Hospital Care by Hospitalists

There is a kind of physician that you most likely have never heard of. If you end up in a hospital, however, you may for the first time encounter a rapidly expanding new breed of doctor called a hospitalist.

One major reason why there is this new medical specialty is that doctors can make a lot more money by staying in their office and seeing many patients a day, compared to spending time in hospitals dealing with their patients. This is especially true for family doctors, internists and specialists. Physicians earn 40 percent less for time spent with a hospitalized patient than one in the office, according to a report in the journal Health Affairs.

A hospitalist, as the name implies, only practices medicine in a hospital.

Odds are that any hospitalist you encounter is a recently-graduated resident, who continues familiar hospital duties for a few years. This relatively new specialty resembles what happened with the evolution of emergency and intensive care medicine, and it is likely that it will become a formal specialty with its own residencies and board certification within a decade or two. Already, there are a few distinct residency and fellowship training programs currently operating at major universities.

So what do hospitalists actually do?

They care for hospitalized patients but also conduct various management and administrative functions, like developing and managing aspects of hospital operations such as inpatient flow and quality assurance. They are physician-administrators. Like social workers and various other professionals, hospitalists act as case managers, allowing them to coordinate the services provided to a patient by a number of specialists. This is a complex problem when a patient has multiple medical problems and may be receiving care, tests and medicines from several specialists.

Hospitalist activities may also include teaching, research, and leadership related to hospital care. Hospital medicine, like emergency medicine, is a specialty organized around a location (the hospital), rather than an organ (like cardiology), a disease (like oncology), a technology (radiology), a procedure (anesthesiologist, surgeon), or a patient's age (like pediatrics or geriatrics).

You hear a lot about patients benefiting from a loved one that is their advocate and watchdog and even that patients themselves may be very informed and involved because of so much information on the Internet. But the hospitalist concept places the responsibility for reliable, comprehensive management on a fully qualified person who can also perform better as an employee of the hospital. Truth is that patients and their families can identify needed changes and interventions, but are not necessarily able to get them implemented because of bureaucratic and professional obstacles. The hospitalist is likely to be in a much stronger position when the views and inputs of several physician specialists are necessary.

As to the history of this new specialty, the term "hospitalist" was first coined by Drs. Robert Wachter and Lee Goldman in a 1996 New England Journal of Medicine article.

There are currently 30,000 practicing hospitalists in the United States. These hospitalists practice in approximately half of the nation's community hospitals. They are now in 5,000 institutions, from academic giants like the Hospital of the University of Pennsylvania to small community hospitals to innovators like the Mayo and Cleveland Clinics. They can be attracted to this specialty because of regular hours and a paycheck of, say, $190,000 - higher by $30,000 than community-based peers.

Here is particularly good news. Because hospitalists are on top of everything that happens to a patient - from admission through treatment and discharge - they have been credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association.

The hospital discharge process is especially important and vulnerable to costly mistakes. Do it very well and the patient gets better. Do it wrong, and the patient can end up back on the hospital doorstep in serious trouble and facing a whole new set of bills. Bad discharges generally result from hurried, unclear or incomplete instructions to patients and families and little thought to where they are headed. Also, necessary information to the regular doctor and family must be passed on well.

In 2008, the hospitalists' organization decided to invent better discharge systems rather than respond defensively to criticism. The basic idea was to create a checklist like various ones being used with considerable success in various domains within hospitals. In 65 participating hospitals around the country, the Society of Hospital Medicine identifies patients at high risk for readmission, provides staff mentoring, and designs user-friendly discharge forms listing follow-up appointments, potential signs of trouble and phone numbers for the hospital team.

Of course, for hospitalists to work well it is necessary that patients accept them as they would a much more familiar doctor. You must have confidence in what seems a strange new type of doctor at a very stressful time.