As an emerging and rapidly growing segment of the healthcare system, hospitalists have become an increasingly important part of inpatient care. Within a few short decades, this new form of practice has become a model of efficiency and safety. As with any change, there will always be detractors. However, within this short lifespan, how has it served the industry as a whole?
Before we can answer this question it is best to go back to the beginning to find out what a hospitalist does and where the need came from. Mark A. Marinella, MD, FACP in his article ‘Hospitalists—Where They Came from, Who They Are, and What They Do,’ he defines a hospitalist as someone “usually available on short notice and is often able to assess acutely ill patients and intervene in their care very rapidly.” The need arose out of a growing necessity to shorten patient’s time in hospitals and increase availability for admissions and discharges. At this point, the traditional method of having primary care physicians make rounds was falling short. Dr. Wachler, one of the creators of the hospitalist model explains, “Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?”
Much of the early opposition to changing a decade’s old way of doing things came from several different groups with a variety of concerns. Some of these concerns were valid, while others were the product of people’s resistance to change. Dr. Watcher in the article ‘HM Turns 20: A Look at the Evolution of Hospital Medicine’ explains: “The biggest brush fire in the early days was with critical care, which kind of surprised me, but ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”
Dr. Watcher goes on to list several other concerns ranging from residents losing autonomy, a loss of income for primary-care providers, and a lack of communication as patients transition from inpatient to outpatient care. Even still, a need was present, and that need was growing.
A Model of Efficiency, Safety, and Economy
During these early years, the 1999 report “To Err Is Human” was published. The report’s most important conclusion was that between 44,000 and 98,000 people died a year from preventable medical errors equating to a jumbo jet a day crashing. The report would send shockwaves through the industry as a whole. This placed hospitalist in an ideal position to reshape an industry now ripe for change. Dr. Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation said in 2000, “hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent.”
Not only did they lead the charge toward change, but they have also been a driving force in integrating other areas of the hospital. Dr. Gandhi said of her experience, “At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”
In the years since the place of the hospitalist would start to solidify. There has still been opposition along the way. One group to voice their concerns is personal care providers. Having a vested interest in the care of patients and activities with a hospital, their concerns do have merit. One of the biggest concerns has been a gap in communications when one of their patients has been admitted to a hospital. The use of electronic records has helped to bridge this gap. Eva Waite, MD, Acting Medical Director of Internal Medicine Associates explains, “Hospitalist care is much more efficient than rounds, the hospital has become a black hole for primary care doctors—even more so if you can’t link to the electronic medical records [EMRs]. Without EMRs, personal care providers don’t even know that their patient was admitted, when he/she was discharged, or what happened in between.”
Using EMR’s can certainly improve the transition of a patient from the care of one provider to another, but it is far from a perfect system. Some of the issues that will still need to be overcome are finding a way for primary care providers to share their understanding of a patient’s history with a hospitalist and for hospitalists to share their experience with primary care providers. Currently, this process can be hindered by a provider not having an affiliation with the hospital their patient was admitted to, or notes from a hospitalist can appear vague and incomplete. Both parties have a shared interest in improving the care of their patients, and they will have to work together to find an effective solution moving forward.
As the hospitalist model has begun to mature, many hurdles have been overcome, some are being overcome and some have yet to be overcome. An upcoming hurdle that is a very real concern is burnout. A natural drawback of round-the-clock-coverage is the threat of fatigue. Hospitalists often spend long hours working with several patients with significant illnesses, plus being on-call and the mental strain of the paperwork associated with discharges can be mentally and physically draining. To help combat this, many institutions have begun rotating on-call duties and having their physicians work in shifts.
Infocus, a quarterly healthcare journal noted that there are fewer primary care providers than there was a decade ago. Their conclusion was despite incentive programs such as gain shares, ” a perception persists among primary care providers that private practice as a model is less financially viable than it once was … two-thirds of medical practices in the United States were owned by physicians, but by 2008, less than half of doctors nationally were hanging out a shingle.” With fewer physicians opening private practices, this shows the hospitalist model is sending ripples throughout the healthcare industry. In recent years they have been a model of efficiency and safety, and this has had a positive impact in other areas they are associated with. From nurse staff to primary care providers and emergency medicine to other specialties, hospitalist have helped to streamline the process as a whole.
Speaking on the future of hospitalist, Dr. Wachter summarized:
We got into post-acute medicines because there was an abyss in quality. We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute. If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before, the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.
As the profession continues to innovate and gradually change the landscape of the healthcare industry, the role of the hospitalist is here to stay.