Thursday, March 12, 2009

Hospitalists and Primary Care

Two decades ago, most doctors who chose a career as a primary care physician did not imagine a professional life restricted to the outpatient settings…Today, many primary care physicians work exclusively in the ambulatory setting, relaying on hospitalists to care for their patients when they are admitted to the hospital.

Mary Beth Hamel, MD, Jeffrey Drazen, MD, Arnold Epstein, MD, “The Growth of Hospitalists and The Changing Face of Primary Care, New England Journal of Medicine, March 12, 2009

Alfred North Whitehead (1861-1947), an English philosopher, once observed, “It takes a very unusual mind to undertake the analysis of the obvious.”

To me it is obvious that the hospitalist movement, defined in 1996 by Wachter and Goldman (“The Emerging Role of “Hospitalists” in the American Health Care System,”New England Journal of Medicine, pages 514-517, 1996), has an unstoppable momentum.

The numbers speak for themselves.

From 1995 to 2006, 20% of general internists became hospitalists, and nearly 50% of all hospitals and 84% of teaching hospitals have at least three hospitalists.

Forces behind the hospitalist movement include the following.

• Managed care, which pressures primary care doctors to see more patients and hospitals to shorten stay.

• More hospital patients being seen by subspecialists.

• Malpractice exposure, wherein lawyers demand expertise for doctors in all spheres of practice – outpatient and inpatient.

• Demands by hospital executives to tighten control of inpatient care and discharges.

• The interests of young physicians for a more controlled lifestyle.

• The approval of older physicians who are pleased to hvae more care-free and call-free nights and weekends.

• Heightened demands by government and health plans for more efficiency.

• The drift towards a more European model, where inpatient and outpatient cafĂ© are seen by different sets of doctors.


In retrospect, rise of hospitalists is perfectly obvious.

Pressing needs were there to see for all but the oblivious,

But for most futurist seers,

And their peerless peers,

The obvious proved devious.

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