Hospitalists in the United States — Mission Accomplished or Work in Progress?
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《新英格兰医药杂志》
Eight years ago in the Journal, a colleague and I described a new breed of physician — the "hospitalist" — whose primary role was to care for hospitalized patients, returning them to the care of their regular physicians at hospital discharge.1 Since that time, the number of hospitalists in the United States has grown from a few hundred to approximately 8000, with projected growth to 20,000 (about the number of cardiologists in this country). With hospitalists at most major U.S. teaching hospitals,2 students and residents (in both internal medicine and, increasingly, pediatrics) now receive much of their inpatient training from attending physicians who are hospitalists. The Society of Hospital Medicine, a professional organization of hospitalists, has mushroomed to 4000 members (see Figure).
Figure. Membership of the Society of Hospital Medicine, 1997 through 2003.
The initial growth of the field was fueled by the belief on the part of leaders at some hospitals, health maintenance organizations (HMOs), and medical groups — later supported by published data — that the use of hospitalists might result in lower inpatient costs without compromising quality or patient satisfaction.2 By the late 1990s, primary care physicians, many of whom initially objected to the concept of hospitalists because of concern about discontinuity in patient care and acceptability to patients, began to embrace the model, in part because inpatient care had become an economically inefficient use of their own time.
Despite its growth, the hospitalist model remains somewhat controversial, with five questions dominating the current debate. What are the effects of the discontinuity between outpatient and inpatient care that is introduced by the model? How ironclad is the case that the hospitalist model improves quality and efficiency? Where will the money come from to support hospitalist programs? Will hospitalists burn out? And what effect will forgoing the provision of hospital care have on the professional satisfaction of primary care physicians? These are important questions, and answers have not been easy to obtain.
The hospitalist model creates a purposeful discontinuity between office and hospital, potentially leading to some loss of critical information relevant to patient care. Good hospitalist programs mitigate this information loss with frequent telephone calls and computerized links to primary care physicians. However, the degree to which programs have bridged this gap has varied, and some programs have unfortunately wavered from their initial focus on pristine communication after the survival of their hospitalist group was assured.
Most outcome studies of hospitalist programs have examined single hospitals, small numbers of hospitalists, and the initial years of the programs; these data may not reflect widespread or current conditions.2 Studies of efficiency have tallied only the use of inpatient resources, raising the possibility that some of the model's economic advantages are eroded by compensatory increases in postdischarge costs. Quality studies have been relatively rudimentary, looking only at overall outcomes (e.g., mortality), without considering more sensitive process measures of quality. The short follow-up periods raise the possibility that initial gains in efficiency or quality might not be sustained. All these concerns are legitimate and should be addressed by larger, longer studies with more robust outcome measures.
Finding the dollars to support hospitalist programs is probably the field's greatest challenge. The core evaluation and management activities undertaken by hospitalists are under-reimbursed by payers, as are many of the other nonprocedural activities they have embraced: leading systems-improvement efforts, managing or comanaging the care of surgical patients and those in the intensive care unit, providing nighttime inpatient coverage (particularly coverage for uninsured patients or those who do not have primary care physicians) for medical staff members that are increasingly reluctant to do so, covering observational and skilled nursing units, teaching students and residents, and staffing non-resident services in teaching hospitals. Many hospitals, medical groups, and HMOs have acknowledged the value of these services by providing funding to support hospitalist programs that would otherwise fail.
Yet the administrators who were early supporters may be reluctant to sustain their initial investment, particularly when the improvements in efficiency or quality plateau (as they inevitably do as programs mature). In part because of this financial hurdle, there has been concern about burnout among hospitalists. Although an early survey revealed high levels of job satisfaction and relatively low rates of burnout,3 the rates may be increasing, owing to growing workloads and fragile institutional support. Some programs have seen rapid turnover in personnel; with such turnover, many of the model's promised benefits, such as leadership in quality improvement and patient safety, as well as strong relationships with administrators and with nurses who care for inpatients, may fail to materialize.
Finally, even as tens of thousands of primary care physicians choose to refer their patients to hospitalists, many of them lament the loss of hospital-based collegial interactions, often recalling their residency or early years of practice. Some observers have even blamed the declining popularity of careers in primary care on the hospitalist model. Although these feelings are understandable, it is important to realize that the average primary care physician's hospital time had plummeted (from 40 percent to 10 percent) over the past generation. As a result, primary care physicians who depended on hospital care for their professional satisfaction and education were already in trouble, irrespective of the creation of the hospitalist model. In the end, the answer to our looming primary care crisis will not be found in the hospital.
The growth of the hospitalist model demonstrates that new forces in health care — cost pressures, the mandate to improve safety and quality, limits on duty hours for residents — can catalyze innovative organizational solutions. Just as emergency medicine and intensive care medicine illustrated in the 1970s, the emergence of hospital medicine shows that our society and profession, enamored as they are of organ-focused and procedure-based subspecialization, still value the coordinative role of site-based generalists. Moreover, the growth of hospital medicine has been accompanied by research demonstrating that the promise of the model is being realized — an all-too-rare example of evidence-based organizational change.
Yet a staffing model is only as good as the people who fill its roles. The challenge going forward will be to attract excellent and committed physicians to hospitalist positions, both in academia and in community practice, and to retain them once they have arrived. The extent to which this challenge is met will determine the ultimate effectiveness and growth of the hospitalist model.
Source Information
From the University of California, San Francisco.
References
Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996;335:514-517.
Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002;287:487-494.
Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med 2001;161:851-858.(Robert M. Wachter, M.D.)
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The initial growth of the field was fueled by the belief on the part of leaders at some hospitals, health maintenance organizations (HMOs), and medical groups — later supported by published data — that the use of hospitalists might result in lower inpatient costs without compromising quality or patient satisfaction.2 By the late 1990s, primary care physicians, many of whom initially objected to the concept of hospitalists because of concern about discontinuity in patient care and acceptability to patients, began to embrace the model, in part because inpatient care had become an economically inefficient use of their own time.
Despite its growth, the hospitalist model remains somewhat controversial, with five questions dominating the current debate. What are the effects of the discontinuity between outpatient and inpatient care that is introduced by the model? How ironclad is the case that the hospitalist model improves quality and efficiency? Where will the money come from to support hospitalist programs? Will hospitalists burn out? And what effect will forgoing the provision of hospital care have on the professional satisfaction of primary care physicians? These are important questions, and answers have not been easy to obtain.
The hospitalist model creates a purposeful discontinuity between office and hospital, potentially leading to some loss of critical information relevant to patient care. Good hospitalist programs mitigate this information loss with frequent telephone calls and computerized links to primary care physicians. However, the degree to which programs have bridged this gap has varied, and some programs have unfortunately wavered from their initial focus on pristine communication after the survival of their hospitalist group was assured.
Most outcome studies of hospitalist programs have examined single hospitals, small numbers of hospitalists, and the initial years of the programs; these data may not reflect widespread or current conditions.2 Studies of efficiency have tallied only the use of inpatient resources, raising the possibility that some of the model's economic advantages are eroded by compensatory increases in postdischarge costs. Quality studies have been relatively rudimentary, looking only at overall outcomes (e.g., mortality), without considering more sensitive process measures of quality. The short follow-up periods raise the possibility that initial gains in efficiency or quality might not be sustained. All these concerns are legitimate and should be addressed by larger, longer studies with more robust outcome measures.
Finding the dollars to support hospitalist programs is probably the field's greatest challenge. The core evaluation and management activities undertaken by hospitalists are under-reimbursed by payers, as are many of the other nonprocedural activities they have embraced: leading systems-improvement efforts, managing or comanaging the care of surgical patients and those in the intensive care unit, providing nighttime inpatient coverage (particularly coverage for uninsured patients or those who do not have primary care physicians) for medical staff members that are increasingly reluctant to do so, covering observational and skilled nursing units, teaching students and residents, and staffing non-resident services in teaching hospitals. Many hospitals, medical groups, and HMOs have acknowledged the value of these services by providing funding to support hospitalist programs that would otherwise fail.
Yet the administrators who were early supporters may be reluctant to sustain their initial investment, particularly when the improvements in efficiency or quality plateau (as they inevitably do as programs mature). In part because of this financial hurdle, there has been concern about burnout among hospitalists. Although an early survey revealed high levels of job satisfaction and relatively low rates of burnout,3 the rates may be increasing, owing to growing workloads and fragile institutional support. Some programs have seen rapid turnover in personnel; with such turnover, many of the model's promised benefits, such as leadership in quality improvement and patient safety, as well as strong relationships with administrators and with nurses who care for inpatients, may fail to materialize.
Finally, even as tens of thousands of primary care physicians choose to refer their patients to hospitalists, many of them lament the loss of hospital-based collegial interactions, often recalling their residency or early years of practice. Some observers have even blamed the declining popularity of careers in primary care on the hospitalist model. Although these feelings are understandable, it is important to realize that the average primary care physician's hospital time had plummeted (from 40 percent to 10 percent) over the past generation. As a result, primary care physicians who depended on hospital care for their professional satisfaction and education were already in trouble, irrespective of the creation of the hospitalist model. In the end, the answer to our looming primary care crisis will not be found in the hospital.
The growth of the hospitalist model demonstrates that new forces in health care — cost pressures, the mandate to improve safety and quality, limits on duty hours for residents — can catalyze innovative organizational solutions. Just as emergency medicine and intensive care medicine illustrated in the 1970s, the emergence of hospital medicine shows that our society and profession, enamored as they are of organ-focused and procedure-based subspecialization, still value the coordinative role of site-based generalists. Moreover, the growth of hospital medicine has been accompanied by research demonstrating that the promise of the model is being realized — an all-too-rare example of evidence-based organizational change.
Yet a staffing model is only as good as the people who fill its roles. The challenge going forward will be to attract excellent and committed physicians to hospitalist positions, both in academia and in community practice, and to retain them once they have arrived. The extent to which this challenge is met will determine the ultimate effectiveness and growth of the hospitalist model.
Source Information
From the University of California, San Francisco.
References
Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996;335:514-517.
Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002;287:487-494.
Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med 2001;161:851-858.(Robert M. Wachter, M.D.)
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