An Unfamiliar Face, But Here All Day
by William N. Southern, MD
Image: Will Southern, MD
The recent article in the New York Times about hospitalists offers us the opportunity to pause and reflect on our own program.
The Einstein/Montefiore Hospitalist Program began in 2000 with three direct-care hospitalists. The program now boasts 39 full time teaching-hospitalists, direct-care hospitalists, and nocturnists. Hospitalists serve the majority of ward-attending teaching months at both Weiler and Moses, and are the attendings of record for the majority of inpatients on the medical service. The implementation of this program has coincided with a dramatic decrease in the length-of-stay on the medical service. A published analysis of our program suggests that hospitalists are responsible for about an average of 1 day shorter length-of-stay per hospital admission without a change in mortality or readmission rates. Hospitalists have the greatest benefit on patients who are medically complex, and who require close clinical monitoring. The decrease in length-of-stay allows patients to get home more quickly, reduces the risk of iatrogenic complications, and reduces the cost associated with inpatient care.
"Admitted patients do not see the physician they know through outpatient visits. I always take this issue head on."
The growth of Einstein/Montefiore’s hospitalist program has mirrored the growth of the field nationally. Over the past decade, practicing hospitalists have grown from just a few hundred to over 30,000. (For comparison, there are ~20,000 cardiologists and ~12,000 gastroenterologists in the U.S.) The American Board of Internal Medicine now allows hospitalists to maintain customized certification through the Recognition of Focused Practice (RFP) in hospital medicine program. It is projected that the numbers will continue to grow and that hospital medicine will eventually have a separate specialty board certification.
The Times article relates the story of an inpatient’s family member who was dissatisfied with the level of communication with their family physician, and paints a picture of a busy primary care physician, who is never seen, rounds early in the morning, and does not return phone calls. I suspect that many primary care physicians, who communicate well with patients and their families, and work late to return phone calls, chafed upon reading this anecdote. There is a lesson here: individual stories, however well written, should not be used to evaluate a new model of care. While the existing evidence suggests that hospitalists offer lower cost care with equivalent or improved outcomes on average, it is not clear that the hospitalist model will prove to be beneficial in all cases.
The Times article does raise an important issue for the hospitalist model of care: the fact that patients, when admitted to the hospital, do not see the physician they have come to know through outpatient visits. When introducing myself to a newly admitted patient, I always take this issue head on. “I know I am an unfamiliar face to you. The downside is that you are just meeting me. The upside is that I am here all day, so if you need to talk to me, or your medical situation changes and I need to respond quickly, I’m right here.” My experience has been that patients and their families understand this trade-off and think it is well worth it.
Hospitalists tend to have long discussions with patients and their families, typically several times per day for days in a row, often when the patient and family are in a time of crisis. Very strong bonds form; the human element of medicine is not lost. Published reports consistently show high patient satisfaction with the hospitalist model.
On the national scene, many academic medical centers are integrating their hospitalist programs with quality improvement and patient safety efforts. It is thought that hospitalists are likely to understand the power of improving systems, offer valuable advice about implementation and workflow, and represent a relatively small pool of faculty who can respond nimbly to emerging quality priorities.
The Times article offers recognition of some of the benefits of the hospitalist model of inpatient care while noting some of the challenges we face in trying to offer more efficient, cost-effective care. It is likely that hospitalists will play a key role in the transformation of our healthcare system to one that is patient-centered, evidence-based, and safe.
Dr. Southern is Associate Professor of Clinical Medicine, Associate Director of the Weiler Division Medical Service, and Chief of the Einstein/Montefiore Section of Hospital Medicine.