Posts Tagged ‘hospitals’

The unintended, but not surprising, negative consequences of hospitalism

By Richard Young, M.D.

A recent study in Annals of Internal Medicine looked at what happened when patients were cared for in the hospital by private physicians (presumably often their personal physicians) compared to hospitalists.

For a little background, hospitalists are doctors whose job is limited to taking care of patients in the hospital. They pick up new patients in shifts or cycles and almost always have no previous relationship with the patients. They rarely see patients in clinics and have no long-term outpatient relationships with patients.

This study found that hospitalist patients stayed in the hospital 0.64 days fewer than the private physician patients. This finding is consistent with previous studies. However, hospitalist patients were 18% less likely to be discharged home (more likely to a nursing facility), 18% more likely to make an ER visit in the 30 days after discharge, and 8% more likely to be readmitted to the hospital. This study was important because it measured real world performance across the U.S. after previous controlled studies showed the hospitalist approach had merit.

The hospitalist movement was born from many factors. One was the assumption that a doctor who is at the hospital can be more efficient because he can, for example, check on a patient later in the day and discharge the patient if a test performed in the middle of the day came back normal in the afternoon (while the private practice physician won’t come back to the hospital until the next morning). The private physician is paid nothing for any work past the first patient encounter each day. The hospitalist isn’t either, at least as a payable charge to Medicare or most insurance companies, but he’s at the hospital anyway so it’s not nearly as inconvenient for him to see the patient again.

To my knowledge, no study or private initiative has ever tried to preserve the personal physician-patient relationship in the hospital by paying the physician for the time it takes to do further work in one calendar day beyond the initial trip to the hospital–neither face-to-face work nor work performed electronically.

The best summary on the research of the impact of hospitalism to me is exactly what this study found — the length of stay decreases a little and is associated with a few problems down the road. Whether a patient spends three days or 10 days in the hospital has a lot more to do with how sick she is, not the kind of doctor providing the care. My biases about family medicine are transparent, but I can’t help wondering: if there is no significant improvement for a patient so sick she needs to be in the hospital to see a hospitalist, then why not create incentives and processes to encourage the pre-existing relationship with her family physician to continue in the hospital, especially when is she is the most ill, vulnerable, and scared?

The hospitalism movement is not a hindrance to improving our health care system, but it’s no solution either.

This post originally appeared on American Health Scare blog on Sept. 4, 2011. It has been reprinted with permission from Richard Young, M.D.

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