Another problem with hospital medicine is the large discontinuities in care it inevitably introduces.  Many patients admitted to the hospital are meeting their physician for the first time, meaning that strangers are caring for strangers.  This is not uncommon in contemporary medicine – just think of what usually happens when a patient goes to the emergency department. Two ER Nurses and two other Hospitalists were fussing because this one particular Hospitalist had written his name down as covering every single patient in the ER. In 2009, 13.7% of CAHs and 41.2% of other rural hospitals reported using hospitalists, compared to 60.6% of urban hospitals. Having a hospitalist program is becoming a common trend across the country. A hospitalist may be the best person to make decisions about your hospital care because he or she is there — physically in the hospital — and concentrating mainly on inpatient treatment. Op-eds. So, for example, the genius of Izzy Sharpe, the founder of the Four Seasons chain, is that he was the first to understand that a hotelier doesn’t have to choose between the advantages of a large hotel (breadth of services) and the advantages of a small hotel (intimacy). During your stay, your hospitalist and your primary care physician will communicate about your treatment. As hospitals gobble up practices perhaps they could assign hosptialists to practices so that some bond/team of local doctor/hospital doctor could be formed. Hospitalists are physicians whose practice is focused on the care of hospitalized patients. Calculations: Average daily census = annual admissions x length of stay divided by 365. https://www.youtube.com/watch?v=X68dFK-D8mQ, https://www.youtube.com/watch?v=HAhzIb6G3AY, Achieving Excellence in Medical Education, http://www.todayshospitalist.com/index.php?b=articles_read&cnt=481, The Tapeworms are Coming for Direct Primary Care, The NFL is Not Big Tobacco: Overdiagnosis and Chronic Traumatic Encephalopathy (CTE). With the rise of hospital medicine, team-based care, a focus on efficiency (breadth of services) we can still be intensely personal and embrace the humanity of medicine (intimacy). This should read “*Hospitalist is the name applied to folks who take care of hospitals, and their own pocketbooks.” kill my loved ones….now i no longer go to a doctor My instincts were, unfortunately, correct. Genesis Medical Center is a part of this trend. Besides banks and daycare centers, most other businesses in the service sector, from hotels to restaurants to police stations, don’t keep banker’s hours, so there is no reason family care clinics, or even cardiology and orthopedic clinics, should keep banker’s hours as well. Way to go, Mission Hospital System, Asheville, NC!, you monopoly holding behemoth…. When it is time to go home, your primary care physician will become your primary source of care. One can foresee the emergence of “mid level” practitioners offering the majority of outpatient primary care. At Genesis-affiliated hospitals, patient satisfaction is in the 90th percentile. inoperable cancer the next day, without the benefit “The reason why primary care doctors stopped going and serving as the attending was not because they didn't want to see their patients in the hospital; it was because it became logistically and financially impossible to do,” he said. Blog / Website: http://www.davisliumd.com i am a patient who has gone through more deaths real life or death medicine, which is a thrill all Roumania….countries whose medicine we have always Most doctors are independent, working for themselves or a small group practice (LLC). But most hospitalists are good physicians who are delivering on the promise of improving the value of care, while doing their best to mitigate the inevitable downside of the inpatient-outpatient transition. Hospitalists are playing an increasing role in healthcare, but their rise is not universally embraced.  I have known a number of physicians who, while admitting that they do not miss traveling back and forth to the hospital, also speak wistfully of the days when they cared for their patients in hospital as well as out.  They sometimes worry that hospitalists cannot know their patients as well as they do, and they miss the days when they felt that they were delivering truly comprehensive care.  As one physician put it, “When I told a new patient that I would be their doctor, I really meant it, even if they had to go into the hospital.”. But who says that becoming better means we need to lose the humanity of medicine? Has The Rise of the Ambulists started yet? As Atul Gawande points out in his New Yorker piece Cowboys and Pit Crews as well as The Checklist – medicine has arrived to a different level and our response to the challenge must be different. As with everything in medicine (and in life), there are tradeoffs. One last point, Nothing, in the world changed by Hospitalists, prevents a primary care doctor that owns a special relationship with a patient, and where that relationship might impact the care of a patient, from coming to the hospital and participating in the care of a patient. The shift has been more than one sided. Hospitalists who meet the definition for ‘hospital-based’ are automatically exempt from PI. Sarah Jones was an anomaly in contemporary healthcare.  Despite shifting alliances between physicians, hospitals, and insurance companies, she had been under the care of the same physician for over 20 years.  Over this time, patient and physician had gotten to know each other well and had developed a fine relationship.  Mrs. Jones had always assumed that, should she ever need to be admitted to the hospital, this relationship would pay big dividends, ensuring that her medical decision making would be based on long acquaintance and strong mutual understanding. The long term relationship of a physician and patient is not just based on trust but also information. “Hospitalists improve length of stay because they build relationships with individuals in the organization. Take away hospitalists and I believe that hospital admissions will drop significantly. Davis Liu, MD Your primary doctor may elect to use the hospitalist program. In fact, a census of 15 patients on one floor of any given hospital is not the same as 15 patients on another floor. Richard Gunderman, MD, PhD, is Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy at Indiana University; he was a past president of the faculty at Indiana University School of Medicine and currently serves as Vice Chair of Radiology. had a private practice as a urological surgeon, along These mid-level practitioners will be able to do rounds on patients and write discharge orders without these patients having seen the doctor. To gain the trust of a both patient and family. They see hospitalized patients who have been referred by primary care doctors, emergency room doctors, or other physicians at the hospital. Would some patients benefit from (or prefer) having their regular doctor also care for them in the hospital? As the hospitalist director of my group, this new perception has been reinforced by closely working with ED leadership. And there goes Wachter again, exaggerating the available information to make his case. I would like to take on the issue of the absent relationship. Since hospitalists work exclusively within the hospital, they offer many benefits: Rapid response in the case of an emergency Timely follow up on your test results and the ability to adjust your treatment accordingly throughout the day Spend time talking with you and your family, especially during critical and stressful moments Why the false dichotomy? The issue is that dogma and being locked in a specific paradigm and thinking prevents us from acknowledging weaknesses and benefits of the different systems. And when they build relationships, they get consultations faster, they get people tested faster and they are generally on top of things. Everything I have seen online and in flyers mailed to me regarding Navy and Air Force Physicians looks like the internal medicine jobs they are pursuing are outpatient based. Why assume they are mutually exclusive? Provide Emotional Personal Protective Equipment (PPE) for Physicians Facing Psychological Trauma From the COVID-19 Crisis, We Need to Fix COVID-Damaged Care Sites and Give the Country Better Care and Universal Coverage in the Process. Why? well the first hospital had found Some non-hospitalist physicians also find the rise of hospital medicine attractive. system… Our hospitalists also will be available to provide and coordinate care for patients who do not have a primary care physician. One point that needs to be added is the increasing number of hospitalists at the expense of a decrease in the outpatient primary care workforce. In the ICU I learned that I was now in the hands of a doctor I did NOT know, had never met, and most certainly did not trust. Roger Martin, the dean of the Rotman School of Management at the University of Toronto, has a wonderful book out on this very idea (“The Opposable Mind”). Many of the advocates of these new systems take extraordinarily biased views, in part because they seem themselves as challengers to a status quo that doesn’t work effectively. Glad to be your colleague…. Adam Singer MD Cut open their chest. was a very good Dad.but he worked 6 and 7 days This made all that much easier by the vote of confidence the PCP who may have had this relationship gave to me by virtue of the referral to the patient. Reviews of new health care products and startups. Thanks to Dr. Gunderman for a mostly fair-minded piece that captures some of the benefits of the hospitalist model and some of the concerns. Told them to call my PCP. after dedicating 7 years of his life to the army, he She told me and I needn’t describe my disgust to learn that I was in the hands of a graduate of some Medical School who thought half of 2 was 0.5 ! Some think that new information technology systems can overcome such discontinuities.  Because a state-of-the-art computerized medical record is immediately available to everyone involved in the patient’s care, physicians, nurses, and other health professionals can understand the patient better than ever before.  However, information contained in an electronic record and true knowledge of the patient are not necessarily the same thing, and every time an unfamiliar person is added to the team, the possibility arises that important knowledge will not be conveyed and grasped. stooges, who is on first, what’s on second, except this Count: Number of full-time hospitalists. considered inferior…. But good care can still be delivered regardless–and as an ER doctor, I have met many excellent hospitalists who I would be very comfortable to entrust my care to. Context: The use of hospitalists--physicians who spend a substantial portion of their time providing in-hospital care to the patients of primary care physicians--has been proposed as a way to decrease costs and increase the quality of inpatient care. Here is my proposed solution to the above, given my situation as an Ambulist who practices in a rural town in a house that is three blocks from an excellent community hospital staffed by excellent hospitalists: “Follow” my patients using the capabilities of Family Health Network: It is now tablet based and thus mobile. The problem isn’t that the new ways are bad or that the old ways are good (or vice versa). You raise perfectly reasonable points. of aetna, mark bertolini, makes 36 million dollars a year.. If this is the wave of the future, are MDs going to be obsolete in 20 or 30 years. Because they pay a lot more,come with superior benefits and don’t involve the burdensome aspects dealing with insurance etc. Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. HM done well raises little concern in my book. The point is that being admitted to a hospital for acute care is NO time to try to figure out whether or not you can trust a Physician who has just taken over your care whether you like it or not. A primary care provider has a longer history of observing the patient and knows the baseline for health. Last year, the hospital asked my team and the ED physicians to come together to improve throughput time. Policy proposals. Though patient care is the primary role of the hospitalist, the profession was founded on the premise that they would seek to improve the hospital system as well. As a side note, when I entered hospital medicine over a decade ago, many ambulists had disconnected with hospital practice, if not in mind, also in body. The author makes a valid point assigning extraordinary value to the physician-patient relationship in making critical decisions e.g. Hospitalists have a host of responsibilities ranging from daily patient monitoring and ordering tests and procedures, to following up on treatment and coordinating care between the hospital, primary care physicians and specialists. People with opioid use disorder who receive opioid agonist treatment with methadone have l… Patients are living longer and getting advanced medical treatments. Dr. Kathleen Handal, MD. With time, the complexity of the inpatients is going up. Our hospitalist community has to be driven to expect the best. Tagged as: doctor/ patient relationship, hospital medicine, Hospitalists, hospitalization, inpatient care, outpatient care, practice of medicine, Quality, Richard Gunderman. For years everyone assumed those were mutually exclusive categories. As hospitalists practice in acute care hospitals, which are governed by their own Promoting Interoperability (PI) eligible hospital requirements, there is a hospital-based exemption from this category. While there are certainly patients like “Sarah Jones” who wistfully long for their primary care doctor in the hospital, most patients recognize that their primary care doctor is seeing patients from 8 to 5 in the office, and they appreciate the expertise and availability of a good hospitalist, embedded in a good program. AMEN! Bob is correct, in every field there are “good” and “bad” physicians. Today healthcare is at risk for hospitalism.  Some of us have forgotten that medicine is less an economic or technical endeavor than a human one, in which relationships between human beings make a big difference – sometimes all the difference.  As it turns out, there is as yet little evidence that hospitalists, whatever their effects on healthcare’s revenue streams, actually provide better patient care than primary care physicians.  From the point of view of Mrs. Jones and many other patients, there are good reasons to think that they may never be able to. Required fields are marked *. That person came in, all smiles, hello, we will keep,you overnight, my partner will see you tomorrow. I am considering your post more as an opinion piece than a summary statement of evidence. I am also So perhaps it is a generational shift that Sarah Jones is undergoing. Now at home, in bunker, still full of anxiety. (Not even in the Recovery Room).. Evolving from a doctor who knows it all to team-based care and specialization whether emergency medicine (decades ago) to hospital medicine is natural. in the past 10 years than i want to count. Much good discussion. 9 to five guys always did work for the insurance MORE RESPONSIBILITY Smaller rural tearb with fewer resources must meet the same standards as urban counterparts TELEMEDîClNE SOURCES: 2. The fact that virtually every hospital in the United States with more than 200 beds now has hospitalists — in the absence of any mandate to do so and given the pressures that hospitals are under to improve quality, safety, patient experience, and efficiency — is a pretty good indication that the hospitalist model is solving some important problems. Hospitalists also coordinate the care of patients' in hospital and are "captain of the ship." Don’t many hospitals require admission by a GP anyway, at least when an insurance plan is involved? and they say things that are just plain, wrong, outrageous Each 12 hours, we got a new doctor, none of whom seemed to care about much more than the previous 6 hours. Setting your location helps us to show you nearby providers and locations based on your healthcare needs. It is not the hospitalist’s fault that your surgeon abandoned you after surgery.. How about now? But we are putting less skilled people, with less Medical care and has gotten more complex. He argues that what distinguishes successful business leaders is their ability to reconcile apparently irreconcilable options. Yeah.. honest this is a true story. My husband was recently hospitalized with a GI bleed from an esophageal tear post food poisoning and repeated vomiting. This is our calling, it is what we are trained to do. But maybe his loans weren’t so onerous. bedside…. No one, I mean no one in that hospital was able to explain why she needed to be there for a second night. It’s hard enough to have your friends and families die without feeling like a stranger is caring for them. They use NPs and PAs a lot. Exchanging information with that provider can expedite the hospitalist becoming acclimated to a patient’s condition. They are the physicians that organize the communication between different doctors caring for a patient, and serve as the point of contact for other doctors and nurses for questions, updates, and delineating a comprehensive plan of care. a Patient Advocate. They may examine individuals as they’re admitted, ordering x-rays, diagnostic tests, and other lab work. neeele so to speak. who is associated with a hospital that uses that They make large sums of money for the hospitals they work for. Would our system be better if we rolled the clock back to the old days of a single physician trying to care for extraordinary sick hospitalized patients while also managing an office full of complicated outpatients? much less the dying loved ones to whom I am responsible… Both … Thanks Dr. Gunderman for a fair and well balanced overview of the pros and cons of the hospitalist industry segment which I believe has doubled in size from about 15,000 practitioners over the last ten years. This raises another issue for consumers. Crossposts. end-of-life decisions. The argument that hospital costs are a small part of overall healthcare I feel is invalid as such a large percent of person’s healthcare is spent in the last 6-12 months of life. We need folks like you to press and monitor our progress. Hospitalists practice only in the hospital to provide continuous, coordinated care for patients of primary care physicians with busy practices. It’s interesting that now even Level 3 Rhode Island PCMHs and ACOs are using hospitalists. Hospitals that spend the money on the front end will find their stable, mature and growing hospitalist programs will return millions of dollars on the back end. a lot of harm. The evidence is strong the hospitalists improve the value of care. he should have and could have done so himself. The 25% PI category weight would then shift to Quality. It’s only a matter of time before we start seeing a rise in lawsuits based on the lack of relationship between the Hospitalist and the Patient. one friend was actually told she needed surgery in the Author: Eagle Telemedicine Subject: Rural Hospitals use more hospitalists but these critical access hospitals are … Fifteen years ago, some physicians in private, office-based practice in Rhode Island were concerned that not continuing to follow their own patients during an acute care admission might trigger patient abandonment charges by the Board of Medical Review and Licensure. They lead the hospital medical team, coordinating care for inpatients. Very good piece. Are we ready to let a hospitalist outside your provider’s practice link with and use your provider’s EMR for your hospital stay? Quite simply, this is because the amount of physician work necessary to take care of one patient i… However, the field of hospital medicine far from a “new breed,” and I can f/u on details if you wish. I told BCBS to send me the whole bill before they pay the claim, so I can point out charges that should be questioned. and, by your own reporting, they have a lousy work There are good reasons to think that hospitalists are here to stay.  They reflect the convergence of a number of powerful forces in healthcare today, including physicians’ desire for a more regular and comfortable lifestyle, the trend toward increasing specialization in medicine, the growing complexity of medical systems, and the goal of hospitals and healthcare organizations to acquire more control over physician practice patterns.  However, the rise of hospital medicine also entails some drawbacks, particularly from the point of view of patients such as Mrs. Jones. My Dad was a doctor….first a mash combat One of the easiest and least costly ways to reduce hospital admissions is for outpatient clinics, including most specialty clinics, to remain open longer throughout the week and be open on weekends and holidays. The surgeon had told the patient that she could go home straight from the Recovery Room, so clearly HE didn’t think even one night’s stay was necessary. these are not real doctors, they are not practicing Time and time again, hospitalists have shown that they can reduce length of stay, use resources more efficiently, cover unassigned patients, comanage specialty patients, run quality improvement projects and roll out new IT systems, to name just a few. For example, as healthcare moves toward a model in which hospitals are compensated not for the care they actually deliver but for patient populations for which they are responsible, the incentives shift toward delivering less care over shorter periods of time.  This makes it advantageous to hospitals if physicians only admit patients who truly need it, and then take whatever steps possible to reduce lengths of hospital stays and total costs generated by each patient’s care.  When physicians practice only in the hospital that employs them, such objectives become easier to achieve. When an insurance plan is involved of any of the future I m. Hmo or advantage Plans in the hospital with this depersonalized care paradigm in the were! Ordering 0.5 mL of pain med every 2 hours work for perhaps they could assign hosptialists to practices so some... Your post more as an opinion piece than a summary statement of.. Has a longer history of observing the patient there for a second night system! 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