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May 1999
Volume 63 |
Number 5
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| Hospitalists -
A Brief Primer |
Ronald G. Angus, Jr.,
M.D.
My name is Ron and I am a hospitalist. Certainly this is the
way many hospitalists felt in the late 1980s and early 1990s.
Now, thanks to the efforts of many hardworking researchers, "hospitalism"
is undergoing extensive scrutiny in an effort that (in my opinion)
will ultimately legitimize rather than stigmatize my chosen career
path.
So what is a hospitalist? Well, that depends on whom you ask.
As Justice Potter Stewart said, "... I know it when I see it."
A hospitalist can be defined as a physician who spends the majority
of his/her working day taking care of hospitalized patients to
the virtual exclusion of outpatients. A survey of individuals
who defined themselves as hospitalists revealed the vast majority
to be internists and the majority of those to be generalists.1
A hospitalist may work in the hospital year-round or, alternatively,
in continuous blocks of time such as one or two months. There
are innumerable ways in which hospitalist groups manage to provide
this level of availability, and several common systems have been
codified elsewhere. 1The main
tenet, however, is to have a responsible physician who is intimately
familiar with a facility and is easily available to patients,
families and hospital personnel 24 hours per day.
Hospitalist practice in the United States has undergone parallel
evolution brought about by both hostile and friendly
environmental pressures in various parts of the country. I view
the forced implementation of the mandatory use of hospitalists
by some managed care organizations (which has been instituted
for several years in some markets) as one of these hostile
forces. In these plans, a patient's primary care physician is
not allowed to direct the patient's hospital care but is forced
to use a hospitalist whom he or she may not even know. This is
not a very tenable arrangement. In Dallas, Texas, the two major
hospitalist groups were formed initially to streamline the care
of unassigned emergency room admissions. Park Nicollet Clinic
in Minnesota (which at the time was a 380-person multispecialty
group) instituted a hospitalist system in 1994, in part, to improve
physician retention and increase physician availability in the
office.2 Regardless of how we
got here, hospitalists are obviously here to stay.
As the number of hospitalists grew in the mid-1990s, some were
bound to accidentally "trip over each other." John Nelson, M.D.,
and Win Whitcomb, M.D., did just that and eventually formed what
is now the National Association of Inpatient Physicians (NAIP).
Although this organization is still in its infancy, it has grown
rapidly from two people to close to 800 members and is now an
affiliate of the American College of Physicians-American Society
of Internal Medicine (ACP-ASIM). This relatively small number
of hospitalists is expanding rapidly. Some have predicted that
the ranks of hospitalists will eventually reach 20,000.3
It is probably a safe bet that if you are in one of the largest
100 cities in the United States, there is a hospitalist lurking
in your midst or there will be one very soon. Thanks to the NAIP
and its affiliation with the ACP-ASIM, I read something about
inpatient medicine in internal medicine literature every week.
Well, what is happening in anesthesia literature? I searched
Medscape and several major Web search engines in March 1999 and
found no articles containing both "anesthesiologist" and "hospitalist."
Certainly this is no surprise, given the paucity of literature
that exists on hospitalism alone. If you refer to my chosen definition
of a hospitalist above, most anesthesiologists could fit the role
of a hospitalist. We therefore, no doubt, have much in common
and an opportunity for collaboration.
Robert Wachter, who helped coin the term "hospitalist," often
refers to the voltage drop in patient information that
occurs when a hospitalist both admits from and discharges to an
outpatient physician. This potential problem certainly could occur
as an anesthesiologist manages a patient with complicated medical
problems whom he/she has never seen before and may never see again
after the immediate postoperative period. How can your experience
in collecting information from outpatient physicians be aligned
with the hospitalists? How can anesthesiologists improve relaying
important perioperative data to the hospitalist who rarely goes
in an operating room but is often seeing a patient in the postanesthesia
care unit for the first time? How can hospitalists get the most
information out of the anesthetic record? These are multiple issues
that have yet to be addressed. I suspect that just knowing that
a hospitalist is immediately available may improve the lines of
communication. When you call to get in touch with someone like
me, you actually get me and not three different people trying
to protect me from another telephone call that will slow down
my office practice.
Another area of convergence and collaboration that may not be
as obvious is end-of-life care and pain management. Most people
who die in the United States do so in an institution rather than
at home. As the number of hospitalists increases, so, too, will
the number of hospitalists providing end-of-life care. This care
almost always involves anxiety and pain relief efforts. Hopefully,
the specific modalities of pain relief chosen will minimize side
effects and complications of pain procedures and drugs. Certainly
we as hospitalists will be looking to your field and expertise
for education and assistance in this arena.
As hospitalists are here to stay, the challenge ahead lies in
improving all aspects of the practice of hospitalism. These efforts
will, by nature, involve the input from a cadre of physician organizations.
Toward that end, the NAIP has established a National Advisory
Board that consists of influential physician leaders from many
different specialty societies. It is hoped that this collaboration
will improve hospitalism and thereby improve both inpatient and
outpatient healthcare delivery.
Pick up the telephone and give a hospitalist a call. We probably
can make each other's jobs a lot easier and certainly more rewarding.
References:
- Lindenauer PK, Pantilat SZ, Katz PP,
Wachter RM. Hospitalists and the practice of inpatient medicine:
Results of a survey of the National Association of Inpatient
Physicians. Ann Intern Med. 1999; 130:343-349.
- Freese RB. The Park Nicollet Experience
in establishing a hospitalist system. Ann Intern Med.
1999; 130:350-354.
- Wachter, RM. The hospitalist movement:
Ten issues to consider. Hospital Practice. 1999; 34:95-111.
Ronald G. Angus, Jr., M.D., is an Attending
Physician, Department of Medicine, Presbyterian Hospital, Dallas,
Texas.
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