They're practicing all over the country: in Gainesville, Fla.; Long Island, N.Y.; Minneapolis; and San Francisco.
They work for HMOs, physician groups and hospitals, or they free-lance.
No one can say exactly how many of them there are; certainly several hundred, maybe even a thousand.
They have no association, no university program, no journal. They don't even have a standard name for themselves.
But they have a calling, clear as a bell, which they can articulate with urgency and passion. They are true believers in a better way to practice a certain kind of medicine.
They are physicians who take care of sick people in hospitals and nowhere else. They aren't surgeons, radiologists, anesthesiologists or pathologists. For the most part they are internists who see only patients referred to them by other primary-care doctors.
They go by a variety of descriptions: hospital-based internist, rounder, inpatient physician, admitting doctor, hospital-based specialist.
Or simply "hospitalist," as proposed by Lee Goldman, M.D., and Robert M. Wachter, M.D., who described them in the New England Journal of Medicine last August as "specialists in inpatient medicine who will be responsible for managing the care of hospitalized patients in the same way that primary-care physicians are responsible for managing the care of outpatients."
Wachter and Goldman have set up a hospitalist model for inpatient care at University of California-San Francisco Medical Center and are training residents to work that way.
"As hospital stays become shorter and inpatient care becomes more intensive," Wachter argues, "a greater premium will be placed on the skill, experience and availability of physicians caring for inpatients."
At the same time that should free the primary-care doctor in the clinic to concentrate on efficient outpatient care without worrying about coordinating inpatient care.
Care manager. In essence, the hospitalist model works like this: When a person is too ill to be cared for as an outpatient, the primary-care physician turns over responsibility to the hospitalist, who manages that patient's care for the entire hospital stay. The hospitalist coordinates consultations with subspecialists, rides herd on diagnostic departments, schedules procedures and generally accelerates the patient's progress through the hospital.
On discharge, the hospitalist returns the patient to the care of the primary-care physician. In purest form, hospitalists have no patient base of their own but depend on referrals from primary-care doctors or health plans.
This kind of practice isn't entirely new. Inpatient-care specialists have practiced in urban hospitals in Canada and Great Britain for many years, Wachter and Goldman report.
But in the United States, the phenomenon is novel. Unlike other developments in American medicine, the hospitalist movement is emerging not from developments in science and technology but from a constellation of factors in medicine: the knowledge explosion, the demand for higher quality and more accountable and consistent patient care, and the insistence on more economical use of resources.
There are many variations on the model, depending on payment mechanism, location, health plan, patient preference and hospital type.
Kaiser Permanente, for example, has been introducing variations on the hospitalist model in several regions, as physicians feel the need. Humana is advertising in medical journals for "internists, 100% hospital-based." It tested the idea in San Antonio and is introducing it in regional markets with sufficient hospital volume. Park Nicollet Medical Group, a large multispecialty practice in Minneapolis, combines full-time hospitalists with rotating general internists. Long Island Jewish Medical Center in New York has established the "A-Team" (for admitting), four doctors who are available to care for patients around the clock. And Pacific Cardiovascular Associates, a group practice in Orange County, Calif., has hired a hospitalist to manage medical complications of its surgical patients (See story, p. 56).
Hospitalists are paid through a variety of mechanisms: some are salaried by the hospital, others by their HMO. They may be in private practice and bill the patient's insurer directly. Or they are paid through capitated contracts. Because the field is so new, there are no average figures on hospitalist incomes.
Driving this bus, of course, is managed care. The pressures for efficiency that managed care exacts inevitably stir providers to think about new divisions of labor.
Garrett Smith, M.D., an oncologist-hospitalist at UCSF, says the hospitalist movement is trying to elicit the best from the potential of managed care. "There's so much negative attitude about managed care," Smith says. "A lot of physicians in practice for decades don't want to change.
"Here we're getting an opportunity to say, `If you look at it carefully, are there things about managed care that can make quality care better for patients?' I think the answer is yes."
Reasons for being. Interviews with practicing hospitalists elicit these observations about this emerging practice:
A doctor who knows the hospital intimately has a keen sense of its strengths and weaknesses, its gears and levers. The physician knows how long a test should take and which nurses are sharpest.
Similarly, that doctor has a better notion of how much things cost and how to use the hospital's resources more efficiently.
Patients get well more quickly if they are being treated more intensively by a physician who can monitor their progress several times a day. That should lead to faster discharges and lower lengths of stay.
Medicine's ever-expanding knowledge base obligates generalist physicians to confine their practice to things they understand fully and deeply. They can't be expected to know everything and perform every procedure.
Likewise, the growing acuity of hospitalized patients means they have more complications, requiring a more sophisticated response on the part of the physician. An office practitioner just can't maintain all the skills needed to treat very sick people.
Patient satisfaction remains constant, or even improves, under this system. Although they're not being treated by their family physician, patients realize they are getting more of the doctor's attention, and more continuity of care, during their hospital stay.
Physician satisfaction rises. Those who enjoy hospital work get to do it all the time, while those who prefer a more regulated office practice don't have to worry about their inpatient load-or weekend call.
"The patient care is actually better," believes Roger J. Hartman, M.D., who spends one week in six as a full-time hospitalist at Kaiser Foundation Harbor City Medical Center near Los Angeles. "When I'm on duty in the hospital, I'm there all day. I can go back to see the patient three, four, five times if need be. I see to it things are being done in a timely fashion, handle problems and talk to the family, who are often there in the middle of the day."
Before his group started this program a year ago, Hartman spent 10 minutes in the hospital each morning writing orders, then kept in touch by phone from an office building several miles away.
Now, when he's on hospital rotation, he's available all day to nurses, dietitians, physical and respiratory therapists, discharge planners and social workers. "The patients," he says, "are attended to much more closely," and they like it.
Embraced by hospitals. Hospitals like it, too.
The pressure of capitation "forces you to look at care differently," said Richard E. Butler, chief executive officer of Fountain Valley (Calif.) Regional Hospital and Medical Center, which has four hospitalists on staff. "What can be done most efficiently? But also, what makes sense to keep the physician as close to the patient as possible? Where you have physicians who are hospital-based, you really have a leg up."
Columbia North Florida Regional Medical Center in Gainesville has four hospital-based internists on site, led by John Nelson. Todd Gallati, the hospital's chief operating officer, cites a number of advantages for the hospital.
Knowing of the availability of the hospitalists, general physicians in outlying counties without admitting privileges at Columbia North Florida more willingly refer patients there. They don't have to drive 70 miles to check up on them, and they're confident they will get the patients back.
Columbia North Florida also uses Nelson's group as a recruiting tool for family doctors who just want to have an outpatient practice. "It's very convenient for them. They can see one patient after another, and never leave the office to go do rounds at the hospital," Gallati says.
Gallati's hospital has one of the lowest average lengths of stay and cost per case in the area. He thinks having the hospitalists instead of the primary-care doctors managing patients might be helping the hospital's statistics. For example, he attributes the hospital's 70% occupancy rate partly to the presence of Nelson and his partners, who are the largest admitting group at the hospital.
Nelson has been doing this kind of work for eight years now. It was lonely at first but now he's glad of the company.
"My belief is this will become a distinct specialty in medicine. You'll find few doctors practicing both in and out of the hospital," he says. "I can't be good at running a code, taking care of a septic patient, lytic therapy for strokes-the things I have to know how to do in the hospital-and be good at cholesterol and cancer screening, recognizing depression in the elderly, all the challenges you face in the outpatient setting."
Indeed, at Long Island Jewish, a teaching affiliate of Albert Einstein College of Medicine, the medical department chairman has set up a residency explicitly to train specialists in hospital care. "I defined the hospitalist position as an academic career track, not just as another house doctor to take care of patients," says Steven A. Wartman, M.D.
The risks. There are potential pitfalls to this system. Every hospitalist physician interviewed for this article stressed the importance of communication between the inpatient doctor and the patient's regular doctor. Wachter worries about a "voltage drop" at the handoff.
Kaiser Santa Clara Medical Center near San Jose, Calif., has instituted several mechanisms to ensure continuity of care, says Diane Craig, M.D., assistant physician in chief. A written discharge summary is prepared for the primary-care physician, and the hospitalist follows that up with a phone call. Further, the patient's hospital paper record-the whole chart-goes to the clinic doctor for the first post-hospital visit. While the patient is in the hospital, the regular doctor is encouraged to make courtesy calls to keep up with the patient's progress.
The American Medical Association has no position on hospital-based specialists but doesn't want any doctor to be forced to do it. "I can see both sides of this," says Thomas Reardon, a general practitioner from Portland, Ore., and vice chairman of the AMA board of trustees. "Our concern would be, this is something that should be done working with the physicians in a given organization so it meets the needs of the physicians and the patients."
But physicians are already organizing themselves around this idea. Nelson is assembling a mailing list for a National Association of Inpatient Physicians. So far he's up to 240. Wachter is putting on a conference in San Francisco April 10-12 to discuss "new models for hospital care in the managed-care era."
"I'm telling you," preaches Wartman from his Long Island pulpit, "this is the way to go in the current healthcare climate. You can reduce the cost of care while increasing the quality. This is one of the rare times you can do that."