A SPECIAL GUEST COMMENTARY EXPLAINING HOW DOCTOR CARE HAS, AND CONTINUES TO, CHANGE

The views presented by Seagraves, MD may not necessarily represent the views of GIIG  We believe this is an important subject for healthier living and the decisions associated with healthier living.

Stan Seagraves, MD, contributed his thoughts to this discussion  An Internist for over 20 years in Missoula, Seagraves is currently practicing at Missoula's St. Patrick Hospital, as the medical director of their hospitalist program

I'm Being Taken Care of by a Hospitalist?
by Stan Seagraves, M.D.

And should I be worried? In a word...no. The title, while certainly descriptive, lacks the elan of, say, “thoracic surgeon.” No surprise, since the term was chosen by an internist - a primary care doctor that deals mostly with adult health and wellness. Hospitalists are physicians that focus their efforts on the care of hospitalized patients. It is the fastest growing medical specialty area in the United States, with the current number at 30,000 plus, double the number from just 2006!

The history of ‘The Hospitalist’:

The decision to divide care between in-patient and out-patient services occurred decades ago in many European health care systems – and some never functioned in any other way. One went to one's “GP” for office visits, but never expected to be admitted to the hospital by that same doctor. The United States followed a different path. One's old fashioned “GP” was the doc that “did it all.” He (and in virtually every case, it was a 'he') treated your pneumonia and took out your appendix. In the 1950's, as the medical specialties developed, the shift began. There was now an orthopedist to set the fracture, obstetricians did more and more of the baby deliveries, and so it went.

Fast-forward to the 1970's through today. Primary care doctors (here defined as family practitioners and internists), continued to provide both in and outpatient services for their patients, but their roles evolved. Rather than “doing everything”, they were the coordinators of increasingly complex and referral-based care. The ability to deliver more sophisticated care in the outpatient setting meant that hospitalized patients were even more seriously ill. The time and complexity demands of the office and hospital life took their toll on providers. These forces were the stimuli behind the hospitalist specialty movement.

Today:

Now you'd be hard pressed to find even a small or medium sized hospital that do not have hospitalists functioning as the main caregivers in their institutions. Again, the “driver” of this shift is the need for office based primary care providers to stay focused and efficient in the outpatient setting, and to turn over the care of the complex and quite ill hospital patient to physicians that do only that work.

‘Work-Hours’ of your typical Hospitalist:

Most hospitalists work blocks of time – typically 7 days on/7 off, 12 plus hour days each shift. Doctors also work evening and night shifts, since patients have such a nasty habit of getting sick after dark. The appeal of the blocks of off- time – a near-impossibility in outpatient practice – is offset by the longer shifts, night work, and stress of caring for only seriously ill patients. That said, many programs staffed themselves with doctors leaving their traditional outpatient practices for the hospital. The idea of a predictable schedule was arguably the biggest draw. There are now many internal and family medicine training programs that focus primarily on hospital-based medicine, and there has just recently been created a specialty certificate in hospital medicine.

Hospitalists are:

Most hospitalists are family physicians or internists, but a lot of hospitals offer pediatric, neurologic, and even surgical hospitalists. The size of the institution and the volume/type of patients drives the equation. Many programs also utilize “midlevel” providers – nurse practitioners or physician assistants.

This “new way” took some getting used to, for both patients and providers. Many folks are understandably annoyed not to see their familiar primary care doctor attending them in hospital, and the primary doc can feel out of the loop. Sometimes it takes a couple trips to the hospital, but the advantages of hospitalist-centered care usually become evident. Admission to and discharge from the hospital is more prompt. If you become unstable, require transfer to the intensive care or a specialist referral, the 24/7 presence of the hospitalist will expedite care. Diagnostic evaluations are moved along more quickly, given the fact that your managing doctor is not buried with office work and managing you in off hours – but is just down the hall.

But NONE of this matters if the most important component of a well-run hospitalist program is not attended to constantly: COMMUNICATION. Given that there are now at least two providers where there used to be (generally) one, the “voltage drop” in information between hospital and primary provider has to be confronted. Only with diligence and attention to detail, helped by the growing array of electronic health records, has this critical part of the process gotten both better and easier.

For those who long for the ‘old days’, I understand. But as the evidence that hospital stays are made shorter and safer by the adoption of hospitalist programs, and that evidence continues to accumulate, the momentum can only build.

SPECIAL GUEST COMMENTARY: This contribution was made solely for the benefit of readers of this web-site and is not an endorsement of GIIG, it’s products or services.