|
Few health care providers would argue that the system that was
created many years ago to provide inpatient care is no longer
optimal today. The question we need to be asking is not should
we change, but rather how do we change. We need to restructure
our current system of inpatient care to meet the demands imposed
by sicker patients in a rapidly changing health care environment
with increasing pressures to reduce cost. A new physician role,
the “Hospitalist,” has been suggested as a way of improving
inpatient physician care. If this role gains acceptance in the
medical community, it could have a significant impact on patient
and organizational outcomes. Most health care providers
have, or will soon have, their own perspective on what “value”
a Hospitalist might add to our current system. Having worked
in hospitals for 20 years as a critical care nurse, I certainly
have mine. I admit that the term “Hospitalist” is very new
to me. But from the moment the role of the Hospitalist was
described to me, I found the essence of the concept appealing.
Despite my initial fascination with this new role, I also
admit that I could list many reasons why I believed it would
not be accepted in an academic medical center. However, having
worked for many years with intensivists, I am convinced that
this new role is feasible, and probably will gain increasing
acceptance over time, just as the intensivist role has.
The purpose of this article is to present the role of the
Hospitalist from the perspective of a critical care nurse.
What is a Hospitalist?
A Hospitalist is a physician who cares for patients when
they are admitted to the hospital. The primary care physician
transfers responsibility for the care of their patients to
the Hospitalist for the duration of the in-patient stay. At
discharge, the care of the patient is returned to the primary
care physician.1 Because the concept is so new, the Hospitalist
role has been implemented in slightly differently ways, depending
on the needs or desires of the organizations and physicians
involved. For example, some institutions make the use of the
Hospitalist voluntary, whereas in other organizations, the
primary care physician is required to utilize the Hospitalist.2
Outcome data comparing these different systems of referral
are not available. Certainly, it is in everyone’s best interest
(especially the patient’s) if all involved parties are satisfied
with the physician caregiving arrangements.
Who are the Best Hospitalists?
One of the key questions that arises regarding Hospitalists
is what type of physician is best suited for the role. The
three major contenders are intensivists, internists, and family
practice physicians. I believe each group brings both unique
qualifications as well as some possible limitations as a result
of their training or experience.
It certainly seems logical that the intensivist would also
make a great Hospitalist. Their ability to care for the sickest
patients and their skills in performing life saving interventions
make them a natural choice for the role.
However, a general internist brings to the role a great wealth
of information and perhaps a greater perspective of caring
for patients over a broader spectrum of illness than their
intensivist colleague. Managing patients on a general floor
is not the same as managing patients in an ICU. These differences
may be better appreciated by an internist with more experience
working in this environment.
The other group of physicians who may be interested in the
Hospitalist role are family practice physicians. Their special
skill in addressing the totality of patient needs makes them
a logical choice in many ways. One could argue that any special
interventional skills they may need (e.g., airway management)
could easily be learned in special credentialing or competency
programs.
The possible role for surgeons as Hospitalists is an interesting
one which has received little attention in the literature.
The inpatient care of hospitalized surgical patients is also
becoming increasingly complex. It would be optimal to have
a qualified attending surgeon readily available to address
inpatient postsurgical issues. Having a surgeon tied up in
the operating room for most of the day makes it difficult
to address the patient’s needs in a timely manner. Many would
argue that a surgeon wants to spend their time in the operating
room as apposed to the wards. Nonetheless, the concept of
surgeon as Hospitalist is still worthy of consideration.
I would imagine that to most nurses, it makes little difference
what specialty training the Hospitalist has. Several colleagues
I polled on this issue made comments such as “Someone would
be better than no one regardless of what kind of doctor they
are” and “They all went to medical school didn’t they?” Clearly,
these nurses were not concerned with the type of training
that the physician had received.
On the other hand, the nurses I spoke with were very clear
on what type of person would make a good Hospitalist. Across
the board, the resounding theme involved a physician who was
a “team player”. It was very important to the nurses I spoke
with that this type of physician possess excellent communication
skills and understand the value of contributions from all
members of the health care team.
The essence of what these nurses were describing was a physician
who would promote a collaborative environment. Collaboration
is the process of working together and sharing in decision-making.
More than any other quality, it seems crucial that a Hospitalist
must possess this collaborative spirit.
Case Examples
The first scenario (see box) may have slightly exaggerated
the cranky, overworked attending, but not by much. This scenario
where the patient, family member, nurse, intern, or resident
struggles to get the attending physician’s attention is very
real. The dilemma described by the harried attending is also
no fallacy.
The pressures on an attending physician can be tremendous.
In addition to their inpatient responsibilities, there are
outpatients/clinics, teaching, research, and administrative
responsibilities. But, do these conflicting responsibilities
concern the patient or the patient’s family when they are
in the hospital? Clearly, the answer is no. Patients who are
hospitalized today are seriously ill. It is inappropriate
that their care receive less than the full attention of a
qualified physician.
Are there attendings who “do it all” and have excellent communication
skills, and are team players? Sure there are! But the price
they may be paying for trying to be all things to all people
may be very high.
We have had the same basic physician structure for managing
inpatients for over a century. Of note is that while in the
last 10 years we have restructured, reengineered, and reorganized
almost every group of professionals in the hospital, we have
not touched the essence of physician practice. It is time
to look more closely at the role that the attending physician
plays in the care of the hospitalized patient. As we examine
this role, it becomes clear that any significant impact on
patient care necessitates close collaboration between the
attending and other members of the in-patient team. The Hospitalist
role, by its very nature, promotes the collaborative relationships
necessary to positively effect patient and organizational
outcomes.
Potential Nursing Impact
From a nursing perspective, it is hard to imagine the Hospitalist
role as anything but a dream come true. This of course assumes
that the right person is in the role and promotes a collaborative
environment.
There are numerous ways that a Hospitalist could support
excellence in patient care. Because the Hospitalist is more
involved in the day to day activities of a ward/floor, he
or she would get to know the staff, developing an appreciation
of their unique qualities and contributions to patient care.
This would lead to the development of trust and respect for
the other health care professionals. The Hospitalist would
also learn about the systems that are in place to support
patient care activities throughout the hospital (e.g., admission/transfer
criteria). An increased involvement in these systems will
help the Hospitalist to appreciate the hows and whys of the
systems and allow a greater appreciation for the impact of
these structures and processes on the patient.
The Hospitalist can also become a more active member in quality
improvement activities that can make a real difference in
how patient care processes occur and in the outcomes they
ultimately impact. Being an integral part of the “team” and
knowing the system well allows the Hospitalist to share in
decision-making regarding which patient care issues need to
be assessed.
Over time, the Hospitalist and other members of the team could
develop multidisciplinary standards of care and protocols.
The involvement of the Hospitalist in all phases of the development
and implementation process makes them committed to these standards
and to the measurement and tracking of patient outcomes.
Research supporting the Hospitalist role is non-existent.
But some assumptions can be made from studies evaluating the
effectiveness of intensivists which suggest that intensivist
guided therapy positively impacts patient outcome.3-6 Now
is the time to study the new Hospitalist role and to examine
its impact on important outcomes such as cost of care, quality
of life and patient satisfaction.
There is an urgency for this type of research for many reasons,
not the least of which is financial. Our current system of
reimbursement is not supportive of roles such as Hospitalists.
A feasibility study which systematically examines the impact
of Hospitalists on organization and patient outcomes will
be necessary to convince third party payers that this system
not only can improve patient outcomes but is also financially
sound.
The time has come to evaluate the current system of providing
in-patient care. It is no longer justifiable to render fragmented,
potentially inferior care because physicians are too busy
with other responsibilities. Hospitalized patients deserve
the full attention of a qualified physicians 24 hours a day.
Emergency departments have already implemented this practice.
It is time for the rest of the hospital to follow suit and
maintain a similar standard of care across the health care
continuum.
References
1. Wachter MR, Goldman L. (1996). The emerging role of “Hospitalists”
in the American health care system. NEJM, 335 (7), 514-516.
2. Henry LA. (1997) Will Hospitalists assume family physicians’
inpatient care roles? Fam Prac Mgmt, July/August, 55-67.
3. Brown JJ, Sullivan G. (1989). Effect on ICU mortality of
a full time critical care specialist. Chest, 96 (1), 127-129.
4.Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW.
(1988). Impact of critical care physician staffing on patients
with septic shock in a university hospital medical intensive
care unit. JAMA, 260 (23), 3446-3450.
5.Pollack, MM, Katz, RW, Ruttimann, UE, Getson PR..(1988).
Improving the outcome and efficiency of intensive care: the
impact of an intensivist. Crit Care Med, 16 (1), 11-17.
6.Pollack MM, Cuerdon TT, Patel,KM, Ruttimann UE, Getson PR,
Levetown M. (1994). Impact of quality-of-care factors on pediatric
intensive care unit mortality. JAMA, 272 (12), 941-946.
-by Elizabeth Henneman, PhD, RN.
Ms Henneman is the Clinical Nurse Specialist for the MICU
at UCLA.
Back to PCCMG Home
Page
Back to Bibliography |
