Hospital Medicine: Better, or Less Personal, Care?

Laurie Barclay, MD

August 12, 2016

Two contrasting perspectives on hospital medicine published August 10 in New England Journal of Medicine describe the potential for better, more efficient care, but also strain on the physician–patient relationship.

"Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system's capacity for massive change under the right conditions," write Robert Wachter, MD, from the University of California, San Francisco, and Lee Goldman, MD, MPH, from the College of Physicians and Surgeons, Columbia University, New York City, in the first perspective.

The contrasting viewpoint notes that physicians are indispensable to patient care, whereas hospitals are not.

"To position the hospital at medicine's center is to create an unbalanced system, one that will continually jar both patients and the health professionals who care for them," writes Richard Gunderman, MD, PhD, from Indiana University School of Medicine, Indianapolis. "The true core of good medicine is not an institution but a relationship...between two human beings.... Models of medicine that ensconce physicians more deeply in spatial and temporal silos only make the prospects for such relationships even dimmer."

Since hospital medicine became a specialty 20 years ago, US hospitalists have increased from a few hundred to >50,000, employed at ~75% of US hospitals and all leading academic health centers. The field now ranks fourth in number of practitioners, behind only general internal medicine, family medicine, and pediatrics, and includes pediatric, surgical, neuro, and obstetrical subspecialties.

Hospital Medicine May Improve Efficiency of Care

Managed care and Medicare's diagnosis-related-group–based payment system were the impetus in the mid-1990s for hospitals to manage care more efficiently.

"Within a few years, evidence showed that using hospitalists could result in reduced costs, shortened lengths of stay, and preserved or even enhanced quality of care and patient satisfaction," Dr Wachter and Dr Goldman write. "The field was off and running."

They attribute the rapid rise of hospital medicine to a viable financial framework, a qualified physician pool, and sufficient momentum to overcome resistance to change.

Increasing numbers of emergency admissions mandated immediate and ongoing attention to acutely ill patients, a role well suited to hospitalists. Meanwhile, declining reimbursement for nonprocedural inpatient care made primary care physicians and academics more willing to relinquish inpatient care.

Significant cost savings from hospital medicine led healthcare organizations to offer hospitalists good salaries and other benefits. An abundant US pool of general internists well trained in inpatient care sustained hospitalist growth. Quality metrics and electronic health record implementation provided a suitable niche for hospitalists, many of whom help avoid financial penalties for readmissions by staffing post–acute care facilities.

However, the hospitalist model is "based on the premise that the benefits of inpatient specialization and full-time hospital presence outweigh the disadvantages of a purposeful discontinuity of care," Dr Wachter and Dr Goldman explain.

Handoff protocols and postdischarge telephone calls to patients incompletely prevent these disadvantages. Exacerbating this "Achilles heel" is hospitalists' shift schedule, limiting their involvement during "off" time.

Other challenges include less exposure of medical trainees to specialists and researchers and greater emphasis of hospitalist research on implementation of quality- and systems-related initiatives, rather than on disease mechanisms or treatments.

Possible solutions include having some hospitalists act as "comprehensivist" physicians caring for a small number of highest-risk, repeatedly admitted outpatients. Hospitalists can develop early-warning electronic health record systems to identify patients at risk for sepsis or falls, improve diagnosis with bedside ultrasonography, make rounds more patient- and family-centric, and implement unit-based leadership teams. Concurrently, academic programs may improve trainee and hospitalist exposure to basic sciences.

"Such innovations are welcome and should be studied," Dr Wachter and Dr Goldman conclude. "In fact, the field's greatest risk may well be complacency — failing to embrace the kinds of transformation and disruption that led to its birth, or being slow to address the inevitable side effects of even the best innovation."

Hospital Medicine May Strain the Patient–Physician Relationship

Hospital medicine is defined by the location in which care is delivered, rather than on patient age, involved organ systems, or specific physician skills.

"What we don't yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians," Dr Gunderman writes.

"As the number of physicians caring for a patient increases, the depth of the relationship between patient and physician tends to diminish — a phenomenon of particular concern to those who regard the patient–physician relationship as the core of good medical care."

More physicians involved in a patient's care may result in miscommunication and discoordination of care, especially at admission and discharge.

"From the patient's point of view, it can be highly disconcerting to discover that the physician who knows you best will not even see you at your moment of greatest need — when you are in the hospital, facing serious illness or injury," Dr Gunderman explains. "The patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers."

Community physicians are also at risk for less professional and personal fulfilment when they do not oversee their patients' hospitalizations. Potential disadvantages for the medical profession include increased fragmentation of patient care, faster burnout, and less knowledge sharing and camaraderie.

Hospitalists may suffer from lack of outpatient experience, becoming less accountable to nonhospitalized patients and their communities, and therefore less effective advocates for comprehensive medical care. Their employment by hospitals may shift their loyalty away from patients and their profession.

Dangers to hospitals include fewer physicians on hospital medical staffs, isolating hospital leaders from community needs.

"The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians," Dr Gunderman concludes. "A good hospital is a great boon to patient care, but the hospital itself is ultimately a tool — to be sure, a large, complex, expensive tool — without which patients can still be given care."

Dr Goldman and Dr Gunderman have disclosed no relevant financial relationships. Dr Wachter reports disclosures involving Agency for Healthcare Research and Quality, IPC Healthcare, CareWeb, Lippincott, Williams & Wilkins, McGraw-Hill, John Wiley & Sons, The Doctor's Company, the UK National Health Service, PatientSafe Solutions, EarlySense, QPID, and Amino.com.

N Engl J Med. Published online August 10, 2016. Wachter and Goldman full text, Gunderman full text

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