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The Unintended, But Not Surprising, Negative Consequences of Hospitalism

September 4, 2011
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A recent study in Annals of Internal Medicine looked at what happened when patients were cared for in the hospital by private physicians (presumably often their personal physicians) compared to hospitalists.

For a little background, hospitalists are doctors whose job is limited to taking care of patients in the hospital. They pick up new patients in shifts or cycles and almost always have no previous relationship with the patients. They rarely see patients in clinics and have no long term outpatient relationships with patients.

This study found that hospitalist patients stayed in the hospital 0.64 days fewer than the private physician patients. This finding is consistent with previous studies. However, hospitalist patients were 18% less likely to be discharged home (more likely to a nursing facility), 18% more likely to make an ER visit in the 30 days after discharge, and 8% more likely to be readmitted to the hospital. This study was important because it measured real world performance across the U.S. after previous controlled studies showed the hospitalist approach had merit.

The hospitalist movement was born from many factors. One was the assumption that a doctor who is at the hospital can be more efficient because he can, for example, check on a patient later in the day and discharge the patient if a test performed in the middle of the day came back normal in the afternoon (while the private practice physician won’t come back to the hospital until the next morning). The private physician is paid nothing for any work past the first patient encounter each day. The hospitalist isn’t either, at least as a payable charge to Medicare or most insurance companies, but he’s at the hospital anyway so it’s not nearly as inconvenient for him to see the patient again.

To my knowledge, no study or private initiative has ever tried to preserve the personal physician-patient relationship in the hospital by paying the physician for the time it takes to do further work in one calendar day beyond the initial trip to the hospital–neither face-to-face work nor work performed electronically.

The best summary on the research of the impact of hospitalism to me is exactly what this study found — the length of stay decreases a little and is associated with a few problems down the road. Whether a patient spends 3 days or 10 days in the hospital has a lot more to do with how sick she is, not the kind of doctor providing the care. My biases about family medicine are transparent, but I can’t help wondering: if there is no significant improvement for a patient so sick she needs to be in the hospital to see a hospitalist, then why not create incentives and processes to encourage the pre-existing relationship with her family physician to continue in the hospital, especially when is the most ill, vulnerable, and scared?

The hospitalism movement is not a hindrance to improving our healthcare system, but it’s no solution either.

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One Response to The Unintended, But Not Surprising, Negative Consequences of Hospitalism

  1. Tracie Updike MD on September 5, 2011 at 2:06 pm

    Hospitalists what are we to do. Dr Young I see where you are coming from. The group I share call with decided five years ago to stop seeing their patients in the hospital–let the hospitalists do it. I screamed and they had to pull me away from my hospital duties but I relented; because I could not do the hospital by myself. So I turned it over to the hospital guys and it is true they could do a HELL of a lot better but they are all I have at this time. Ther is no way I would go back to seeing patients in the hospital again; unless I did it a week at a time and then closed my office for that week. The rules and regs in the hospital are overwhelming and I came to realize that I am a better office doctor then both office and hospital. I call my patients in the hospital to see what is going on and make sure they follow up with me ASAP. It is still hard to send my patients off to another doctor for hospitalization but you got to realize I would rather they see some one who admits 30 people a month then someone who admits one or two. The experience is important and I had goten where I was only admitting about 20 people in a year and most of these were my collegues. We have to do something to make it better. One of the things I do is if you need skilled nursing I will take care of you in the nursing home. I also try to get all of the info from the hospital to keep up to date. We got to do better.

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