Thursday, January 08, 2009

A realistic view of the hospitalist movement

A post from The Hospitalist Leader is titled Will the last traditionalist leaving the hospital please turn in your parking pass. It refers, of course, to the mass exodus of traditional practitioners (even specialists!) from hospitals. After describing how the exodus is accelerating the post says this:

Just to make this interesting, let’s assume for a minute that no one believes that a practice focused on a site of care, such as hospitalists, ER doctors, and intensivists, offers no [sic] improvement in quality or efficiency. Would ER doctors and hospitalists have still been “invented?”

I’m confident the answer is yes.

ER doctors appeared in the 60’s and 70’s largely because existing specialties on the medical staff were less willing to treat emergency patients, especially if the patient was “unassigned.” And hospitalists began appearing in the ‘90s because PCPs were less willing to provide hospital care.

OK, this is exactly what I said a while back. Like emergency medicine, the value of the hospitalist model is the large and ever expanding niche. And the statement above regarding no improvement in quality or efficiency is not merely hypothetical in my view of the evidence, as I’ve said time and again.


shadowfax said...

You must be joking. Now, for reference, I'm an ER doc, I have no brief for hospitalists, and I have not looked at the literature about hospitalists. BUT.

There's not a shred of doubt that hospitalists increase the efficiency of inpatient care. Admits are faster, care protocols are more standardized, and patients are seen more expeditiously. The discharges are timed to coordinate with the influx of new patients daily. There's always one in house. They are experts in inpatient billing and facility reimbursement. That's incredible efficiency. Quality is a lot harder to measure, and the outcomes are indirect enough that I don't know if it can be assessed to a statistical certainty.

Screw the literature, anyway. I've worked under both regimes and the difference is night and day. This is a case in which common sense and real-world experience are so overwhelmingly in agreement that I would view askance any study which claimed otherwise.

One other note -- you wrote in the linked post that "I don’t recall an obsession among emergency medicine doctors with convincing others of their “value”. The value of emergency medicine was self evident. The need was there and emergency medicine responded. " You must not have been paying attention -- it took ER docs 20 years to get the house of medicine to concede our right to exist as a separate specialty (you can see that this prejudice still exists today). Hospital medicine has a slightly different existential argument to make, since they're not a new specialty but a weird offshoot of IM; they don't need to argue that they have the right to exist, but rather that they are better than the pre-existing status.

I don't know if that argument will ever be made to the satisfaction of the purists such as yourself. The point is probably moot, since, as you said, the market forces which created hospitalists are so powerful that hospital medicine will be a fixture on the medical landscape regardless.

R. W. Donnell said...


You draw on your personal experience and say “screw the literature” which, you acknowledge, you haven’t examined. But how can you generalize from your personal experience without examining the literature? Your experience may not mirror that of others. Several years ago, before the mass exodus, a traditional internal medicine group admitted a large number of patients to our hospital. They were superb internists with very tight call coverage, and they knew their patients well. When we decided to compare efficiency stats we found, to our frustration and initial disbelief, that their numbers were as good as ours!

My main point about the literature concerning efficiency and outcomes attributable to the hospitalist model is that the boosters seem to have spun this literature inappropriately, leaving out one of the largest and arguably most methodologically sound studies on hospitalist efficiency and outcomes showing no benefit attributable to the model. It was presented at the SHM 2005 national meeting but, curiously, never published.