Hospitalists – A Specialty Coming into its Own
July - August 2004
A decade after a few pioneering hospitals embraced the concept of hospitalists, those early adopters say the practice is a success and is likely to grow. Hospitalists, they say, become experts in the conditions they treat, are more committed to improving hospital processes that result in efficiencies, and free primary care physicians from having to come into a hospital to make patient rounds.
Enthusiasm is not universal, however. Many family practice doctors prefer to make rounds, checking on their own patients. Other observers question whether hospitals actually save money using hospitalists or simply push the costs to the outpatient arena.
Mercy Medical Center, Springfield, Mass., started using hospitalists in 1993, just to take care of unassigned patients from the emergency department. Primary care physicians were wary to entrust their patients to others, however, and the program expanded slowly. Finally, at “about the seven-year mark, we hit a tipping point,” says Win Whitcomb, M.D., program director. Busy primary care physicians saw that the hospitalists were “in it for the long haul” and that they delivered good care, he says.
Whitcomb’s group now cares for two-thirds of the medical patients at the hospital and has grown from six to 12 doctors. Its responsibilities have grown, too. Now the hospitalists do presurgical workups and care for the hospital’s rehab patients, and their duties are not likely to stop there.
“These physicians will continue to grow as a resource for surgical patients,” says John Schuster, Mercy’s executive vice president. “When patients come in for a hip replacement, they might also have a cardiac or diabetic problem. Hospitalists can consult on that part of treatment that a surgeon isn’t comfortable with.”
Mercy employs the physicians; their cost is mostly covered by professional billings, but the hospital kicks in $300,000 to $400,000 annually. That’s a small sum, Schuster says, compared with the $4.5 million a year that Mercy saves through resource efficiencies and decreased length of stay.
Cost savings aren’t the only financial indicator. The program has allowed 320-bed Mercy to compete with a larger teaching hospital in the same town. “If Dr. Smith sends his patient with crushing chest pain to us in the middle of the night, we will take care of the whole thing,” Whitcomb says. “If he sends the patient to a teaching hospital, he’ll have to see to the admission of the patient, telephone in orders . . . it goes on all night for him.”
Mercy plans to add more hospitalists sometime down the line. “This is absolutely the right thing to do,” Schuster says. “This is a core service we feel we will have forever.”
A Growing Necessity
In some markets, hospitalists provide more than a competitive edge, they’re a necessity. “A number of primary care physicians have chosen not to come to the hospital,” says Janet Grayson, M.D., director of the hospitalist program at Park Nicollet Clinic, Minneapolis. “If we didn’t take their patients, they would go somewhere else.” Every major hospital in the Twin Cities has a hospitalist program. “It’s become the way things are done,”she says. “We take for granted the system works.” Grayson points out that Park Nicollet no longer bothers to measure whether the 10-year-old program is reducing costs and length of stay.
A number of studies have shown that hospitalists do make a difference to the bottom line, but the difference is harder to see over time because a new baseline forms for cost and length of stay. “Cost and length of stay opened the door and allowed hospitalists to get past the political resistance; mature programs have moved on to the harder problems to solve,” says Robert Wachter, M.D., chief of the hospitalist program at University of California at San Francisco Medical Center. Doctors who practice at the hospital all day every day are in a better position to tackle these more complex problems, such as improving patient safety and outcomes, proponents say.
“Any problems the hospital has are magnified to the hospitalist,” Whitcomb says. For instance, a primary care doctor might be annoyed if she finds during her rounds that two patients aren't using their oxygen and haven’t gotten out of bed. But a hospitalist who finds the same conditions with seven patients will do something about the situation. And hospitalists are better suited to take action because they are likely to have established relationships with the nursing and respiratory departments, he says.
No large-scale studies have been conducted so far that attribute quality improvement to hospitalists. But Mercy Medical Center points to two of its own successes. In the space of a year, Mercy hospitalists improved the percentage of patients with heart failure who left the hospital with ACE inhibitors from 74 to 88 percent. During that same period, they improved documentation of left ventricular function in congestive heart failure patients from 81 to 88 percent.
“Hospitals are going to have to demonstrate quality to be paid,” Whitcomb says. “How can you bring about change if you are trying to work through three dozen primary care physicians you can’t even reach?”
Linchpin of the New Medical Staff
This new specialty also could help anxious hospital executives deal with fundamental questions about the future of their medical staffs. Physicians, disgruntled by income, managed care and other issues, are no longer as willing to do the volunteer work hospitals used to take for granted, such as serving on hospital committees and in staff leadership positions. And a growing number of specialists don’t even practice in a hospital.
“It used to be that most doctors needed the hospital to be successful; now that’s not the case,” says Laurence Wellikson, M.D., executive director of the Society for Hospital Medicine, Philadelphia, the national professional organization for hospitalists. Wellikson predicts that doctors on a hospital’s “home team” — hospitalists, intensivists and emergency department physicians — will become more prominent on the hospital’s committees.
That’s already happened at the University of California at San Francisco Medical Center. While Wachter says it is still important to have other specialists serve on medical staff committees, hospitalists participate on all committees, chairing some of the crucial ones, such as patient safety. “The structure of the medical staff won’t change, but the doctors who participate will,” Wachter says. “They will be more invested in the hospital, so the nature of the committee work will change. It will become more effective.”
Source: Reprinted from Hospitals & Health Networks, Vol. 77, No. 11, by permission, November 2003, Copyright 2003, by Health Forum, Inc.
Back to Top
