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What Is a Hospitalist? A doctor explains what these specialists do.

by Stella Fitzgibbons, M.D.

doctorQ: What's a hospitalist?

A: "Dr. Joe has been seeing me for years. Why won’t he take care of me in the hospital?”

Dr. Joe has a common-sense, caring attitude that his patients love, and he excels at preventive medicine and longterm care. But both caring and common sense have led him to call a hospitalist like me when you get sick.

Hospitalists find that their specialty is in demand because they improve cost-effectiveness, shorten hospital stays and improve patient care. That sounds fine to hospital administrators and insurance company executives, but what’s in it for sick people?

Let me explain why Dr. Joe stopped admitting patients to the hospital.


MRS. SUBURBIA
Too many tests, not enough money

Last spring Mrs. Suburbia arrived at his office at 10 a.m. with pneumonia and some serious wheezing. Since Dr. Joe couldn't abandon his office patients to meet her at the hospital, he called a lung specialist, ordered oxygen, then asked the nurses to call the lung guy if she needed anything else.

The lung doctor arrived at 2 p.m. and ordered a CT scan and lung-function study. Neither was urgent, or even necessary in a lifelong nonsmoker, but hey, specialists are expected to order that stuff.

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Dr. Joe got to the hospital just after sunset. Checking Mrs. Suburbia’s blood work took a while since he rarely used the hospital computer system, and finding her X-rays took even longer. By then she had left the floor for her CT scan, so he had to ask how to get there.

By 9 p.m. Dr. Joe had spent two hours seeing Mrs. Suburbia. The lung doctor was making all the important decisions, the patient complained about waiting hours to see him, and the nurses were confused as to who was in charge.

Two days later Dr. Joe got a call from the hospital case manager, a nurse who reviews charts to make sure insurance companies pay for everything they should. Mrs. S. was on oral medications and walking around comfortably without oxygen, so when would she be going home? Remembering memos from hospital administrators about cost control, Dr. Joe promised to discharge her the next day. Two weeks later her insurance company denied payment for the last two hospital days.


MR. BADKIDNEYS
Sick and alone

Mr. Badkidneys arrived at the emergency department the day Mrs. S. left. The critical-care consultant did an excellent job ... but Mr. Badkidneys had a serious infection, a dozen blocked arteries, and too many years of cigarettes to breathe without a ventilator. He died in intensive care the next afternoon while one of Dr. Joe’s office patients was describing her abusive marriage, and the Badkidneys family was shocked that Dr. Joe could admit somebody that sick and then be elsewhere when the patient got worse.


THE HOSPITALIST
There for you

Now Dr. Joe calls my hospitalist group to admit his patients. One of us meets them in the ER and is in the hospital all day. The hospitalist has time to explain treatments and test results and return calls from families and nurses. And a doctor who treats life-threatening problems every day can manage them better than one who sees them only a few times a year. When patients return to Dr. Joe, he can handle their problems in the office without being interrupted by hospital calls.

Cost-effectiveness: Hospital accountants and insurance companies may be more interested in cost-effectiveness than in compassion. Insurance companies may not cover tests they consider unnecessary or treatments that can be given at home. Administrators spend hours looking at days spent in the hospitals for various diseases, referrals to specialists and patient satisfaction surveys—all of which translate into dollars, with the numbers favoring care by hospitalists.

Training: Most hospitalists train in adult- or pediatric-medicine residencies with an emphasis on inpatient care. Many tried a practice like Dr. Joe’s, ran into the same problems he did, and decided it was more satisfying taking care of sicker patients. And some of us just like the excitement.

How it works: The critical part of hospitalist care is the transition between office and hospital care. When a person comes to the ER, her primary-care doctor faxes me records or gives me a phone summary of all he knows. As a patient leaves the hospital, my group’s computerized fax system sends vital information to Dr. Joe. I often phone him so he knows that Mrs. Chestpain will call him Monday or that Mr. Bloodsugar’s insulin schedule has changed.


BACK TO MRS. SUBURBIA

Mrs. Suburbia called Dr. Joe a few nights ago complaining of abdominal pain and vomiting, and he sent her to our ER. Larissa at the front desk finagled a bed on the appropriate floor and called a surgeon whom I see every day. Thomas from Patient Escort wheeled her to her room; Sam the X-ray tech did her chest X-ray; Christy the respiratory therapist started asthma treatments; and Sandra the ward clerk paged the radiologist on call to approve a midnight ultrasound study. Four days later I reported to Dr. Joe that Mrs. Suburbia was recovering from gallbladder surgery, thanks to a lot of help from my friends.

For my partners and me, the hospital is the only practice we have. The people there are our patients’ supporters and helpers, and our job is to manage medical problems as efficiently and effectively as possible. Serving on hospital committees means not an extra trip and missed office visits, but a chance to work out problems that concern us every day.

 

Hospitalist STELLA FITZGIBBONS, M.D., is a JHMFD Online Expert.

Last updated and/or approved: February 2008.
Original article appeared in summer 2004 issue.

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