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History of the Hospitalist Movement

Traditionally, the Primary Care Physician (PCP), usually an internist or family practice physician, has been responsible for outpatient and inpatient care. There have been many forces in healthcare that have pushed toward a separation of care provided to patients in both of these locations. Changes in hospital management systems, hospital size, increasing severity of patient illness, and out-of-control healthcare costs have all been integral in the push towards an inpatient physician-driven care model.1 Within the context of these changes, there has been a growing sense of PCP dissatisfaction in the ability to provide timely and efficient care to both their outpatient and inpatient populations. This has ultimately given birth to the hospital medicine “specialist.” This emerging specialty is defined, much like Critical Care and Emergency Medicine, by the site of care rather than a disease, patient population, or organ-system.1

While physicians with inpatient care duties have existed both in North America and Europe for some time, the appearance of the hospital physician is a newer phenomenon. Certainly, the ever-present “house-officer” has had a place in history as the physician who essentially lives in the hospital; however, this role has been mainly restricted to the medical trainee with little experience and much responsibility, and has served as a rite of passage to become the more senior and less-present attending physician. In distinction, however, the hospitalist physician is a more experienced physician, not under the same training and hierarchical constraints as the house-officer, who is available at almost all times to the care needs of those patients in the hospital setting.

It has been almost 10 years since the coining of the term “hospitalist” by Wachter and Goldman.1 Definitions have been reworked and adapted, but currently the Society of Hospital Medicine (SHM) has defined Hospitalists as, “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.”2 The drive and expansion of this newer field of medicine has been felt throughout the US and abroad, and its popularity continues to grow exponentially. During the past decade we have seen this new specialty form its own professional society, have dedicated journals, and inundate existing, well-respected, traditionally general medicine journals with abundant evidence-based literature. SHM estimates indicate that there were about 2,000 hospitalists in 1998, 8,000 in 2003, and that number is expected to rise to as much as 30,000 by the end of 2010.2 Indeed, this is one of the only fields of medicine where there is a vast surplus of jobs comparative to physicians to fill them.

The majority of hospitalists have been trained in internal medicine (89%), mostly general internal medicine (51%); there is a large subset of internists who have subspecialty training (38%), usually in pulmonary medicine, critical care medicine, or a combination of the two.3 The remainder are made up mainly of family practice physicians, pediatricians, and other subspecialists like infectious disease and cardiology. Currently, there is no formal training required to become a hospitalist. However it is indeed true that a significant amount of one’s training in internal medicine is geared toward care of the hospitalized patient. However, there are at least six hospitalist fellowships currently in existence with more being planned for the future. In many ways, these are designed like general internal medicine fellowships, gearing the physician towards further experience in education and clinical research while providing continued exposure to inpatients and their medical problems.

Models of Hospitalist Care

Wachter has described four stages of hospital care that help to illustrate the driving forces behind hospitalist models.4 These stages help us to understand inpatient care structure, but they are not meant to be hierarchical nor do hospital systems sequentially pass through them. Rather, they are meant as a tool to help us understand that many external forces predicate how hospital care is provided. The first stage is the PCP model in which every PCP cares for his/her own patients admitted to the hospital. This has been the classic model of care in medicine. The second stage involves rotating coverage of hospitalized patients between members in a private practice. Each physician takes turns caring for those patients admitted. This model became popular as groups started to get larger and increase the number of patients in their practices. In the third stage, we see the emergence of a dedicated hospital physician who cares for inpatients. PCPs may hand over care to the hospital physician, but are not required to do so. In stage four, in contrast to the voluntary hospitalist stage, PCPs are required to hand over care to the inpatient physician. Every stage has its own associated advantages and disadvantages. For example, in stages three and four, the inpatient physician can provide continuous care to admitted patients while the PCP is free to spend more time in the office setting. However, this may lead to discontinuity of care due to multiple providers, or dissatisfaction in not being able to see one’s own doctor. Given the forces of healthcare today, many, if not most, hospital systems are at least in part relying on at least a voluntary hospitalist system of care, as described in stage three above.

There are numerous hospitalist models of care in place today. In many ways, the models continually redefine themselves based on changes in hospitals themselves and changes in physician training. For example, recent restrictions in house staff work hours have necessitated that hospitals find alternative ways to cover patients.

One type of model includes a private practice group employing a hospitalist to admit and care for their patients. A much more popular model is that in which a private practice group of inpatient physicians provide care to those patients admitted to the hospital. Typically, these hospitalist groups contract out to private practices or hospitals to care for their patients. These former models are popular with community facilities. Other models include those in which hospitals and health maintenance organizations hire their own inpatient physicians. Finally, many academic centers now have divisions or sections of Hospital Medicine. Academic hospitalists generally work in direct patient care less than private hospitalists, usually between 1 and 6 months per year. However, their time is usually supplemented by activities such as house staff training, academic research, and administrative duties.

Benefits of Hospitalist Systems

As one might imagine, there are several areas of benefit inherent in having a dedicated physician caring for patients requiring hospitalization. This doctor is not limited or constrained by the problems imposed by having an office practice. As such, the hospitalist is available throughout the day or night to see patients immediately, meet with family members and loved ones, and respond to emergency situations. The hospitalist is also in a prime position to foster a culture of patient safety, primarily by participating in multidisciplinary teams.5 Additionally, by virtue of the fact that this doctor practices only in the hospital, over time he or she becomes more attuned to developing and maintaining the necessary skills to manage acute inpatient medical issues.

Hospital medicine is a relatively young field, but the body of evidence in the literature showing benefits of this new system is growing rapidly. Published data demonstrates that utilizing hospitalists decreases total costs per case and patient’s length of stay6; preserve patient satisfaction despite not having direct PCP involvement in care6; trend towards a decrease in short-term mortality7; provide benefit in end-of-life care8; and improve resident education.9 There is also data to suggest that some of these changes, particularly length of stay and cost per case, are derived only when experienced hospitalists are present in a program or after a program has been established for some time.7 This is of growing concern since the recent explosion of popularity in hospital medicine has left many slots open for inexperienced hospitalists, and since some programs are designed to be transient in nature and are filled by recent graduates from residency. Nonetheless, benefits derived from hospitalist use are widely present, and certainly this concern will diminish over the next decade as the number of providers begins to equilibrate with the number of available employable positions.

A large number of hospitalist literature and journals now exist. Interestingly, almost every journal devoted to hospital medicine has a section in each publication focusing on quality improvement or patient safety. Again, the fact that these physicians are working within the hospital most of the time affords them the unique ability to police the system, recognize areas of improper or inefficient care management, and formulate and carry out care plans that have been proven to enhance inpatient care.

Hospitalists as Acute Providers

Compared to hospital models from decades ago, sicker patients are admitted to and stay in the hospital. No longer are the majority of patients simply staying in facilities awaiting tests. Most have serious, volatile problems, and clearly their conditions can change at any time. One can, therefore, make an argument that round-the-clock care of patients by an in-house physician is much more beneficial that traditional outside overnight call coverage.10

By virtue of focused training in hospital medicine as well as advanced cardiac life-support (ACLS) techniques, the hospitalist is in a prime position to care for the inpatient in urgent and emergent situations. In general, adverse events follow a gradual clinical patient deterioration, and much of the time the signs of impending doom go unrecognized or are even ignored.11 While there is not much direct data to suggest a link between hospitalists and early recognition of deterioration yet, there is some suggestion that the omnipresence of the hospitalist allows for more prompt recognition of acute problems with patients and implementation of appropriate and directed care to prevent adverse outcomes.7,9

The hospitalist can work alone in this venue, but more commonly he or she works on a multidisciplinary team as part of a Rapid Response System (RRS). The concept of a “code team” is not new, and certainly many facilities rely on intensivists and intensive care unit (ICU) teams to provide emergency care. The newer trend is an attempt to make these teams more focused, and more rapid to respond to less severe crises, and avoid delays in care for suddenly critically ill patients. This has mostly been done by having a smaller number of well-trained staff respond to the emergency in a controlled fashion, rather than a larger number of junior staff with sub-optimal skills or experience. While the RRS is composed of many parts, the response teams (MET or RRTs) can be comprised of any number and type of care provider experienced in resuscitation skills. METs generally involve a combination of hospitalists (non-intensivist or intensivist), ICU nurses, respiratory technicians, anesthesiologists, and even emergency room physicians, whereas an RRT does not have a physician as a first responder. In this situation, a hospitalist is a convenient and effective physician who can respond should the RRT need physician backup.

The use of a hospitalist system does not preclude the need for an RRT or MET. Rather, the two usually go hand in hand. The two main types of hospitalists, non-intensivists and the intensivists, both can be a part of this response team. The non-intensivist (those inpatient physicians trained in a primary specialty but without critical care training) often do not have major instruction beyond basic life-support and ACLS, and in particular may lack complex airway management skills. Often this non-intensivist hospitalist is the first responder to an urgent or emergent situation, is involved in calling the RRT to the bedside, and can certainly be involved as an integral member of the MET, including the “code leader.” However, the more skills-based aspects of code management, again mainly related to difficult airway problems or other procedures, may be reserved for the intensivist. In general, the major benefit of the non-intensivist hospitalist to the system is being in a position (geographically and intellectually) to foster a more rapid and astute recognition of the clinical deterioration of patients, and then set in motion the necessary elements to trigger the rapid response system to send a team to the aide of the patient.

There continue to be clinical trials examining the usefulness of RRTs and METs. At least two studies (both were non-randomized and non-blinded) have shown some benefit to having an RRS, namely a decreased incidence of unanticipated ICU transfers, lower incidence of death without a DNR, a decreased incidence of and mortality for in-hospital cardiac arrests, and a reduction in overall hospital mortality.12,13 There has been at least one meta-analysis evaluating the effects of an RRS on clinical outcomes, and this study failed to find any consistent improvement in outcomes through the use of an RRS in the 13 studies included.14 Nevertheless, there may be some advantage from an RRS; however the extent of the advantage remains to be demonstrated.

Thoughts for the Future

It is evident that the wave of the future in hospital care will almost universally involve the hospitalist. Yet given the rapid nature with which this assumption is occurring, steps will need to be taken to ensure that hospitalists are prepared for the situations they will encounter on a daily basis.

Instituting steps to improve retention (incentive programs, reasonable shifts and work hours, etc.) will likely improve performance and care delivery in programs that employ hospitalists. There may also be changes in residency training programs to allow candidates interested in a career in hospital medicine an opportunity to obtain more experience in the care of the inpatient and in managing inpatient emergencies. While more fellowships for hospital medicine may continue to emerge, it remains to be seen if completing a fellowship will ever be required for those wishing to pursue a hospital-based position.

Ultimately, it may become necessary to define the specific types of training required for hospital medicine, and this will almost certainly evolve around management of acute scenarios. Steps need to be taken in order to fully train hospitalists to deal with emergent events, particularly non-intensivists. In academic centers, residents are being given less and less exposure to urgent or emergent events and procedures. Interestingly, they are getting more controlled experience in the lab setting but much less bedside emergency situation experience. And since there is no formal training in Hospital Medicine that is required, much of these duties are falling onto the shoulders of already busy and short-staffed intensivists.

Focused training for hospitalists participating in multidisciplinary teams (METs) or aiding a nurse-led team when called (RRT), may prove to be extremely beneficial for every aspect of patient care. While the former will almost certainly allow for better management of quality issues and patient safety, the latter will literally be the basis for provision of care during acute hospital emergencies.