Hospitalists serve no purpose
There have been many smaller studies that have demonstrated that having physicians who "specialize" in inpatient medicine improves all of the above. Meltzer's study however showed no significant improvements in any of these parameters.
Great. It was for my expertise as a hospitalist that I received my academic appointment at UCLA. I can imagine my department head at the next budget meeting. 'Now remind me, why did we hire Ford?'
In fact, I'm giving a grand rounds lecture on the benefits of the hospitalist paradigm in a few weeks. I guess I can make it a very brief one. I'm reminded of Gilda Radner's line while playing character Emily Litella: "Never mind!"
OK, maybe the title of this post is a bit melodramatic. I haven't thoroughly evaluated Meltzer's study as it hasn't yet been published. But judging from some of the methodology used, I'd say his results were somewhat predictable.
The whole idea of developing a hospitalist program is to improve the efficiency of managing inpatients. By having a physician who specializes in seeing inpatients and who is generally stationed in the hospital for most or all of the day, it is hoped that they will provide better care than primarily office based physicians.
The theory is that when doctors specialize in inpatients, they build up special skills in that unique area. They also become far more efficient and adept at navigating through the idiosyncrasies of their particular base hospitals simply because they spend so much time there.
In addition, most successful hospitalist programs have other features that distinguish themselves from traditional models. Generally they make a significant capital investment in ancillary services such as case managers (usually special trained RN's) who assist patient and family in their progress through their hospitalizations. There is also investment in other infrastructure that is important post-discharge such as home nursing, outpatient IV infusion services, outpatient physical therapy, etc.
These other features go a long way towards shortening hospital stays and optimizing outcomes.
There are many controversies that have arisen from what is increasingly being seen as the new norm when it comes to inpatient care (far more than I'm able to address in this short post). However, one of the most important motivations driving this practice is that hospital costs, lengths of stay and patient outcomes should all improve. It was axiomatic that specialists in inpatient care and the infrastructure designed around them had to be more efficient than an office doc making special trips to several hospitals to see only one or two patients and then rushing back to a full clinic.
So why didn't Meltzer's study confirm this? He himself speculates on the most likely reasons. What it come down to is that the "study" group, the patients followed by hospitalists, wasn't managed sufficiently differently from the control group. This was likely for the following reasons:
- This study took place in academic institutions. Instruction from hospitalist to house staff may be expected to make the residents and interns function more like hospitalists on later rotations even though their future attendings might be non-hospitalists.
- Since more hospitalists were placed on inpatient rotations during the study period, there was less demand for non-hospitalist attendings. Programs might then be expected to have placed their "better" non-hospitalist attendings to staff these inpatient rotations.
Another factor wasn't specifically addressed in the presentation. I seriously doubt that the study made provisions for the hospitalist group to have better ancillary services as described above than the control group. The presence of such services is known to be an integral feature of and greatly contributes to the success of any hospitalist program. Again, this would tend to make the two groups more similar than different.
For these reasons, I still have faith in this paradigm. I've seen it make dramatic differences in several large commercial settings when adopted (with very good metrics in each case) and there are multiple formal studies in community hospitals that bear this out.
Bottom line: I'm not yet looking for another career change.