Hospitalists throughout the Years: Growth of a Specialty...and Its Problems

TASA ID: 3333

In the early 1990s, Americans started seeing a new type of doctor who spent all of his or her work hours in the hospital and never went to an office. Pediatricians, family practitioners and internists were the first to divide themselves into those doing outpatient care and "hospitalists." The original incentive for the change was simple efficiency: hospital rounds take primary care doctors away from more-lucrative office visits, and a doctor who spends all day at the hospital knows the way around and can serve patients faster. Doctors who got tired of driving from office to hospital and back were happy to have their sickest patients seen by somebody else; doctors fresh out of training, on the other hand, generally know little about managing an office but are very comfortable in the hospital environment.

Over the next couple of decades, both large and small hospitalist practices developed. National organizations like InPatient Consultants (IPC), TeamHealth, Cogent and Sound Physicians grew by offering financial and organizational services, such as recruiting new physicians, since doctor turnover is a chronic problem. At about the same time, training programs were required to put limits on work hours for resident physicians. As a result, teaching hospitals needed hospitalists to do some of the patient care previously done by doctors in training.

In the 1980s it became clear that hospital practice would need to change. Medicare and other federal insurance programs, which had once unquestioningly paid for all the days a patient spent in the hospital, began insisting on documenting the need for those days--and other services as well. Not only did admitting someone "just for tests" become obsolete practically overnight, hospitals started pressuring doctors to eliminate avoidable days in the hospital. Before long, you had to actually be sick to be admitted, and insurance companies were more than happy to follow Medicare's lead. This convinced even more office doctors that keeping up the skills needed to care for ever-sicker inpatients was not worth the trouble, and hospitalists prospered.

A typical hospital stay now begins with a day or so of rapid-fire testing and initial treatment, followed by a few more days to be sure every problem requiring hospital services has been resolved. And once the patient no longer needs care by hospital personnel, the insurance company will stop paying for it. So today's hospitalists' mantra is, "Discharge planning begins on the day of admission." Hospitals hire nurse specialists called case managers to help the process by arranging rehabilitation stays, finding nursing facilities for people needing more help than they can get at home, and even finding primary care doctors for people who never had one before.

In the past five years, health care professionals of all kinds have been required to start using electronic medical records (EMRs), which are supposed to make record-keeping clearer and more efficient. Whether EMRs improve patient care is a matter of intense debate; what they do improve; however, is hospitals' ability to keep tabs on how doctors practice medicine. Newer software interfaces with patient records and produces tables showing which doctors' patients stay in the hospital longer, who uses the most expensive medicines, and whose patients spend the longest in intensive care. Doctors who admit only a few patients a month will usually be less skilled at discharge planning, and as a result of their length-of-stay and cost-per-diagnosis statistics, the chief of medicine or pediatrics may suggest either a change in their practice or a return-to-office only medicine. Hospitalists, on the other hand, often are pressured by the hospital they contract with to handle heavier patient loads, meaning that if patient rounds start at 7 am the last patient may wait until suppertime to see a doctor. Hospitalists may work a "7 on 7 off" schedule and share night call, so it's not unusual for three or four doctors to see a patient during a hospital stay.

As hospital administrator jobs increasingly go to business majors instead of health care professionals, the pressure to practice with an eye on the bottom line has intensified. Families of frail elderly patients are encouraged to look for a skilled nursing facility even before they've had time to consider their options; patients who need a week or two of intravenous antibiotics may be encouraged to finish the treatment at an outpatient infusion center. Not surprisingly, patients with little or no insurance come under special scrutiny: Medicaid HMO policies sometimes insist that a patient be transferred to a different hospital, or if non-emergency surgery is needed that we discharge them and have them readmitted after their primary care doctor completes the necessary paperwork and gets it approved.

So, how do these changes affect medical malpractice? You are likely to see more lawsuits charging that patients were discharged prematurely and got worse or died as a result. As doctors spend more time at a computer terminal and less at the bedside, the impression they make on patients and families will get worse too--and an unhappy patient is far more likely to sue than one pleased with her care. The increased workloads for hospitalists mean higher odds that something will go unnoticed or be postponed for too long, with what we tactfully call "bad outcomes." And assuming that the doctor whose name heads the chart is responsible for everything is no longer safe: many hospitals like for hospitalists to admit everybody and have the specialist who takes care of the main problem serve simply as a consultant.

Whether you are on the plaintiff or the defense side of the table, it's worth checking (1) the client's insurance status and (2) the relationship between the hospitalist and the hospital. If you're defending a hospitalist, ask how much pressure there is to "treat 'em and street 'em;" he may be able to produce some emails and internal communications showing the administration's efforts to encourage early discharges. If the complaint is about complications from a surgical or diagnostic procedure, the hospitalist may have had no voice in how it was handled...and the specialist may have refused to respond to concerns about the patient's low blood pressure or falling blood count. Handoffs are another concern, since communication between hospital and office may be incomplete, and a "night call" doctor may not be aware of all of a patient's problems when the nurse asks for help.

I encourage my fellow hospitalists to document situations that affect patient care, even if they're non-medical. Phone calls from insurance company representatives insisting that a patient "no longer meets inpatient criteria," hospital administrators' restrictions on expensive care, and the hospitalist's opinion as to what is going on in a post-surgical patient can all affect treatment outcomes.

And as for you attorneys--try to give credit and blame where it's due. It will help the reviewer to know which doctor took care of which problem, and whether one hospitalist saw the patient every day or if there were three or four. A list of doctors with their specialties will help a reviewer figure out who did what. And maybe the next time you or a family member needs hospital care, you'll know which questions to ask.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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