Richard Davis: Hospitalist

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The term hospitalist was created in 1996. It means that there is now a medical specialty for doctors who only practice in hospitals. There are mixed feelings in the medical community, meaning not all doctors feel that this new medical specialty was a step in the right direction for the practice of medicine and for the well-being of comprehensive, coordinated care.

Supporters of the specialty such as Drs. Wachter and Goldman writing in the September 15 issue of the New England Journal of Medicine (NEJM) noted that, "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, M.D., PhD., writing in that same NEJM issue opined that, "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 that system is meant to serve. As the number of physicians caring for a patient increases, the depth of the relationship between patient and physician tends to diminish — a phenomenon of particular concern to those who regard the patient–physician relationship as the core of good medical care."

Gunderman laments the loss of connection that is created with a well-established doctor-patient relationship. "From the patient's point of view, it can be highly disconcerting to discover that the physician who knows you best will not even see you at your moment of greatest need — when you are in the hospital, facing serious illness or injury. Who is better equipped to abide by an incapacitated patient's preferences or offer counseling on end-of-life care: a physician with whom the patient is well acquainted or one the patient has only just met? The patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers."

There are arguments to be made on the other side of the coin. When primary care doctors no longer have to provide hospital care they can concentrate on their office practice and spend more time with patients in that setting. Having hospitalists also means that primary care doctors can have more control over their personal and work lives because they no longer have to deal with emergencies.

Hospitalists have become the largest subspecialty of internal medicine at 50,000 and according to Wachter and Goldman, "Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field's rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades."

Hospitalists are employees of institutions and as such they become gatekeepers for the system. They can provide greater control of length of stay and expenditure of resources and these are contentious issues among the medical profession. When doctors have allegiances to institutions are they compromising values relating to patient care?

Gunderman weighs in on this issue saying, "A high percentage of hospitalists are employed by hospitals or work at only a single hospital, which can shift loyalty away from patients and the profession and toward the hospital. Some physicians may be captured by the hospital, whose incentives to increase market share and profits are not always well aligned with the best interests of patients and communities."

It is interesting to note that in 2013 two of the top three states with the highest percentage of community hospital hospitalists were Vermont at 73 percent and New Hampshire at 68 percent. Of course, most of the hospitals in those states are community hospitals so those kind of statistics need to be considered in that context. Yet, those are still high numbers.

Does the fact that Vermont and New Hampshire community hospitals seemed to have embraced the hospitalist model mean that we will soon see more fragmented care and less of the kind of care that has been the hallmark of the time-honored doctor-patient relationship? Time will tell.

My personal take on the hospitalist movement is not positive based on personal and professional experience. Imagine that you spend 25 or 30 years building a solid home, raising a family and finally feel that you have a place where you are comfortable. When you reach the point of accomplishment and comfort you abandon your home during a major storm or catastrophic event and decide to sleep in a hotel during those times and only return home when things are calm and peaceful.

That is how I see what the hospitalist specialty has done to people's lives.

Richard Davis is a registered nurse. He writes from Guilford and welcomes comments at rbdav@comcast.net. The opinions expressed by columnists do not necessarily reflect the views of the Brattleboro Reformer.


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