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'Hospitalist' Movement Catching On, But 'Handing Off' Patients Seen as Risky.

August 19, 2005

Increasingly, hospitalized patients are being cared for by in-house physicians-called "hospitalists"-instead of their own doctors. The hospitalist system, a recent and rapidly spreading outgrowth of the managed-care movement, has been shown to reduce hospital stays and thus cut health-insurance costs, and some studies say it can improve medical care. The biggest benefit, say proponents, is the potential increase in the quality of care because every patient with, for example, pneumonia, is treated with the same evidence-based treatment, versus each [primary-care] physician treating it his own way.

However, separating patients from their regular doctors has unique risks, some of them with the potential for leading to medical mistakes and possible malpractice. The transition from the old approach to the new also leaves some patients and their families bewildered, unable to secure the care they believe they need. "Absolutely," acknowledges Dr. David Ansell, chief of medicine at Rush University Medical Center who previously held the same position at Mt. Sinai Hospital. "My brother was in the hospital, and woke up in the middle of the night and there was this doctor he didn't know. Afterwards he told me, 'This [hospitalist system] is a terrible idea!'

Ansell, who supports the new system, says he was talking to the board of Mt. Sinai about how hospitalists shorten the length of patients' stays, "and two of my board members went into soliloquies about being handed off to strangers: 'Who were these doctors?' "

At many hospitals these days-including Evanston Northwestern , Northwestern Memorial, the University of Chicago, Rush, Mt. Sinai and others in the Chicago area-you might still see your own physician, but it's increasingly likely you'll be in the hands of an unfamiliar hospitalist. Ideally you've been told in advance that you'll be seeing someone new once you're admitted. But often those conversations don't take place, and patients and families are mystified by what seems like their doctor's neglect. "The landscape is changing very rapidly," notes Dr. Hoangmai Pham, a senior health researcher at the nonpartisan Center for Studying Health System Change in Washington, D.C. "There's a real risk that patients are being left behind."

Unfortunately, to most doctors studying the phenomenon, issues of patient awareness and satisfaction are secondary. Even Ansell, among the most sympathetic to patients of those working in the field, points out: "Nine times out of 10 it doesn't matter [that your doctor is a hospital specialist]. It's just that the tenth time, it matters a lot."

Dr. David Meltzer of the University of Chicago is principal investigator on a study comparing the new hospitalist model with the traditional system. The new approach, he says, serves patients better because care is more focused. "You wouldn't want brain surgery done by your primary-care physician," he says. "The issue is the value of continuity versus the value of expertise."

Vyju Ramaswamy, a hospitalist at Northwestern Memorial, believes she has a better understanding of the urgent needs of hospitalized patients and of state-of-the-art care than a primary-care physician. "You'll have [hospitalists] who are knowledgeable about the details of inpatient care, so they can focus on that and try to make it as safe and effective as possible." For example, a primary-care doctor may be just as good at treating basic diabetes, she says. But if a diabetic patient develops a diabetes-related infection in the hospital, "that's a more acute issue, and there are a whole range of [hospital-based] strategies available."

Critics say while this point sounds good in theory, in practice it only works if the two doctors-primary-care and hospitalist-share vital information about the patient. Otherwise, the hospitalist might misinterpret the nature of the acute illness because he lacks familiarity with the chronic condition-in this case, diabetes-underlying it.

Statistics on the impact of the new system, while not definitive, favor hospitalists so far. A 2002 study by Meltzer found that they decreased costs and improved patient outcomes, reducing both readmission and mortality. A more recent and broader study shows smaller savings and less improvement year to year; its mortality data are not yet available. In any case, as Northwestern's O'Leary says, "Some studies show better outcomes; some show the same. I'm not aware of any that show worse outcomes."

One key group of doctors-those who treat the elderly- remain unconvinced that the new system is an improvement. Older people are the most likely to be hospitalized, these geriatricians argue, and are the ones worst served by the hospitalist approach. "Good communication and continuity are the cornerstone of all good medical care, but older Americans are a particularly vulnerable population," says Dr. Martin Gorbien, chief of geriatrics at Rush. "When someone is very ill and in crisis, that's when they need the person they know and trust."

Another problem for hospitalists, he says, is that they must deal with the repeated transitions from one caregiver to another that older patients often experience. "From inpatient to outpatient to rehab center to nursing home, the transfer of information is a concern. If you've never seen [a particular] old person before, you don't know what their baseline condition was." And, he adds, "hospitalists are often very young, so some of the hardest medicine is being practiced by physicians who are newly minted."

As for the claim of lowered mortality, "I don't think that's been proved," Gorbien says. "Of course, mortality is an important endpoint, but so many things go into the measure of a successful hospital stay. We wonder if the internists who practice hospital medicine will be sensitive to the geriatric issues of immobility, hydration, nutrition, mental status."

Others point out that most geriatric patients are treated not at academic medical centers like Rush or Mt. Sinai but at community hospitals, where part of the hospitalist's job is to improve utilization of hospital beds-that is, to minimize patient stays. "It was just a big mill," says Dr. Brian Rubenstein, who left a hospitalist position at a community hospital to join a private practice. "The pressure to move patients out sometimes superseded in importance what we were doing to them." But he concedes that "a good doctor can do good care in this model," noting especially the value to elderly patients of shorter stays in the hospital. "There's less opportunity for them to get the wrong medication or get demented or get a hospital-acquired infection."

However debatable its merits, there's little doubt that the hospitalist system is the wave of the future in health care. The Society of Hospital Medicine reports that the field has exploded from about 800 self-identified hospitalists in the mid-1990s to about 10,000 today, and is projected to more than double-to 25,000-in the next five years. Half of all U.S. hospitals employ or use hospitalists in some capacity, and about half of all managed-care organizations operate either voluntary or mandatory hospitalist programs, according to the New England Journal of Medicine.

Though geriatric specialists and others are critical of the hospitalist system, most doctors have something positive to say: that it's convenient for primary-care physicians who no longer have to drive across town to visit a hospitalized patient; that it moves patients in and out of hospitals more efficiently; that it reduces costs for the employers and government agencies paying for medical care; and, especially, that it improves outcomes for patients, including reduced mortality.

But Laura Stempel, whose mother was treated by hospitalists at Evanston Northwestern Hospital for injuries suffered in a fall, is not reassured. At first, Stempel says, the only question she knew to ask was the furious, "Where is my mother's doctor?" She didn't get an answer for several days. Finally, another member of the doctor's practice explained that their medical group had stopped making rounds.

Despite her mother's considerable pain, Stempel says, the hospital doctors assured her nothing was broken. But after she was discharged, her personal physician told her she had a broken rib-after which she fired the doctor for leaving her in the hospitalists' care. In a written statement, Evanston Northwestern Healthcare responded: "We were surprised to hear Mrs. Stempel had a poor experience in our hospital. In reviewing her medical record, there is no indication of dissatisfaction, and our Service Excellence office has no record of complaints. In recent years, Mrs. Stempel has continued using the physicians and hospitals of Evanston Northwestern Healthcare."

Communication between a patient's regular doctor and the hospitalist is another matter. "There's a lot of work being done about transferring patients from one setting to another and about the handoff [between doctors]," says one doctor. Indeed, the handoff of crucial patient information from the general practitioner to the hospitalist has been called the Achilles heel of the new system. One doctor observes that specialists, including hospitalists, tend to talk to each other instead of to primary-care physicians, and information about a patient's overall health may not get passed along.