22 August 2013

Hospitalists – What This Can Mean for You

Dr. Richard Gunderman is correct that in about 15 years ago, the hospitalist has evolved into being to care for hospitalized patients. Today there are over 30,000 hospitalists in the US. Dr. Gunderman follows this up with a statement that is supposed to be from a patient's point of view, which I have to disagree with very carefully. He says that hospitalists offer a number of advantages. Yes, they do from the hospital's point of view, but I think not from a patient's.

The reason is that they are employees of the hospital and answer to the hospital and the hospital's directives. Yes, in many hospitals they are on duty (in shifts) around the clock which is an advantage for the patient, but if an administrator wants certain tests done for certain types of patients, this may harm these patients when they don't need the tests. Because the hospitalists are familiar with the hospital's standard procedures, information systems, and personnel, you would think this would help. If the standard procedures are always to do more tests, then the patients may be the ones not benefiting.

Hospital medicine offers many benefits to the hospitals. This is where Dr. Gunderman nails it. Since hospitalists are generally hospital employees, they are easier to manage. They receive their paychecks from the hospital; they are more inclined to be responsive to the initiatives of the hospital leaders and easier to integrate with other members of the hospital's staff. The hospital has more control over the financial dimensions of this type of medical practice and can ensure that little or no potential revenue is lost because of the decisions hospitalists make. This is the downside for hospital patients.

When family physicians came in to see their patients, the hospitals had no control on the length of stay, or what procedures were ordered or not ordered. Now as healthcare under the ACA moves toward a model in which hospitals are paid not for the care they actually deliver, but for patient populations in the hospital, the incentives will shift to delivering less care over shorter periods of time. Again, the patients may suffer when they need to be in the hospital for longer periods, but are discharged too early.

Now it will be an advantage to the hospitals if hospitalists only admit patients who truly need to be hospitalized. Then they will be responsible to take steps to see that the length of hospital stays and costs associated with their stay in kept to a minimum. Because the hospitalists are hospital employees, these objectives will be easier to achieve.

A problem with hospital medicine under this system will be the large breaks in cohesion of care that will be introduced. Many feel that the information technology systems can overcome the lack of cohesion. The fact that an electronic medical records (state-of-the-art is questionable) is available to everyone involved in the patient's care, the health professionals supposedly will understand the patient and what is wrong. The interesting fact that everyone forgets is that an electronic record and true knowledge of the patient are not necessarily the same thing. Therefore, every time another person is added to the team, it makes sense that important information will not be conveyed.

Another shortcoming is that the hospitalist is focused on short-term care. When someone is admitted to the hospital with a heart attack, there are definite advantages in being cared for by an acute-care physician. These physicians are knowledgeable in follow-up and long-term care and they understand the patient's life outside the hospital. If patients are to survive for the long term, they need physicians who see beyond the hospital stay.

Trust is something often missing between a hospitalist and a patient. Trust relies on the human relationship that takes time and effort to build and not on electronic records. An hospitalist will be short-changed on this every time and the patient will always prefer physicians that have known them for years and have built this trust, not a doctor that they have just met. From the patient’s point of view, where the physician happens to be based is generally much less important than the quality of their relationship with the physician.

This is where small local hospitals will make a comeback and large, cold hospitals will begin to struggle for non-critical care patients will prefer dealing with their own physicians. The large hospitals will continue in some of the more difficult medical conditions, but many will struggle because they do not have physicians that have their patients' trust and a doctor-patient relationship built over the years. Be sure to read the blog by Dr. Gunderman.

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