ heel of hospital medicine. Care becomes fragmented as patients are handed off from hospitalist to their primary care doctors, and patients can become confused about who’s in charge.
Let’s talk -- or not
Communication and coordination are critical to a smooth and safe transition between settings -- and doctors. But things don’t always happen the way they should. A 2007 study published in the Journal of the American Medical Assn. found that direct communication between hospital physicians and primary care doctors occurs less than 20% of the time. Typically, primary care physicians rely on written discharge summaries for information about their patients’ hospital stay. Unfortunately, these summaries frequently lack important details such as diagnostic test results and a list of discharge medications.
Hospitalists say patients seem largely willing to accept the trade-off -- that they’ll be cared for by an unfamiliar doctor but one who can be by their bedside. “Given the forces at play, I think people understand that it’s a more logical way of doing things,” says Wachter.
I’m not sure I’d be terribly accepting of a doctor I have no history with and little knowledge of, particularly if I was sick enough to be hospitalized. I invest a lot of time and energy into the process of selecting my physicians and like the ones I’ve found.
Nonetheless, it appears that hospital medicine is here to stay and that the time might come when I’ll have to. If it does, I still won’t accept anything less than the very best -- but it will just have to be the best hospitalist or a hospital that picks the best hospitalists.
Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.
