Mr. Johnson first met his internist, Dr. Rogers, when he had a sinus infection and needed a primary care physician. He returned to see her months later when she helped counsel him to quit smoking, and then yearly for checkups. When he was 40 years old and was troubled by a bout of depression, she treated him. A few years later, after taking up smoking and becoming overweight, he developed severe chest pain and was taken to the hospital. The emergency room physicians dutifully informed Dr. Rogers that her patient was to be hospitalized, but when he was admitted to a medical service, he was surprised to be met not by Dr. Rogers but by Dr. Kennedy, who introduced himself as a “hospitalist,” a word unfamiliar to Mr. Johnson.
It is increasingly likely that patients or their loved ones will encounter hospitalists during the patients’ next hospital stays. This change is the result of a “hospitalist movement” that began two decades ago and was designed to provide efficient, responsible care of hospitalized adult patients on internal medicine services. Hospitals, under increasing organizational and national pressure to deliver high standards of care and reduce length of stay and costs, hired internists whose chief clinical responsibilities were to manage inpatients.
Because of growing financial pressures, most primary care practitioners embraced the idea of relinquishing their hospital responsibilities to focus on efficient delivery of healthcare to their outpatients.
The concept of physicians who practice purely hospital-based medicine was not new. Emergency and critical care medicine physicians have staffed emergency departments and intensive care units for years, without any concurrent maintenance of office-based practices.
However, in the 1990s the field of internal medicine began a dramatic organizational transformation that affected both hospital and office-based practice. This change encompassed all types of medical communities, including large, tertiary academic medical centers as well as hospitals and practices serving small, community-based regions.
It is clear that hospitalists set off a seismic shift in healthcare that is still being felt as it spreads through various fields, including pediatrics and surgery, and the consequences have been substantial:
- Patient care in the hospital setting has become more efficient, consistent, and accurate.
- Medical education for trainees and students can be enhanced by hospitalists whose focus is exclusively on caring for inpatients, not on returning to their “home bases” in their offices.
- The hospitalist career choice has become appealing to trainee graduates in both the short and the long term. The ability to practice medicine with more-structured hours and without the burdens of managing outpatients is less restrictive, and may open up avenues for academic and educational pursuits.
At the same time, patients like Mr. Johnson have felt the impact of hospitalists, though they might not be so pleased with the results. Care may be better and more efficient, but it has become less personal. Mr. Johnson was troubled that Dr. Rogers, his longtime internist, did not manage his care when his health concerns became more sudden and serious. Dr. Kennedy seemed professional, knowledgeable and nice, but he wasn’t his doctor. Hospitalists may not possess the sense of connection to their patients that internists who managed their patients in any domain would have in years past, the way Dr. Rogers used to practice.
This past decade has finally brought the hospitalist movement to one of the last fields of intensely personalized medicine: neurology. Neurohospitalist programs have emerged nationally, and a few major academic centers have developed neurohospitalist fellowship training programs.
Brain disease is deeply personal, and patients with neurological conditions such as epilepsy, multiple sclerosis, stroke, chronic migraine, Parkinson’s disease and dementia form strong bonds with their neurologists. It may be jarring to our patients not to be met by their neurologists when the patients go to the hospital with breakthrough seizures, falls, strokes or disease exacerbation.
Nonetheless, patients and practitioners must adapt to changes in medical care, and hospital-based medicine is no exception. It might not be old fashioned, but if hospitalists can deliver care that is better and more cost-effective, and communication among inpatient and outpatient practitioners is maintained, then the model will continue its success and diversify into even more specialties.
Mr. Johnson may ultimately be grateful for this model, because the next time he sees Dr. Rogers in her office for a follow-up visit, chances are she will be much less harried and more attentive than she would have been if she were rushing to and from the hospital on a daily basis.