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Hospitalists (ZZ)
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发表时间:2009-07-23
更新时间:2009-07-23
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发信人: taxiang (hill), 信区: MedicalCareer
标 题: Hospitalists (ZZ) 长篇
发信站: BBS 未名空间站 (Thu Jul 23 19:07:34 2009, 美东)

(ZZ)

In 1996, Robert Wachter and Lee Goldman proposed
the word hospitalist to describe a physician
who primarily dedicates his or her practice to the
care of hospitalized patients.1 There is no clear
consensus on a more exact definition of the term,
although physicians who spend at least 25% of their
time practicing inpatient medicine have often been
given the designation.2 By this terminology, any physician
in a busy traditional outpatient-inpatient practice
may be considered a hospitalist. For purposes of this
article, however, the term hospitalist will apply to any
physician (typically a general internist) who concentrates
almost exclusively on the practice of general
inpatient medicine.

HISTORY OF THE HOSPITALIST MOVEMENT
Historically, traditional internists or family practitioners
are physicians who care for patients in both
outpatient and inpatient settings. The practice model
typically mandates that these clinicians make hospital
rounds early in the morning and again at the end of
the day. Not infrequently, physicians are interrupted
throughout the day with telephone calls concerning
hospitalized patients or admissions from the emergency
department. Such interruptions often interfere
with the ability to efficiently treat patients in the office.
Whereas many clinicians still enjoy the traditional
model of patient care, a growing number of primary
care physicians find it increasingly difficult to provide
efficient, prompt care simultaneously to patients in the
hospital and those in the office because of constraints,
such as the preauthorization necessary for insurance
companies, excessive paperwork, and frequent interruptions.
In addition, with declining monetary reimbursement
for both ambulatory and hospital patient
care, many clinicians have noted a decline in office
productivity when they have to make visits to the hospital
for a small number of patients. Moreover, with the
rapidly changing therapies and diagnostic technologies
necessary for care of hospitalized patients with
often complicated disorders, it can be difficult to remain current with the
latest modalities for commonly
encountered inpatient problems. Some physicians
also may find it difficult to maintain inpatient procedural
skills (eg, central venous catheterization, lumbar
puncture, endotracheal intubation) if they only perform
these procedures infrequently. Partly because of
these reasons, the hospitalist movement has increased
in popularity in recent years.
The concept of “outpatient physicians” and “inpatient
physicians” is not new and has, in fact, typified
patient care in Great Britain and Canada for some
time.1,3 However, when Wachter and Goldman first
used the term hospitalist to describe an emerging role
in the American health care system, the concept was
less familiar in the United States. Somewhat prophetically,
Wachter and Goldman predicted a rapid increase
in the number of hospitalists and a surge in their popularity.
1
In 1999, a national organization exclusively dedicated
to this emerging field was formed, known as the
National Association of Inpatient Physicians (NAIP).2,4,5
The NAIP is currently an affiliate of the American
College of Physicians-American Society of Internal
Medicine (ACP-ASIM) and hosts a national meeting
annually, in the days preceding the national ACP-ASIM
meeting. Currently, the NAIP has approximately 1800
members and continues to grow at a rapid pace.5
Surveys conducted by the NAIP have identified no
fewer than 4500 hospitalists nationally. In fact, most
adult general hospitals with a bed capacity of 200 or
more have a hospitalist system implemented or are in
the process of launching such a program.5,6

WHO ARE HOSPITALISTS?
Based on surveys conducted by the NAIP, the majority
of hospitalists are general internists by training, typically having
completed a 3-year residency in internal medicine.
However, a significant minority of hospitalists have
subspecialty training, usually in pulmonary and/or critical
care medicine. Less commonly, cardiologists, nephrologists,
and infectious diseases specialists act as hospitalists.
A small percentage of hospitalists are family
practitioners.6
Demographically, the mean age of a hospitalist is
approximately 40 years, and 81% of hospitalists are
men. Indeed, most hospitalists are relatively young, with
approximately 75% of them having completed their
residency training after 1984. Table 1 contains demographic
data relating to hospitalists in the United States.
Because hospitalist is a relatively new job description,
82% of physicians in this field have been working as a
hospitalist for 5 years or fewer, and about a third
entered the field directly from residency training.6

MODELS OF HOSPITALIST PRACTICE
There are several different types of models of hospitalist
practice. Private practice groups are perhaps the most
popular model, as is evident in the increasing number of
classified and Internet-based advertisements for employment.
7 Private practice groups may be composed solely
of general internal medicine–trained hospitalists, of a
mixture of generalists and subspecialists (typically, pulmonary
or critical care), or purely of subspecialists. In
this model, primary care physicians often directly refer
patients to hospitalists from the emergency department
or ambulatory clinic. Alternatively, a hospitalist may
admit patients for a large group of primary care providers
or for a multispecialty group.
Other models of hospitalist practice include the
hospitalist being employed by a hospital or health
maintenance organization.8 Another practice model of
growing popularity is the academic hospitalist.9 In this
model, the physician is typically employed by an academic
medical center and is responsible for supervising
house officers involved in the care of hospitalized
patients. In this model, the physician usually is only
involved with the inpatient service a few months of the
year and does not directly care for patients, as in the
other models. However, academic hospitalists are usually
involved with various types of research, typically
outcomes-based research.

DUTIES OF THE HOSPITALIST
In general, the duties of the hospitalist are to provide
prompt, efficient, and competent care to hospitalized
patients. These patients are often referred to
hospitalists by primary care providers, emergency physicians,
or subspecialists. In addition, many hospitalists provide consultative
services to patients admitted to
orthopaedic, surgical, rehabilitation, and other subspecialty
services. The bulk of the hospitalist’s workload,
however, typically involves acute admissions from the
emergency department or an outpatient clinic. Depending
on the training of the hospitalist or the availability
of subspecialists in the area, some hospitalists
provide critical care support to their patients. However,
approximately 95% of hospitalists focus their care on
the medical ward.6 Preoperative consultations are also
a growing segment of the hospitalist’s duties, often
involving orthopaedic patients with hip or other fractures. An experienced
hospitalist can usually manage the
majority of general medical problems encountered in
the hospital setting. In fact, some authors have predicted
that subspecialists may eventually object to the
smaller number of consultations requested by hospitalists,
compared to primary care physicians, which could
lead to a decrease in subspecialists’ revenue.6
Many hospitalists also perform a variety of general
medical procedures frequently used in the care of the
hospitalized patient.10 Common hospitalist procedures
include central venous catheterization, endotracheal
intubation, lumbar puncture, thoracentesis, paracentesis,
arthrocentesis, and arterial puncture. Proficiency in
these procedures may decrease the occurrence of iatrogenic
complications, as well as the cost of having to
consult another physician to perform them.
The hospitalist typically manages most aspects of
patient care after admission—not only providing medical
care but also organizing subspecialty services, palliative
care, and social services, when necessary. Some
studies have further shown that the hospitalist model
can decrease hospital stay by approximately half a day.8
This benefit most likely results from the availability of
the hospitalist and the timely orchestration of discharge
planners and social workers from the outset of
hospitalization.11
Just as importantly, a major duty of the hospitalist is
timely, accurate communication with the patient’s primary
care provider.2 Hospitalists often contact the
patient’s physician by telephone on admission, discharge,
or any change in patient status. A written letter
or summary at discharge is also an important way of
providing information to the primary care physician
and ensuring continuity of care.
In some settings, teaching is another duty of the
hospitalist.9,10 Private practice hospitalists often provide
teaching to house officers and medical students in private
teaching hospitals. In fact, hospitalist rotations
have been shown to increase short-term knowledge
of hospital medicine in fourth-year medical students.
12 As noted earlier, the academic hospitalist acts
in more of a supervisory role to house officers and students
rather than becoming involved in direct patient
care.1,9,13
Lastly, clinical research is another growing area of
hospitalist practice.4 Academic hospitalists conduct
the majority of hospitalist research, most of which is
outcomes-based. However, various observational and
retrospective studies also are performed by hospitalists
involved in other practice models, and these studies can
provide useful information for patient care in this relatively
new field.

PROS AND CONS OF THE HOSPITALIST MODEL
As with any new and unfamiliar undertaking, there
are potential concerns about the role of hospitalists in
our health care system. Nevertheless, hospitalists can
have several beneficial effects on patient care. First of
all, hospitalists are usually available on short notice and
are often able to assess acutely ill patients and intervene
in their care very rapidly. Hospitalists can also potentially
shorten a patient’s time in the emergency department
by being available throughout the day to expedite
admission.3 In contrast, the offices of primary care
physicians may be distant from the hospital, making it
difficult for them to assess patients quickly in the emergency
department. Another benefit of hospitalist care is
the availability of physicians to frequently assess ill
patients throughout the day and to follow up on laboratory
and radiologic data more expediently. Frequent
follow-up can lead to more prompt and efficient institution
of therapy, which could potentially decrease the
number of adverse outcomes and the length of stay.10
As noted earlier, an efficient, experienced hospitalist
often becomes very comfortable caring for a variety
of acute medical conditions. As such, the need for subspecialty
consultation may decrease in some cases,
leading to lower hospital costs and allowing more
focused care. Of course, experienced hospitalists
should realize the limitations of their expertise and
obtain timely subspecialty consultation when necessary.
Hospitalists often are very familiar with consultants
from a variety of surgical and medical specialties and
also may know which consultants to avoid in certain situations,
thus directly benefitting patient care.
Perhaps the strongest argument to be made in favor
of the hospitalist system is the old adage “practice makes
perfect.”6 Physicians who spend practically their entire
clinical experience directly caring for hospitalized
patients become more versatile and comfortable in the
hospital setting.3 For example, a full-time general
internist practicing as a hospitalist in a busy practice may
have daily responsibility for 15 to 20 patients who have
various disorders. Not surprisingly, the hospitalist will likely
care for more patients with conditions such as pneumonia,
sepsis, heart failure, stroke, and diabetic complications
than would an ambulatory medicine–focused
physician, who may see only a handful of hospitalized
patients within a given week. By frequently caring for
patients with acute medical illnesses, the hospitalist often
becomes more comfortable caring for significantly ill
patients and treating complications that are unique to
a hospitalized patient population (eg, venous thromboembolism,
refeeding syndrome, aspiration, nosocomial
infections), as well as performing certain procedures (eg, central venous
catheterization, endotracheal intubation).
10
On the other hand, primary care physicians, by dedicating
their time to an ambulatory practice, can develop
extraordinary outpatient skills, most notably in preventive
health services, which can vastly benefit patients.
The hospitalist system, as noted earlier, can increase
efficiency of office-based physicians by eliminating the
need to interrupt them with telephone calls about hospitalized
patients and hospital admissions during office
hours.2
Another benefit of the hospitalist system that has
been reported in some studies (and was mentioned previously)
is a decreased length of hospital stay for patients
admitted to a hospitalist service. This decrease has not
been shown to adversely affect patient outcomes and has
been shown to decrease hospital costs.8 In addition,
timely discharge also may reduce the rate of iatrogenic
complications or nosocomial infections in patients at
risk, although this outcome needs future study.
The discipline of hospitalist medicine also has
opened up new areas of research, typically outcomesbased
studies that assess various aspects of acute hospital
care, such as cost containment, length of stay, overall
cost of hospitalization, and quality of care provided
by hospitalists.4 In addition, clinically based research
that is not of interest to subspecialists may be potential
areas of research conducted by hospitalists. As noted
previously, most hospitalist research is conducted by
academic hospitalists at university medical centers;
because house officers provide direct patient care, faculty
can focus more intently on research.
Despite these potential advantages of the hospitalist
system, many have voiced concern about establishment
of such a system. Some physicians fear that some hospitals
may adopt a “closed system,” only allowing hospitalists
to admit patients and thereby excluding primary
care physicians from inpatient practice.4 Only time will
tell whether larger hospitals will develop a closed system,
although the concern is certainly valid. Therefore,
a voluntary hospitalist system would benefit all
parties by avoiding understandable hard feelings and
providing a healthy environment of accountability and
competition.
Another proposed disadvantage of the hospitalist
system is the possibility of primary care providers losing
their inpatient skills. However, this loss is counterbalanced
by the improvement of ambulatory skills necessary
for optimal patient care.2 Indeed, it is very difficult
for physicians to stay current with the vast amount of
literature pertaining to ambulatory as well as hospitalized
patients. Hence, by concentrating on ambulatory issues, primary care
physicians can stay current with
the latest advances in that field.
As suggested earlier, some subspecialists may
approach the hospitalist model with trepidation out of
fear of fewer consultations requested by experienced
hospitalists.1 Experienced hospitalists often treat many
common syndromes (eg, congestive heart failure,
chronic obstructive pulmonary disease, various bacterial
infections) traditionally considered to be the realm
of various subspecialties. However, this decreased need
for consultation may not only lower health care costs
but also aid the specialist in becoming more efficient in
his or her subspecialty by avoiding excessive consultation.
In any case, subspecialty consultation is often necessary
in the ill adult patient, and a prudent hospitalist
will obtain assistance from a subspecialist whenever
necessary.
Some opponents of the hospitalist model voice concern
about the potential for poor communication
between hospitalists and primary care physicians, a
concept termed the information voltage drop.2 However,
as long as appropriate telephone calls are made and
letters and discharge summaries are promptly sent to
primary care physicians, this eventuality can (and
should) be avoided.
An interruption in the relationship between a patient
and his or her ambulatory physician when a hospitalist
takes over the patient’s care is another potential
problem.7 Now that a “stranger” is caring for the patient,
the fear is that there may be a loss of medical
information, because the patient may be hesitant to
fully confide in or trust the hospitalist. To the contrary,
however, studies have shown that most patients are satisfied
with the care provided by hospitalists and are willing
to sacrifice familiarity with their physician for the
hospitalist’s availability and expertise in the care of
acutely ill patients.2 In addition, in the author’s experience,
patients rarely object to being cared for by an
unfamiliar physician if they believe they are listened to
and given expedient, competent care. Overall, the hospitalist
system seems to have more pros than cons, not
only for the involved physicians but also for the patient.

FUTURE ISSUES IN HOSPITALIST CARE
The hospitalist movement in American health care is
enjoying immense popularity and continues to grow at a
rapid pace. Currently, the majority of hospitalists are general
internists, with board certification in internal medicine.
Issues regarding separate board certification or a
certificate of added qualification in hospital medicine
have been raised and certainly are valid. After all, 3 relatively
new specialties—emergency medicine, critical care medicine, and family
practice—all originated from
trends in medical practice that filled a specific niche4;
subsequently, all of these disciplines became areas of
board certification and currently enjoy security as specialties.
One could argue strongly that hospitalists deserve
the opportunity for additional board certification
beyond internal medicine, especially because the discipline
of hospital medicine meets many of the criteria
required by the American Board of Internal Medicine
for subspecialty certification: (1) the subspecialty must
have a unique body of knowledge, (2) the subspecialty
must be clinically applicable and sufficient to support a
distinct form of practice, (3) the subspecialty must generate
new information and areas of research, (4) the
subspecialty must require a training period of at least
12 months, and (5) the subspecialty must have both
ample trainees and potential training programs.4 The
hospitalist model fits well into each of these criteria.
For example, the body of knowledge required to practice
hospital medicine is very broad and quite different
than that of primary care medicine. The subspecialty
of hospital medicine is clearly clinically applicable, and
there is little doubt about its ability to support a distinct
form of practice. In addition, hospital medicine has
opened up new avenues for generating research on
hospitalized adults and outcomes. A training period of
an additional 12 months seems reasonable and may
appeal to house officers wishing to advance their
knowledge and technical skills. Whether the field of
hospital medicine will eventually enjoy the status of
board certification, however, remains to be seen.
Another future issue in hospitalist care involves the
real threat of burnout.10 Hospitalists, especially those in
private practice, frequently spend long hours in the
hospital and care for significantly ill patients with multiple
medical problems, both of which activities can be
physically draining. On-call and nighttime responsibilities
also play a role in physician fatigue. Moreover, in
addition to the intense mental stimulation hospital
medicine demands, the additional issues of discharge
planning, pressure from insurance companies and
health maintenance organizations, and declining reimbursement
all contribute to potential burnout. Ways to
avoid burnout include sharing call responsibilities,
instituting shift work, and working several days on followed
by several days off duty. The academic hospitalist
model may decrease burnout as well, because the
physician functions as a supervisor with largely predictable
hours because of housestaff availability for
direct around-the-clock patient care.
In conclusion, this is a unique time for hospitalists, in
light of the rapid increase in the popularity of their discipline
and the growing number of employment opportunities.
It seems that Wachter and Goldman may have
been right1 and that hospitalists are here to stay.


REFERENCES
1. Wachter RM, Goldman L. The emerging role of “hospitalists”
in the American health care system. N Engl J
Med 1996:335:514–7.
2. Wachter RM. An introduction to the hospitalist model.
Ann Intern Med 1999;130(4 Pt 2):338–42.
3. Redelmeier DA. A Canadian perspective on the American
hospitalist movement. Arch Intern Med 1999;159:1665–8.
4. Kelley MA. The hospitalist: a new medical specialty? Ann
Intern Med 1999;130(4 Pt 2):373–5.
5. Wellikson L. NAIP at age four: strong, robust, and still
growing. Hospitalist 2001;5(5):4.
6. Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM.
Hospitalists and the practice of inpatient medicine: results
of a survey of the National Association of Inpatient
Physicians. Ann Intern Med 1999;130(4 Pt 2):343–9.
7. Pantilat SZ, Alpers A, Wachter RM. A new doctor in the
house: ethical issues in hospitalist systems. JAMA
1999;282:171–4.
8. Craig DE, Hartka L, Likosky WH, et al. Implementation
of a hospitalist system in a large health maintenance
organization: the Kaiser Permanente experience. Ann
Intern Med 1999;130(4 Pt 2):355–9.
9. Goldman L. The impact of hospitalists on medical education
and the academic health system. Ann Intern Med
1999;130(4 Pt 2):364–7.
10. Schroeder SA, Schapiro R. The hospitalist: new boon for
internal medicine or retreat from primary care? Ann
Intern Med 1999;130(4 Pt 2):382–7.
11. Showstack J, Katz PP, Weber E. Evaluating the impact of
hospitalists. Ann Intern Med 1999;130(4 Pt 2):376–81.
12. Marinella MA. A “hospitalist” rotation increases shortterm
knowledge of fourth-year medical students. South
Med J 2002;95:374.
13. Sox HC. The hospitalist model: perspectives of the patient,
the internist, and internal medicine. Ann Intern
Med 1999;130(4 Pt 2):368–72.
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