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President's MessageHospitalists — A New Medical Specialty Or A Passing Fancy?N.H. Tucker, III, M.D., President |
The first major article addressing the emerging field of hospital-based or inpatient-based physicians was by Drs. Wachter and Goldman in the New England Journal of Medicine in 1996. Since then, hospitalists have formed their own organization (the National Association of Inpatient Physicians); have developed their own web site (http://www.naiponline.org/); and have affiliated with the American College of Physicians. They have held several national meetings, including their first annual meeting in April 1998. Most hospitalists are general internists, pulmonologists, or critical care physicians. Although they are not yet recognized as a medical specialty, they may be eventually. The impetus behind this movement appears to be three-pronged. Managed care organizations have embraced the concept of hospital-based physicians as a means to streamline and reduce costs. Many office-based physicians like the idea of eliminating the stress, regulation, paperwork, emergency room call, and all the other resulting hassles involved with hospital work. Finally, a cadre of physicians, often fresh out of training, has developed that prefers the high voltage acute care medicine practiced in hospitals. There is much to be said in favor of the hospitalist physician. He would seem to be performing a valuable service for managed care organizations, hospitals, other physicians, and patients, provided several caveats were met. First, the patient would need to accept the discontinuity of care arising from a physician other than his primary care physician being responsible for his hospital care. Presumably the patient's primary care physician knows him best. Secondly, the office physician should not be forced to relinquish his in-patient practice. He should have the option of using or not using hospitalists. Finally, it is imperative that the hospitalist have timely communications with the primary physician to minimize discontinuity and ensure quality care. On the other side of the coin, there are some potential pitfalls from the hospitalist movement. The discontinuity of care might tend to depersonalize physicians in the eyes of patients and further erode the traditionally close patient-physician relationship. In addition, the outpatient physician might come to be regarded as a second class physician. As the argument goes, physicians tend to be judged by both patients and other physicians on their ability to care for the complicated "sick" patient. The physician who can care for these difficult problems is felt to be "better." Therefore, the physician who has abdicated the care of the "sick" patient to others is not one of the "better" physicians. Finally, the hospitalist might be placing himself in an impossible situation. A young physician fresh from a residency program would seem to fit nicely into the role of a hospitalist. However, as that physician matures, he might find the role of acute care physician extremely demanding in physical energy and extremely shallow in terms of mental and emotional growth. After all, aren't we essentially extending the physician's residency (without the intensive teaching) for a lifetime? The unfortunate consequence could be burnout, cynicism, and the dehumanization of patients by looking upon them as "pathologic objects" to be fixed. This must be guarded against. As Dr. Faith T. Fitzgerald (Internal Medicine Residency Program Director at the University of California, Davis) stated in a recent article about the hospitalist movement, "The management of acute disease may be improved; the care of patients may not." REFERENCE: Fitzgerald, Faith T. Hospitalists. The Hospitalist. Winter 1998. June, 1999/ Jacksonville MedicineWhat's New
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