An Introduction to the Hospitalist Model

Although hospital care has long been provided by specialists in inpatient medicine in Europe and Canada, the United States has only recently considered the potential advantages of a system that uses dedicated inpatient physicians. Rare examples of these specialists were scattered across the United States in the 1980s and early 1990s (with such diverse titles as inpatient manager, hospital rounder, and house doctor), but it was not until the past few years that interest in the hospitalist model was greatly accelerated (1-6). The National Association of Inpatient Physicians, a newly formed professional society representing hospitalists and a formal affiliate of the American College of Physicians-American Society of Internal Medicine, estimates that at least 3000 hospitalists are currently in active practice in the United States. Movement toward the hospitalist model comes in the midst of a debate about the relative merits of specialty and generalist care. Advocates of the latter cite the merits of comprehensiveness and continuity (7-9). Yet recent papers have emphasized the benefits of specialized care in patients with organ system-specific problems, such as acute myocardial infarction (10); in patients with complex diseases, such as AIDS (11); and in the performance of such procedures as percutaneous transluminal coronary angioplasty (12). Although the notion of a site-defined (rather than an organ-, procedure-, or disease-defined) specialty seems novel, it is not: Medicine in the United States embraced the oxymoron of the generalist specialist when it codified the specialties of emergency medicine and critical care medicine. What is new, at least in the United States, is the use of a site-defined specialist on the main hospital ward. As the hospitalist model proliferates, the need for research and dialogue increases. Even as system after system converts to this model, particularly in highly competitive and managed care-dominated markets, such as San Diego, San Francisco, and Minneapolis, many questions remain. For example, should hospitalists be full-time inpatient providers, or should their jobs have outpatient (or other) components? Conversely, should all inpatient care be delivered by hospitalists, or should a core group of hospitalists work with a small cadre of primary care providers in the hospital? Should generalists or specialists be the hospitalists of the future? Who should employ hospitalists, and how should hospitalists be compensated? How should hospitalists be trained? Is the hospitalist a new specialist and, if so, what are the implications of this for organized medicine, medical staffs and other credentialing organizations, and academic medicine? These questions, among others, are a starting point for rigorous study and analysis of the hospitalist model. At the national hospitalist conference that led to this supplement, we assembled leaders of managed care organizations, medical groups, payers, health care foundations, credentialing organizations, organized medicine, and academia. We heard preliminary data on the logistics and outcomes of hospitalist systems, and we heard of the clinical and political experiences of practicing hospitalists and primary care physicians. We emerged with a clearer vision of the benefits and risks of the hospitalist model, a deeper understanding of the various shapes of this model and of how some shapes might be better suited to some settings than others, and the framework of an agenda for future research and policy efforts. A Definition of Hospitalist I propose the following definition for the term hospitalist: A hospitalist is a physician who spends at least 25% of his or her professional time serving as the physician-of-record for inpatients, during which time he or she accepts hand-offs of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge. This definition has two key elements. The first is the hand-offa built-in, purposeful discontinuity in care between outpatient and inpatient providers. The second is a temporal floor, here defined as at least 25% percent of time spent in the hospital. These elements are discussed in this supplement, but I make some preliminary observations here. The Hand-Off The hand-off is fundamental to the hospitalist model. In fact, the discontinuity of care created by the hand-off is the source of one of the great strengths of the hospitalist model: the presence of a physician in the hospital throughout the day who can coordinate inpatient care and react to clinical data in real time. However, this discontinuity leads to the two greatest potential drawbacks of the hospitalist model: 1) an information voltage drop, caused by movement of information from the office to the hospital ward and back to the office, and 2) potential patient dissatisfaction caused by assignment of a new physicianoften a strangerto care for patients at their time of greatest need. Hospitalists, like others, are concerned about discontinuity of care. In a survey of 372 U.S. hospitalists, only 1% thought that communication always suffered under the hospitalist model but 88% stated that it occasionally (80%) or regularly (8%) suffered (13). Although much of the debate over discontinuity has focused on the transition of the patient from the office to the hospital, a larger concern may arise at hospital discharge. In a recent survey of 23 763 previously hospitalized patients, almost one third reported problems with peridischarge issues (14). Of note, at the University of California, San Francisco, we believe that the hospitalist system has markedly improved inpatient-outpatient communication simply because it forces us to focus on this communication as never before. For example, we now fax hospital progress notes to primary care physicians every day. We have also established a follow-up service in which hospitalists and their teams can see patients briefly once or twice soon after discharge to ensure stability before the patient resurfaces in the primary care physician's office. Information that can be captured in bits and bytes can be easily transmitted from the office to the hospital and back to the office again. That is not to say that this is currently being done in many systems (it is not) or that a linked office-hospital information system entirely solves the problem: A filtering function is needed or the vast amounts of computerized data will simply be ignored. Nevertheless, it seems reasonable to posit that the transmission of computerizable data will not ultimately be a major obstacle to a successful hospitalist system. Ultimately, the issue is how to transmit information that cannot be captured electronicallynamely, the patient's life story, values, and preferences about end-of-life care. There is no way to transmit these data other than through personal communication between the hospitalist and the primary physician, at least at admission, at discharge, and at the time of any important change in patient status. We have found that the primary care physician's presence during a discussion about resuscitation or a family conference can be invaluable. The bottom line is that the hospitalist and the primary care physician must act as a team to effectively care for the patient across the continuum. One hospitalist in Baton Rouge, Louisiana, using an analogy ripe with local color, put it this way (15): An analogous role [to that of the hospitalist] is performed by Mississippi river pilots. River pilots board all ocean liners as they enter the deceptive and changing currents of the Mississippi River. They guide the vessel safely to and from port, returning the controls to the ship's captain for the homeward voyage. Their collaborative efforts yield navigational quality that neither could attain alone. Another concern raised by the transfer of care to the hospitalist relates to the potential dissatisfaction of patients who do not see their doctor in the hospital. This is a legitimate concern, but it is being refuted by surveys showing that satisfaction among inpatients under a hospitalist's care is at least as great as that under the primary care physician-based system (16-18). These data indicate that patients may be willing to trade familiarity for availability. Some studies have also shown increases in outpatient satisfaction with the overall hospitalist system because primary care physicians can be more predictably available to their office patients (16). The Temporal Floor The second key element in the definition of the hospitalist is the temporal floor. The 25% floor is admittedly arbitrary, but a minimal amount of hospital experiencenot necessarily the 100% that some full-time hospitalists have urged (5) but certainly more than the 12% that the average U.S. physician spends providing hospital care (19)is critical to the value that the effective hospitalist brings to the system. This time commitment allows the hospitalist to become expert in the care of common inpatient disorders, learn to recognize outliers and anticipate problems, become familiar with the key players in the hospital (such as medical and surgical consultants, discharge planners, nurses, and clergy), and become sufficiently invested in the hospital system to be accountable for its cost and quality and to lead its quality improvement efforts. The Stages of Hospital Care To understand some of the forces driving the emergence of the hospitalist model, I have proposed that we consider hospital care in four distinct stages (20) (Table). Table. The Four Stages of Hospital Care In stage I, the primary care provider stage, all patients are cared for in the hospital by their own primary care physicians. For this purpose, I consider patients who are admitted to the hospital for nonspecialized general medical problems that would fall within the usual expertise of an internist (for example, community-acquired pneumoni