Hospitalists: The new model of inpatient medical care in the United States

1 . The origin of hospitalists This now meant that the primary care physician who, a generation earlier, had ten patients in the hospital across Within the last 5 years, there has been a dramatic change the street, many of whom were there for diagnostic workin the way inpatient medical care is delivered in the USA. ups, now had but one or two extremely ill patients in a A new breed of inpatient physicians called ‘hospitalists’ hospital across town (as the one across the street closed in has emerged and has largely replaced primary care physithe name of efficiency). Faced with the mandate to be cians in the hospital setting. Hospitalists are physicians maximally productive and efficient in two places at the (usually general internists) based in hospitals who accept same time, the old model of primary care physician-based patients from primary care physicians upon hospital admishospital care became untenable. At the same time, there sion and care for them until they are discharged back to was an increasing body of evidence from other medical their primary care physicians [1]. fields that practice makes perfect. It made sense that this Prior to the emergence of hospitalists, inpatient medical might also be the case with the practice of both inpatient care was largely provided by a patient’s primary care and outpatient medicine, and thus American general interphysician in the USA. A generation ago, such physicians nists had yet another reason to choose one setting or the would have several patients in the hospital at any given other setting but no longer both. Those who chose intime. These physicians often spent several early morning patient-based practices were called hospitalists. hours ‘rounding’ on their inpatients; they would go to their offices for the remainder of the day and, if needed, they might return to the hospital one last time late in the day. 2 . The current climate Their inpatients were often not severely ill, the hospital was frequently near the physician’s office, and there were Over the past several years the hospitalist model has not significant concerns over office or hospital availability flourished. In 1999, 65% of internists reported having [2]. The last decade, however, has brought dramatic hospitalists in their community, and in areas of the US change to the American health care system that has made with a high penetrance of managed care, the use of that model of practice all but impossible. hospitalists was even greater. For example, in heavily The earliest forces favoring a hospitalist model were managed care California, 62% of primary care physicians largely financial. As American health care became more reported using hospitalists to provide inpatient care [3]. It expensive, managed care was devised to create incentives is estimated that there are nearly 6000 hospitalists presthat would stem health care inflation. Among other effects, ently practicing in the USA, and recent analyses project an managed care raised the bar for levels of acuity that ultimate workforce of 19 000. If these numbers were to be justified hospital admission. At the same time, there was achieved, the hospitalist workforce would be comparable pressure on hospitals to make inpatient care more efficient in size to that in cardiology [4]. A recent report found that in an effort to safely reduce the length of stay. Similar 12 of the USA’s ‘Top 15 Hospitals’ (as defined by US levels of efficiency were expected in the outpatient setting. News and World Reports) have active hospitalist programs, and most of these hospitals are affiliated with the nation’s most prestigious medical schools. Finally, at a time when *Corresponding author. Tel.: 11-415-502-2399. E-mail address: flandrz@itsa.ucsf.edu (S.A. Flanders). many specialty societies are seeing their membership