I would think even admission via an ER at least has the ER as a gatekeeper. They do operate their own unit for their patients with spinal cord injuries, because they want them to be cared for by people who know them well–literally as in, where’s the best vein to get an IV in. While Sherif Abdou, MD, CEO of Pinnacle Health Systems in Phoenix, has watched the company’s 200-hospitalist group lose business because of exclusive contracting, he urges hospitalists to try to understand why a hospital might want to set up an exclusive contract. The hospitalist is the attending physician and primary caretaker starting from the person's admission day to discharge day. 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. Her blood pressure had stablilized, her pain meds were oral and working fine… and most important she was stressing out over being kept in the hospital for just 1 night let alone 2. I have some experience working with an oorganization called Commonwealth Care Alliance which specializes in care for the disabled and the poor, frail elderly. but lets not feign that this system has anything to do of aetna, mark bertolini, makes 36 million dollars a year.. hands of these people and their complete comfort 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.”. Dr. Kathleen Handal, MD. Sharpe realized that you can, in fact, do both. And there goes Wachter again, exaggerating the available information to make his case. They lead the hospital medical team, coordinating care for inpatients. In my impression, “Hospitalist” is the name applied to folks who take care of hospitals. He was too lazy to do so himself and so transferred the patient to the hospitalist. hospitals are no place for lazy clock counting doctors.. All of my relationships were short term but had very high impact. Whilst not specialists, these clinicians are nonetheless experienced in their years of medical practice, and depending on their … Are we ready to let a hospitalist outside your provider’s practice link with and use your provider’s EMR for your hospital stay? My experiences with socialized medicine were far It unites the patient with: care givers, family members, care professionals (internists such as myself, specialists, hospitalists….etc), pharmacists, the public internet, medication management, self-care advice….etc. A few months ago I had the misfortune to need an AAA repair. 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. As with everything in medicine (and in life), there are tradeoffs. in the past 10 years than i want to count. They see hospitalized patients who have been referred by primary care doctors, emergency room doctors, or other physicians at the hospital. However, the field of hospital medicine far from a “new breed,” and I can f/u on details if you wish. Now thats a joke. When it is time to go home, your primary care physician will become your primary source of care. 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). 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. … morning, had some bowel issue in the afternoon, and The idea that “a stranger is taking care of a stranger”. I don’t think so. The evidence is strong the hospitalists improve the value of care. Our hospitalist community has to be driven to expect the best. He had the hospitals for Normandy and the occupation Mimission rates do not warrant a FT rural hospitalists Often night shifts. The scientific evidence has only grown in confluence with an epidemic of opioid overdoses that, according to CDC estimates, kills 142 Americans every day. Excellent discussion. Your email address will not be published. Great ideas for improving the health care system. real life or death medicine, which is a thrill all It is currently being implemented in the Advanced Care Clinic at UNC-Chapel Hill. And are the current EMRs of value to the casual user? Then, today, I found that the patient had been re-assigned to a Nurse Practitioner who was keeping her over another night, quite unnecessarily. not remember what happened at the other hospital Whatever happened to reading in, especially on older AMEN! 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. the president It was rare that I had a long term relationship with a patient before I entered the room, had to rapidly develop a relationship. it has to do with business. Hospitalists provide general medical care to hospitalized patients. Some non-hospitalist physicians also find the rise of hospital medicine attractive. doesnt get any easier than that. I intend to write a grant to support its use with my “advanced care patients” in my solo private practice in NE North Carolina in the “Inner Banks” – a very “rural and remote” (and relatively poor and diverse) area. 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. Led by a neutral third party, we attempted to dissect and understand the barriers to patient flow from the ED to the medical floors. They make large sums of money for the hospitals they work for. I won’t return to that hospital, and dread having to deal with this depersonalized care paradigm in the future. 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. So, he did… to his mind… ordering 0.5 mL of pain med every 2 hours. 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. The hospitalists will be available to provide and coordinate care during your hospital stay. We at SHM strive to move our profession forward (I speak as a founder and active member, not in an official capacity); and if you skim our site, you will note a trove of information on everything we work towards: 1) improve the wards (a woefully neglected place, even harkening back to the golden age–not so golden), and 2) advance a science we still know little about. inoperable cancer the next day, without the benefit From a quality-of-care perspective (focusing on hard outcomes as well as processes of care), the rise of the hospitalist does seem to make sense, as it helps reduce the fragmentation of the care within the hospital, while GPs working with hospitalized patients often run in and out and don’t have ongoing relationships with staff. The discussions that can avoid chasing futile ends are grounded in trust. well the first hospital had found Not one meal offered, but I did wring out an orange juice, and a pack of unsalted saltines after the horsesasspitalist said I could have a meal. We saw 2 ER physicians (the shift changed) with a wait of 10 hours for admission before they were convinced he was bleeding. Hospitalists examine test results, order treatments and medical services, and prescribe medications. The attraction of primary care is indeed the long term relationship but also mostly comes with impact achieved over a period of time. Because hospitalists are generally hospital employees, it makes them easier to manage. The evidence is clear: Taking buprenorphine or methadone for opioid use disorder increases retention in treatment programs and decreases overdose, drug use, infectious disease transmission, and criminal activity, according to the National Institute on Drug Abuse. Another pitfall of the hospitalist is the focus on short-term care.  When someone is admitted to the hospital with an acute medical condition, such as a heart attack or stroke, there are definite advantages to being cared for by an acute-care physician.  However, excellent care for many patients requires a physician who is focused on follow-up and long-term care, and who understands the patient’s life outside of the hospital.  If patients are going to thrive over the long term, they need physicians who see beyond the boundaries of the hospital stay. During your stay, your hospitalist and your primary care physician will communicate about your treatment. Evolving from a doctor who knows it all to team-based care and specialization whether emergency medicine (decades ago) to hospital medicine is natural. i have seen three ‘hospitalist’ run hospitals nearly Yes, widespread after-hours clinics do help lower ER use, but I’m not sure it has to do with the availability of hospitalists. Twitter: @davisliumd. In fact, I’d bet that, if Marcus Welby were practicing today, he’d use hospitalists. In the first half of the 20th century, a new pediatric disease was identified.  Some infants cared for in hospital failed to grow and develop normally, despite adequate feeding.  Many eventually grew sick and died.  This disorder was more common in well-off institutions than poor ones. Hospitalists provide inpatient care predominantly in settings such as medical wards, acute care units, intensive care units, rehabilitation centers, or emergency rooms. But maybe his loans weren’t so onerous. companies. The Hospitalist hadn’t seen the patient one single time since surgery. Shouldn’t happen, but it will….. Each 12 hours, we got a new doctor, none of whom seemed to care about much more than the previous 6 hours. Who … The claim that hospitalists improve care merely based on their presence is incorrect at worst and native at best. It speaks to hospitalist medicine, but also to the broader context in which medicine is practiced today. In a previous post, I discussed why the work required to take care of 15 patients at one hospital does not equal the amount of work required to take care of 15 patients at another hospital. 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). So many good points. Hospitalists who meet the definition for ‘hospital-based’ are automatically exempt from PI. There is a problem with defining physicians by the contexts in which they practice instead of the kind of care they give.  From the patient’s point of view, where the physician happens to be based is generally much less important than the quality of their relationship with the physician.  Life-changing and even life-and-death decisions may need to be made during the course of a hospitalization, and both knowing their physician and knowing that their physician knows them makes a big difference. 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. people…no need for history….just the eye of the To gain the trust of a both patient and family. You are picking on the wrong guy. Op-eds. The Nurse Practitioner had never seen the patient AT ALL… And, this is who made the decision to hold the patient over for another day in spite of the patient’s objections and the medical lack of necessity for the extra day. Welby would BE a hospitalist. But as patients become hemodynamically unstable or acutely ill, patients are in need of short term but very high impact care. 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. This is our calling, it is what we are trained to do. 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 I cannot tell you how many of my outpatient colleagues are very happy to have us working with them in the hospital. 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. and it is a cruel and inhuman thing to do to an Conversely, we also need our overwhelmed cadre of primary care physicians to concentrate on caring for their outpatients, not just via an office visit but increasingly through population management. 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. The problem is that many primary care doctors don’t follow their patients in the hospital, and, as you know, there is a significant deficit of primary care doctors to even see patients in the outpatient setting. The next day we met another hospitalist, who was non-committal as to the cause of the continued GI distress, and the falling blood count. Why the false dichotomy? the same thing, done all the recommended invasive 3. The shift has been more than one sided. had a private practice as a urological surgeon, along Why? trauma after a motor vehicle accident or cholecystectomy for right upper quadrant pain. They do not need to travel to one or more hospitals each day to see patients, which takes considerable time and generates little revenue.  They do not need to work so hard at staying abreast of changes in hospital procedures and technologies, which often vary from institution to institution, as do requirements for acquiring and maintaining hospital medical staff privileges.  And finally, they can focus their energies on outpatient care, avoiding the more acutely life-threatening and complex situations associated with hospitalization.