AAMC Reporter: April 2005

Hospitalists Emerge as Major Partners in Acute Care

By Donna Coffman, Special to the Reporter

Higher hospitalization costs, lower insurance reimbursements and an emphasis on outpatient care combine to make caring for hospital patients more difficult for primary care physicians. The result has been a shift toward the use of hospitalists.

In an attempt to contain medical costs, more patients are being cared for as outpatients. Besides adding to the workload of primary care physicians, this means patients in the hospital are sicker and require more attention than in the past.

The Society of Hospital Medicine estimates that there are 10,000 to 12,000 physicians who work primarily with inpatients. The term "hospitalist" was coined in a 1996 article by Robert Wachter, M.D., and Lee Goldman, M.D., referring to physicians who consult patients exclusively in the hospital.

Acceptance of this newer approach to inpatient care has been growing rapidly. Christopher Veremakis, M.D., supervisor of the hospitalist program at St. John's Mercy Medical Center in St. Louis and chairman of graduate medical education, noted that the success of hospitalists is a function of economics.

"Everyone is accepting that the future is going to be hospital-based physicians taking care of almost everything in the hospital," Veremakis said.

New Breed

As healthcare institutions increase their reliance on hospitalists, the demand for such specialists increases. Hospital medicine is not yet a formal medical specialty; its ranks are composed of internists, pediatricians and family practitioners. To meet the educational needs of future hospitalists, changes in training are beginning in some residency programs.

At the University of Colorado School of Medicine, residents start in the traditional program and then during the final two years have the option of concentrating on outpatient, research or hospitalist training. At the end of hospitalist training, residents receive a certificate noting the emphasis in hospital medicine.

Jeff Glasheen, M.D., director of the school's hospitalist training, said Colorado is currently the only program in the country that uses different tracks in internal medicine training. Glasheen designed the hospitalist program to cover deficiencies in traditional training.

"While a resident spends a lot of time in the hospital, they are not necessarily doing the same things you do in practice as a hospitalist," he said.

In each of the last two years, hospitalist residents at the University of Colorado complete a month of consult medicine training. There are also lectures on non-clinical topics such as efficiency, malpractice, developing protocols and reducing medical errors. Students are also offered preceptorships where the resident follows a hospitalist on the job.

Glasheen continues to research the field to determine what skills hospitalists need.

"The program we have now is good but it's not the end product," he said. "I think we are going to evolve as our research evolves."

Veremakis points out that the recent trend in internal medicine training has moved toward increased outpatient experience. He anticipates a change.

"I think there's a good chance internal medicine will go to four years of training with different tracks for inpatient and outpatient care occurring in the last two years," he said.

Tangible Benefits

Doug Carlson, M.D., director, hospitalist program, St. Louis Children's Hospital

Economics may have driven the initial change, but hospitalists offer advantages that ensure they will be a permanent part of healthcare. Veremakis pointed out that when physicians leave their offices to attend to patients in the hospital, it reduces the number of outpatients they can see in one day and increases waiting periods for their patients. Since reimbursements for hospital care were dropping, it did not make economical sense for many office-based physicians to continue seeing patients in the hospital.

Hospitalists reduce the average patient's time in the hospital by as much as 30 percent, according to the Society of Hospital Medicine. A hospitalist can follow up on tests right away, order any additional tests and obtain specialty consultation when needed.

"In the 70s and 80s, everyone got used to the idea that the doctor had a partner covering certain days of the week and weekends on call," Veremakis said. "We explain to patients that the hospitalist is another type of partner."

Doug Carlson, M.D., director of the hospitalist program at St. Louis Children's Hospital, agreed that hospitalists contribute to cost savings in pediatrics as well.

"It's hard to measure safety and quality, but when you measure it as cost savings and length of stay, both are clearly better when you have patients cared for by a hospitalist on a daily basis," he said.

Carlson notes that pediatrics is seeing changes as well. There are currently five pediatric hospital medicine fellowship programs in the country, and officials at St. Louis Children's Hospital are considering creation of their own fellowship in the field.

Continuity of care can be maintained without the primary physician. Veremakis notes that at St. John's, the policy calls for the hospitalist to complete a discharge summary immediately after the patient leaves the hospital. It is faxed to the primary care doctor's office within six hours.

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