Once upon a time, primary care doctors had the time and flexibility to look in on their patients who had been admitted to the hospital. This often happened after normal business hours, at the end…
Once upon a time, primary care doctors had the time and flexibility to look in on their patients who had been admitted to the hospital. This often happened after normal business hours, at the end of a long day of appointments with other patients in their office. This was manageable, up until sometime in the 1990s, when many primary care physicians found they just didn’t have the bandwidth to appropriately oversee care for their admitted patients. And thus, hospital medicine was born, and with it came the arrival of a new specialist, called simply the hospitalist.
Dr. Robert M. Wachter, professor and chair of the department of medicine at the University of California, San Francisco, coined the term “hospitalist” in a 1996 New England Journal of Medicine article. He describes his role as “a site-based generalist-specialist, which is a mouthful, but it means someone who specializes in taking care of hospitalized patients. It’s probably easiest to understand it by contrasting it with the dominant system in the old days in the United States,” in which a patient’s primary care doctor would take the lead on overseeing care of his or her hospitalized patients.
This traditional approach “has some logic to it — the doctor knows you and it would at least presumably ease the transition of coming into the hospital and leaving the hospital. The problem with it is it just doesn’t work,” Wachter says, “because primary care doctors are extraordinarily busy seeing patients all day long. That meant that when patients did come into the hospital, there was no one there to be their orchestrating doctor, to oversee their care and make sure the right things were happening at the right time.”
One of the reasons it became so important to have a doctor dedicated specifically to coordinating care for hospitalized patients is because patients who are hospitalized these days tend to be much sicker and have more complicated medical problems than they once did, Wachter says. “There are a lot of things we used to put people in the hospital to do that we don’t need the hospital for any more” — for example, IV drips, dialysis and many other formerly hospital-based treatments can now be administered at home. “Therefore, the threshold to be hospitalized is getting higher. If the patient is sick enough to be in the hospital, they’re awfully sick,” and they likely have several problems that are complicated.
Having someone on site who can help navigate the patient through the gauntlet of working with multiple specialists and to oversee the care has become a more important aspect of caring for hospitalized patients. “Because they’re so sick you need someone to be the orchestra conductor,” Wachter says. “It just doesn’t go very well if they’re left on their own all day long and being cared for by a revolving group of different subspecialists, because then there’s nobody to weave it together to make an integrated plan, nor does the patient feel that there’s anybody there in the middle of this complicated mess who’s advocating for them and translating to them what the issues are.”
Dr. Nasim Afsar, president of the Society of Hospital Medicine, adds that “our acutely ill patients in the United States have higher comorbidities or levels of multiple medical conditions than they did in the past, so you need to have additional expertise. You really needed to have someone who was going to own that on the hospital side.” Having an internist who knows the hospital and the other providers there while also being more available to tend to patients “on an hour-to-hour minute-to-minute basis” as their condition changes became increasingly important — and increasingly difficult for primary care physicians to manage, given all the other demands they have on their time seeing patients outside the hospital.
“Simultaneous to that was the quality movement,” Afsar explains, “where in addition to patient care, it’s critical that we are delivering the highest quality of care for our patients.” This increased doctors’ responsibilities and need to demonstrate that they were hitting certain regulatory measurements of quality, which added additional time and tasks to an already very busy day for many primary care physicians. Hence, the field of hospital medicine flourished in the context of these pressures.
Wachter says this shift in approach has improved patient outcomes. “The evidence is pretty clear that it works better,” and hospital medicine is the fastest growing specialty field. When he first described the role of the hospitalist in the mid-1990s, Wachter says there were a few hundred doctors across the U.S. working in that capacity. Today, there are more than 50,000, and the model has seen near universal adoption by virtually all hospitals in the country.
“Hospital medicine has now been around for over two decades,” Afsar says. “These doctors see a little bit of everything, from heart disease, lung disease, malignancies and infections to helping manage the patient’s medical issues with surgeons in models that we call co-management.” As the “physician of record, you’re responsible for their care, and what that entails is sort of whatever it needs to be,” Wachter says.
While many hospitalists care for adult patients, there’s also a growing number of pediatric hospitalists, and some hospitalists care for patients of any age from infancy to geriatrics, no matter what caused them to land in the hospital.
Most hospitalists, as the name implies, are found in hospitals, but Afsar says that some skilled nursing facilities also employ hospitalists to help “acute patients transition to the outpatient setting.” These doctors look after patients as they move from the hospital back to their living facility “to make sure all the acute issues are addressed and the patient is recovering.”
Wachter says most hospitalists are trained in internal medicine and make the decision that they want to practice in the hospital instead of working in an outpatient setting, which would mean becoming a primary care doctor. “The bulk of American hospitalists are internal medicine doctors who simply choose to take that job at the end of their training,” he says. Unlike some specialties that require additional fellowship training, most hospitalists don’t have to complete such, but for those who do want to pursue additional training, which often focuses on leadership and quality improvement, there are now about 15 or 20 fellowship training programs that focus on hospital medicine around the country.
In recognition of the growth of the specialty, several years ago the American Board of Internal Medicine began offering a focused practice in hospital medicine Maintenance of Certification program that allows hospitalists to demonstrate their skills in this field. “It’s not a full-fledged specialty, because most people don’t go on to do a fellowship,” Wachter says, but it’s a sign that hospital medicine as a specialty field is here to stay.
Although the rise of the hospitalist has produced cost savings and has helped ease the burden off primary care physicians in coordinating care for admitted patients, there could still be some room for adjustment to the model. That’s according to a 2017 study led by Dr. Jennifer Stevens, director of the Center for Health Care Delivery Science at Beth Israel Deaconess Medical Center in Boston, which found that there could be a trade-off with the hospitalist model. While she doesn’t recommend changing the hospitalist model as we know it today, the study did point out some potential pros and cons in terms of patient outcomes that could guide discussions of the future development of the field.
The observational study analyzed Medicare claims for more than 560,000 hospital admissions to ascertain which hospitalized patients had the best outcomes. “We asked the question about hospitalist care slightly differently than people have in the past,” Stevens says. “Most of the time researchers have compared hospitalists to nonhospitalists, and we said, ‘there’s actually a third group there.’ The third group is the physicians who are covering — the ‘doc of the day’ — the person who is not generally a patient provider and is covering for your primary care doctor because not every primary care can see their patients when admitted to the hospital 365 days a year.”
This third group of doctors were physicians who typically practice outpatient medicine, but didn’t have familiarity with the patients they were caring for in terms of outpatient care over the previous year, meaning effectively that this doctor didn’t know the hospital intimately like hospitalists do, but also didn’t know the patient all that well either, as the patient’s own primary care physician would. This three-tiered analysis of the data allowed Stevens and her team “to ask the question, ‘does familiarity with your patient provide any benefit in terms of patient outcome or resources used?'”
According to this study, it might. “We saw that many of the things that folks had found before held up, which is that hospitalists know the hospital well,” which translated into shorter hospital stays for patients. Because they knew the environment and how to get things done, patients could see specialty consultants and receive diagnostic testing faster and be discharged sooner.
By the same token, survival rates improved when the primary care physicians knew the patients. “We found there was a benefit to having a provider who knows you,” in that patients seen by their own primary care doctor were more likely to be discharged home, rather than to a skilled nursing facility. “For an elderly population, that makes a huge difference, and there was actually a survival benefit at 30 days. We didn’t expect to find that. we thought it would be null, but we were surprised to find that primary care providers did have better survival at 30 days.”
Lastly, “the folks who were in that third group, who neither knew the hospital nor knew the patients, did the worst across all measures. They had a longer length of stay, worse readmissions, worse mortality and patients were less likely to go home. So, you kind of have to know either the hospital or the patient,” which seems very logical.
Stevens is quick to add that even though hospitalists had worse outcomes on some measures of this analysis than primary care physicians, “I don’t think that’s necessarily a criticism of it. I think it means there is significant value to patient familiarity with your physician,” and that this could inform slight changes to the pervasive hospitalist model that could improve patient outcomes by “incorporating that familiarity with existing models.” She says there might also be a path to developing alternative models for “very medically complex patients for which familiarity might be more valuable.” Establishing a “high-risk hospitalist service” that would address these patients who are most likely to be hospitalized could increase physician familiarity with their cases and “might make the difference between getting to go home or not getting to go home.”
“Just like anything in health care, there’s always advantages and disadvantages,” Afsar says, but communication between providers can help improve outcomes. “I think the challenge with the primary care doctors was that they didn’t have the flexibility to be able to address the patient’s needs as they come up throughout the day because they had to split their time between hospital and clinics. The challenge with having a hospitalist is that you don’t have a provider who’s known you for a long time, and that’s where it becomes really critical to be sure that handoffs and care coordination are done seamlessly.” Therefore, for the hospitalist, “contacting the primary care doctor at the time of admission to make sure you understand what the patient’s medical issues are” is important. Electronic health records can help bridge the gap, but still, making contact with the primary care doctor can help clarify the most important issues. “I think making sure that the issues are addressed in a coordinated way with the primary care doctor at time of admission and time of discharge are part of the core work that the hospitalists do.”
The fact that the hospitalist model has been so widely adopted is a point of pride for Wachter, who credits others with helping launch the field. “I was there at the creation and I probably had a disproportional role in the academic part of the growth of the field, but it really was a team effort. There were a number of folks at the very beginning who said, ‘this feels important and feels like we’re the right people in the right place.'” He notes that creating “a specialist society that was a big tent so that internists and pediatricians would both feel comfortable; academics and community docs would both feel comfortable; physicians, hospitalists and nonphysicians would all feel comfortable,” was also important and a key to the success of the field.
Afsar also uses the term “big tent” to describe the SHM today and its mission of furthering the field of hospital medicine. “We have pediatricians, internists, family practice providers, advanced practice providers, medical students, residents, pharmacists — it’s a big tent of providers and professionals who have dedicated themselves to the care of the hospitalized patient and ensuring that we’re delivering the highest quality of care for those patients.”
To that end, Afsar says she wishes everyone knew what a great resource hospitalists can be for patients in the hospital. “Hospitalists are your advocate for care during your hospitalization. Please communicate with them and leverage their knowledge and expertise to make sure that you’re getting the best care possible.”