October 3, 2008
By: John Kasprak, Senior Attorney
It has become increasingly common for hospital patients to be cared for by hospital-based physicians, called “hospitalists,” most of whose specialty training is in internal medicine, and who coordinate care for the patient during their stay.
What is a Hospitalist?
Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are distinct from other physicians in that they do not have an office-based practice but instead practice full-time in an institutional setting. Under the hospitalist model, community-based physicians basically relinquish inpatient care to hospitalists.
A hospitalist's 'normal' day consists of admitting, managing, discharging, and consulting for hospitalized patients. This also includes going on patient rounds.
When Did Hospitalists Enter the Health Care Delivery System?
The term “hospitalist” was first used in a 1996 article in the New England Journal of Medicine. Some physicians have been in hospitalist practice since the 1970s and 1980s, but this type of practice grew significantly in the mid 1990s. In the mid 1990s, there were less than 1,000 hospitalists in the United States. By late 1998 the number had grown to 3,000 and in 2004, nearly 13,000 hospitalists were practicing in almost 1,800 hospitals or 37% of all acute care hospitals in the country. Projections indicate that by 2010, as many as 30,000 hospitalists may practice throughout the nation.
What Education and Training Do Hospitalists Have?
Hospitalists are licensed physicians. They come from several medical disciplines, but general internal medicine is by far the most common (about 75%). This reflects the fact that residency training in internal medicine typically focuses on the care of acutely ill hospitalized patients. Hospitalists may also come from internal medicine subspecialties, pediatrics and pediatric subspecialties, and family practice disciplines.
At present, there is no formal board certification for hospitalists or hospital medicine. But several medical schools have recently added “hospitalist tracks” to their residency training programs. The University of Colorado, for example, began this in 2004.
A hospitalist practicing in Connecticut would have to be licensed under the physician licensure statutes (Chapter 370 of the Connecticut General Statutes).
What is the Model for Hospitalist Practice?
There are a number of common models for hospitalist practice. They differ primarily in who employs the hospitalist. In order of approximate prevalence (from most to least common), hospitalists are employed by hospitals; managed care organizations; local medical groups, usually large multispecialty groups; geographically diverse, for-profit, hospitalist companies; and academic hospital practices. Some are self-employed.
Different practice models sometimes coexist in the same hospital. For example, a hospital might employ its own hospitalists, but also allow affiliated medical groups to use their own hospitalists.
Do Connecticut Hospitals Use Hospitalists?
Yes, many do. UConn Health Center states, “Many of the patients cared for in UConn Health Center's John Dempsey Hospital are cared for by our group of hospitalists. Studies have shown that hospitalists improve the quality of care delivered to hospitalized patients and that patients are more satisfied with the care that they receive in a hospital that utilizes hospitalist services.” UConn continues, “The hospitalist will work together with the referring primary care provider to insure the best possible care is delivered to the patient. At the time of admission the hospitalist will call and inform the primary care provider of the admission, and will collect information regarding the patient.” (see http://health.uchc.edu/referringphysicians/hospitalists.htm).
The “New England Physician Recruitment Center” website recently indicated a number of job listings for hospitalists in Connecticut hospitals. These ranged from small to large hospitals as well as a multi-specialty group seeking to add five hospitalists to its staff. (see http://www.neprc.com/Hospitalist/Connecticut/hospitalist_jobs.html).
What Are the Pros and Cons of Hospitalist Practice?
Compared with traditional inpatient care, the hospitalist model has a number of advantages. Research suggests that hospitalists may reduce lengths-of-stay, improve quality of care for specific conditions, and lower hospital costs, without harming patient satisfaction.
Hospitalists also enable systematic quality improvement within hospitals, some argue, because they are more likely than community physicians to assume leadership in these efforts and be available to implement them (see “Hospitalists and Care Transitions: The Divorce of Inpatient and Outpatient Care,” Health Affairs, Vol. 27, No. 5, September/October 2008, pp. 1315-1327).
Some of the most commonly cited reasons that physicians choose a hospitalist practice are: (1) the opportunity to focus on inpatient care, finding it more rewarding than ambulatory care; (2) their training provided better preparation for inpatient care than ambulatory care; (3) hospitalist practice is a simpler business to manage than outpatient private practice; (4) a hospitalist employed by a hospital or group doesn't have to spend months or years building a practice; and (5) hospitalists have greater flexibility in scheduling.
For many, the most significant drawback to a hospitalist practice is that the hospital must have coverage on a 24 hours a day, seven days a week basis. That creates some challenges in shift scheduling and can result in a schedule that requires working more nights and weekends than in outpatient-based practices. This can be offset by more weekdays off and can be seen as similar to the lifestyle of emergency medicine practice.
Those who have examined hospitalist practice note that it has fundamentally changed the processes of care delivery. Under the hospitalist model, community-based physicians relinquish inpatient care to hospitalists, thus adding another practitioner to the flow of care. Some observe that under the hospitalist model, coordination becomes more complex simply by increasing the number of providers and organizations involved in “hand-offs” of patients, because hospitalists may be affiliated primarily with the hospital, a health plan, or other sponsors (see the Health Affairs article cited above).
Sometimes a patient is admitted to the hospital through its emergency department (ED). Hand-offs between the ED and the hospitalist who admits the patient are subject to particular ambiguities or difficulties, according to some observers. A decision may be made, for example, to admit a patient, but the patient remains in the ED until an inpatient bed becomes available. It may not be clear who is responsible for the patient during this time. Information from the patient's primary care physician may get lost in this transition.
What Are Some Additional Resources on Hospitalists?
In addition to the information cited above, the following provide more information on hospitalists:
● The Society of Hospital Medicine (http://www.hospitalmedicine.org)
● The American College of Physicians (http://www.acponline.org)
● Kaiser Network (http://www.kaisernetwork.org)
● “Communication Between The Primary Care Provider, Hospitalist, And Other Health Care Providers-Transitions of Care and Health Care Handoffs,” Report to the Commissioner of the Connecticut Department of Public Health by the Quality of Health Care Advisory Committee, Subcommittee on Best Practices and Adverse Events, January 2008.
● “Outcomes of Care by Hospitalists, General Internists, and Family Physicians,” The New England Journal of Medicine, December 20, 2007, pp. 2589-2600 (www.nejm.org).