Dr. Who? Hospitalist medicine.

Last week when Mr. Jones went to his local emergency room with chest pain and was told he would require admission to the hospital for further evaluation, he expected at some point in the ER to be comforted by the sight of his own doctor, Dr. Gupta. Dr. Gupta, his primary care doctor, had been his doctor for over the last twenty years, had seen him through his first heart attack, had successfully gotten him to quit smoking, and had cared for his wife.

Mr. Jones was surprised to hear, though, that Dr. Gupta no longer saw patients at the hospital and that instead another doctor he had never met before, a hospitalist named Dr. Stevens, would be taking care of him at the hospital.

Hospitalists are doctors employed by hospitals or by groups that contract with hospitals to care for patients in the hospital. They are typically specialists in general internal medicine who practice only inpatient medicine. Because of financial pressures on hospitals and financial, lifestyle, and time pressures on outpatient physicians, the hospitalist system is a growing trend in U.S. healthcare.

Advantages to the patient?

Despite patients’ general resistance to change and Mr. Jones’ initial anger and sense of abandonment on not seeing Dr. Gupta, there are advantages to care by a hospitalist physician.

Availability

A hospitalist by definition only works at the hospital and therefore is generally able to both more quickly evaluate a patient and transfer him upstairs from the emergency room to a regular room. If a patient’s condition deteriorates, a hospitalist is already present at the hospital. In contrast, a patient’s regular physician may have to wait until a break in the day, such as lunchtime or after work, to leave the office and drive to the hospital. In an emergency, the physician must drop everything to rush to the hospital.

Focus on inpatient medicine

A hospitalist focuses on inpatient care and as a result hones these skills while a primary care doctor, at a time when more medical care is being performed in an outpatient setting, may have fewer patients in the hospital and greater difficulty in keeping up those skills.

Fresh look

By having a fresh set of eyes and ears, the hospitalist may pick up on details that a patient’s regular doctor may have overlooked. Changes that occur to a patient slowly over time also may be imperceptible to the patient’s primary care doctor who sees him regularly.

Shorter hospital stays

By spending their day at the hospital, hospitalists tend to shorten patients’ stays. Even paperwork, ordering of tests, or calls to specialists that might otherwise be pushed to later that day or the following day when the primary care doctor has a window of free time, may get done sooner by the hospitalist and thus facilitate a patient’s evaluation and stay.

Disadvantages to the patient?

There is no substitute for knowing a patient

A patient’s regular doctor knows his patient better than a hospitalist meeting the patient for the first time. While hospitalists attempt to communicate with patients’ primary care doctors, all of the subtleties about a patient cannot be transmitted in a simple five or ten minute conversation or in papers faxed from a chart.

How a patient complains of chest pain – the words used, the tone of voice, the look on the face - may be as important as what is said. Abnormal findings on physical examination may be present for many years and not warrant concern or further studies.

The primary care doctor may know that a given patient is not one to complain or go to the ER and may, therefore, be even more suspicious that something is truly wrong. On the other hand, the doctor may know that a given patient has complained about this same chest pain for the last fifteen years, the quality or severity of the chest pain is the same, and it has been evaluated already numerous times. The doctor may instead recognize that the patient’s visit to the ER may have as much to do with the patient’s recent strained relationship with his wife as it does chest pain.

Loss or distortion of information

There is also inevitably the potential for a loss or distortion of information whenever a patient’s care changes doctors’ hands. The greatest risk is at the time of admission and discharge between the hospitalist and primary care doctor. There is also a risk between hospitalists changing shifts as the same doctor is not necessarily always seeing the patient. Hospitalists faced with the details of many patients who they have met for the first time, may also overlook or under emphasize important details of a patient’s history.

…and consequences of the game of telephone

A doctor with a lack of information may make wrong diagnoses and make changes to a patient’s care that are unnecessary or not warranted, such as order additional tests, repeat tests, or change medicines.

The consequences can be quite serious. An article in the New York Times six years ago described the story of a patient recently released from prison who was brought to a New York City ER. Several different doctors saw the patient over several shift changes. The patient who originally went to the ER for an exacerbation of her asthma was later errantly diagnosed by new doctors with worsening of her psychiatric disease.

(http://query.nytimes.com/gst/fullpage.html?sec=health&res=9A01E0DB1E3CF93BA25755C0A9649C8B63)

The new doctor

A patient may spend a fair amount of time choosing his regular doctor, but he has little choice in the hospitalist who takes care of him. A patient is seen by the hospitalist working that shift. While hospitalists are usually specialists in internal medicine, as are the primary care doctors, due to the shift work nature and the high burnout rate, hospitalists are often hired soon out of residency and therefore may initially be long on training but short on experience. That situation may change as more doctors decide to become hospitalists.

Emotional aspects

A patient’s emotional response to a doctor can play an important role in the healing process. Patients get to know their primary care doctors over time. End of life issues are much easier to discuss and implement by a doctor who has an ongoing relationship with a patient. In addition, a patient who doesn’t have confidence in their doctor would not receive the highest level of care.

In the end

Hospitalist medicine is a growing trend in U.S. healthcare and is here to stay. The question is how the system of hospitalist medicine will evolve to meet our needs and to minimize its shortcomings.