Wednesday, May 18, 2011

The hospitalist movement at 15

That was the topic of Bob Wachter's keynote at the just finished SHM national meeting in Dallas. Recently he gave a synopsis of the talk in his blog. It's an interesting and lively read (as Bob's posts always are) although I disagree on a couple of points.

Concerning, for example,the efficiency of the hospitalist model:

Proving that we could cut costs without harming quality was central to gaining hospitals’ support and creating a viable economic model for hospitalists. The early research unambiguously supported this proposition, as I knew it would.

Whoa. Early research was mixed. In 2005 one of the largest and arguably best studies on the hospitalist model, presented at the national meeting, showed no cost saving attributable to the model. Unfortunately that study fell victim to publication bias. It never saw the light of day except for a brief splash in the blogs. Accordingly that important study was left out of every systematic review to be done since then. It was not until a very recent study was published that the balance of evidence tipped in favor of efficiency attributable to the hospitalist model. It's still not a slam dunk.

As Bob points out tough economic times produce tension, and not always healthy tension, in negotiations between hospitalist groups and their health systems. But he says this:

It will be critical that hospitalist groups produce measurable value. I worry about programs organized around the convenience or the income of the physicians. You know the ones – programs whose patients say, “Oh, the hospitalist just flies in and out of the room,” or “I saw a different hospitalist every day,” or ones in which every patient complaint and lab abnormality reflexively triggers another subspecialty consult or CT scan. Such programs are not likely to achieve the status of being indispensable.
And the opposite of indispensable is, of course, dispensable.

Don't get me wrong here. Hospitalists should strive to be efficient and provide superb service because it's part of their professionalism---just the right thing to do. But what makes them indispensable is the plain and simple fact that without hospitalists (and they're still in short supply) there's hardly anyone left to care for most patients in the hospital anymore. Look at Emergency Medicine. EM is indispensable not because of any claim of increased efficiency but because primary care docs left the department decades ago.

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