The Hospitalist Dilemma
Today’s issue of the New England Journal of Medicine has back to back editorials reflecting on the rise of the hospitalist system. The first article, by Robert M. Wachter and Lee Goldman, notes that the hospitalist role developed as a response to the economic pressures on physicians and hospitals in the mid-1990’s to both managed care and the disappearance of the elective medical admission to the hospital. It was made possible by a large pool of internal medicine physicians who chose to turn toward the hospital rather than office practice when hospitals began to subsidize physician income to make it economically advantageous to do so. They note:
“Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specialization and full-time hospital presence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing systems…to mitigate harm from discontinuity, it remains the model’s Achilles’ heel.”
Despite this concern, they conclude:
“When we described the hospitalist concept 20 years ago, we argued that it would become an important part of the health care landscape. Yet we couldn’t have predicted the growth and influence it has achieved. Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system’s capacity for massive change under the right conditions.”
Richard Gunderman, on the other hand, thinks the discontinuities of care has been more disruptive than described by Wachter and Goldman. He notes:
“What we don’t yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians…In fact, increasing reliance on hospitalists entails a number of risks and costs for everyone involved in the health care system—most critically, for the patients the system is meant to serve…The hospitalist model also carries risks and costs for physicians.”
He identifies the communication risks inherent in the model, but also notes that patient’s don’t like the notion that the physician who knows them best is not available when they are the sickest. He also notes the negative impact caused by withdrawal of community based physicians from the hospital, and the isolation of the hospital based doctor from the community, the loss of collegiality and many of the other ills afflicting the current system. Perhaps his most telling observation, though, is the following.
“The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians…A good hospital is a great boon to patient care, but the hospital itself is ultimately a tool—to be sure, a large, complex, expensive tool—without which patients can still be given care. To position the hospital at medicine’s center is to create an unbalanced system, one that will continually jar both patients and the health professionals who care for them.”
As a practicing nephrologist who continues to see patients in the hospital, the office, and the dialysis clinic, but who also led the introduction of the hospitalist model in my medical community, I see the both sides of this argument. Those who yearn for “the good old days” aren’t dealing with reality. Patients who needed care from an internist were likely to be seen at either end of the workday by a tired physician who was in a hurry. If he was seeing his own patient, there would be value added, but he usually had to see many others who were not “his.” The value there was likely more marginal than those suffering from nostalgia would like to admit.
I also think the centrifugal forces noted by Gunderman were already in play—the hospitalist model is more a response to changing reality than a cause of the fragmentation. I have talked about the decline of collegiality, particularly as it makes informal clinical leadership possible, but the decline was well under way when I was a young doctor. As to the negative effect on the physician, I remember some impassioned conversations with my general internist colleagues after we started the hospital model. After initial opposition, they had decided this was a good thing and abandoned their hospital practices, despite my warning they might be making themselves obsolete.
On the other hand, I think the virtues of the model noted by Wachter and Goldman are overstated. What I see is a system where patients present to the emergency room with a variety of both acute and chronic problems, are assessed in a vacuum and then admitted to “sort it all out” on the inpatient wards. Hospitalists are rewarded by hospitals for keeping the place full, and, of course, if the patient goes home, there is no money.
The perverse incentives are not theoretical and when the volume overwhelms the supply of hospitalists any of the putative benefits of the model are erased. The problem of volume is even worse in hospitals like mine, where the decline of physician-delivered primary care and the closure of the small outlying hospitals has resulted in even more debilitated, chronically ill patients showing up and needing admission, sometimes because there is nowhere else from them to get effective care.
Although I am not sure we can blame the hospitalist model, I do agree with Gunderman’s observation that a hospital-centric system is seriously out of balance. In my view, this issue can only be addressed by physicians. Even hospitalists understand that admission to the hospital is an “episode of care” for the patient, not the central medical event of their life, particularly for those with multiple chronic illnesses. And hospitalists are the only people who can care for those who are “hospital-dependent.”
These physicians will be in a better position to deploy the massive resources of the in-patient service more wisely, if not more efficiently, than anyone else, particularly procedural specialists. Until payment changes make admission to the hospital unprofitable, it is difficult to imagine health care systems being able to change from seeing admission as a positive financial event to viewing admission as negative. Said another way, until the hospital is seen as a cost center, not a revenue center, it is difficult to see how, or why, health care systems would want to change their world view. The view from being the center of the system looks pretty good to most of them.
15 September 2016
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