Long-term Care

Use of hospitalists instead of primary care physicians to care for hospitalized patients has both pros and cons

The use of hospitalists—physicians who spend at least 25 percent of their professional time serving as physicians-of-record in place of primary care physicians—is expanding rapidly. The February 16, 1999, supplement to the Annals of Internal Medicine, entitled, "The Hospitalist Movement in the United States," explored many aspects of the new model for inpatient care. The supplement's 10 papers were drawn from the proceedings of a December 1997 conference sponsored by the Agency for Health Care Policy and Research (HS09544). Lead editor of the supplement is Robert M. Wachter, M.D., of the University of California, San Francisco, who first coined the term hospitalist in a 1996 article in the New England Journal of Medicine. Dr. Wachter's work is supported by AHCPR.

In the introductory article, Dr. Wachter highlights the potential advantages and drawbacks of the hospitalist model. Advantages include increased availability to hospitalized patients, greater hospital experience and expertise, and an increased commitment to hospital quality improvement compared with primary physicians. Potential disadvantages include the loss of information caused by the outpatient-hospital discontinuity and the dissatisfaction of patients who are "handed-off" to a new physician at the time of hospital admission. Loss of information can be minimized through careful attention to interpersonal communication. Patient dissatisfaction has not proven to be a major problem at institutions such as UCSF, Kaiser Permanente, and Park Nicollet, whose experiences are described in the supplement.

Also included in the supplement is the first national survey of the members of the National Association of Inpatient Physicians (NAIP) (http://www.naiponline.org/index.html), a new organization representing the Nation's hospitalists. The survey demonstrated that 89 percent of hospitalists are internists, with 51 percent being general internists and 38 percent medical subspecialists. Most limit their practice to the inpatient environment, although 37 percent continue a limited outpatient primary or consultative practice. Employment arrangements vary significantly: 35 percent are employed by a medical group, 23 percent by a hospital, and 14 percent by a managed care organization. Although concerns have been raised about hospitalist burnout, most respondents were satisfied with their work, and 84 percent of the generalists and 73 percent of specialists expected to still be a hospitalist in 3 years.

These articles, as well as others examining the experience of large health systems, the impact of hospitalists on academic medicine and on employers, and whether hospital medicine is a new specialty, are published in the February 16, 1999, supplement to the Annals of Internal Medicine 130(4).

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