Once, when patients were hospitalized, their own doctors would follow and coordinate the care provided by whatever specialist was needed. But economics, the desire to reduce the length of hospital stays, and the unique challenges of providing hospitalized care led to the development of the “hospitalist,” that is physicians who specialize in treating patients in the hospital.
I have nothing intrinsically against the concept, except that in today’s health care system increasingly challenged by utilitarian pressures, I have worried that hospitalists— being employees or contractors with the hospitals rather than specifically the patient’s own physician—could come to unconsciously represent the hospital’s bottom line and culture rather than the needs and values of the sickest patients. I am especially concerned about this potential paradigm in futile care theory cases in which hospitalists who want to terminate wanted care could unduly sway ethics committees. And, not being a patient’s usual doctor and with no history with the patient or family, I have also been concerned that communication with families in catastrophic situations could be difficult or become hostile. On the other hand, I have seen the work of hospitalists in my local hospital and have, so far, been quite impressed.
My concerns aside, it is pretty clear that the hospitalist movement has succeeded and is moving quickly from the experimental stage to becoming the norm. This is clear from the conclusion of an article in the current New England Journal of Medicine (no link) entitled, “The Hospitalist Movement—Time to Move On,” by Laurence F. McMahon, Jr., M.D., M.P.H.. He concludes:
The hospitalist movement has arrived, and it has transformed the care of hospitalized patients. Investigations similar to the early studies of hospitalist practice, which were focused on cost and comparing outcomes with those of other providers, should begin to wane. New investigations should focus on quality improvement, comparative effectiveness, clinical informatics, the safety of patients, and the translation of new medical advances to clinical practice. Academic medical centers must make strategic investments to provide opportunities in research training for hospitalist physicians and to support the research infrastructure. The academic focus and role models in the training environment will enhance the pipeline for hospitalists, but the underlying payment structure for evaluation and management needs to be dramatically enhanced if this field is to be sustained. Hospitalists are now an integral component of our delivery system; we must take advantage of these skilled physicians and take the next steps to enhance the care of hospitalized patients. It is time to move on.Like it or not, this is clearly the future of medicine.
