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THESE NOT-QUITE-YET SPECIALISTS:
Care exclusively for hospitalized patients // Reduce the average length of stay // But do they cut costs and boost quality in the long run?

Enter Hospitalists

By Linda Keslar // Illustrations by Laura Carlin // Spring 2012
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hospitalists

Laura Carlin

A decade ago, a morning visit to check on hospital patients was a way of life for most primary care physicians. But these days, when someone is admitted to the hospital, someone else—a hospitalist—is likely to take charge. Shawn Lee, one of 18 hospitalists at Overlake Hospital Medical Center, a 330-bed community facility in Bellevue, Wash., is trained as a physician in internal medicine and has broad knowledge of the maladies he’s apt to see during a typical day. One morning last December, for example, his 15 patients had conditions ranging from pneumonia and complications from a stroke to gastrointestinal problems and dementia. One needed surgery.

Unlike other hospital physicians, in the emergency room or in critical care units, hospitalists coordinate all aspects of patients’ treatment during their entire hospital stays. Lee may make a diagnosis, order tests and medications, consult with specialists, visit the patient and keep family members informed. Though he shares some of those duties with another Overlake hospitalist who takes over on the night shift, Lee is in charge of his patients until they’re discharged, at which point their primary care physicians take over again.

Sick elderly patients with multiple problems tend to dominate Lee’s daily roster, and his ability to provide what he terms “almost instant” feedback helps them get prompt treatment that may involve several people. “I’m in the hospital all day, and everything happens in real time,” Lee says. “I order a test, get results back in several hours and can start additional testing or therapy, if necessary.”

All of that should translate to better care, and it can also lead to early discharges. Hospitalist care has been shown to reduce the average length of patients’ hospital stays, and because of the way Medicare and other insurers pay for care, shorter stays are a financial benefit for hospitals. Moreover, hospitalists increasingly take a role in managing hospital programs for quality improvement, patient safety and efficiency, and some now are involved in doctor training programs and in doing research on hospitalist care. Lee has been working with colleagues to develop best practices for prescribing in the hospital. “Ten years ago, when I started, I wasn’t expected to be part of these quality initiatives,” he says.

With hospitalists playing many roles, they’re much in demand, and their ranks have grown from approximately 1,000 nationwide in the mid-1990s to more than 34,000 today, according to the Society of Hospital Medicine (SHM). Nearly two-thirds of U.S. hospitals, including some 90% that have at least 200 beds, now use these specialists. “Within 10 years, virtually every hospital will have hospitalists,” says Robert Wachter, chief of hospital medicine at the University of California, San Francisco. And the U.S. health reform law could further speed up this trend. Starting this year, hospitals risk financial penalties for excessive readmissions, medical errors and other operating inefficiencies, and hospitalists are expected to emerge as leaders of efforts to meet the new standards.

For now, with the switch to this model of hospital care in full swing, hospitals face an array of challenges. Though hospitalist programs have delivered short-term savings, it’s not clear whether that trend will hold up in the long run. Designing an effective, efficient hospitalist program can present problems with scheduling, patient records and coordination of care, and securing adequate funding for hospitalists can be difficult when budgets are tight. And there’s no consensus yet on whether having hospitalists on staff actually improves care. Still, Wachter remains convinced of the benefits. “There are growing pains, but hospitalists fill a lot of unmet needs,” he says, such as caring for patients who can no longer be handled by residents because of new duty-hour limits.

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Hospitalists: A Field on the Move

The number of hospitalists is growing, but their turnover is greater than other physicians.

Hospitalists: Off Call

The hospitalist life may provide an appealing alternative to being available 24/7.

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hed-dossier

1. State of Hospital Medicine: 2011 Report Based on 2010 Data, published by the Society of Hospital Medicine and the Medical Group Management Association. The most comprehensive source of information about trends in the field.

2. “Association of Hospitalist Care With Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study,” by Yong-Fang Kuo and James S. Goodwin, Annals of Internal Medicine, Aug. 2, 2011. In this national study of nearly 60,000 Medicare patients, care by hospitalists was associated with shorter lengths of stay and lower hospital charges compared with inpatient care by primary care physicians. But these savings were eaten up by increased costs within 30 days after discharge.

3. “The Hospitalist: Better Value in Inpatient Care?” Issue Brief No. 842, National Health Policy Forum, March 30, 2011. This analysis examines the effect of hospitalists on the quality and efficiency of care delivery, the outlook for the physician workforce and the development of new models such as accountable care organizations.

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