Home Q&A A new debate surfaces over hospital medicine

A new debate surfaces over hospital medicine

September 2008

Published in the September 2008 issue of Today’s Hospitalist

WITH HOSPITALS DESPERATE TO RECRUIT hospitalists, the question of whether or not hospital medicine is good for patient care seems to be a done deal.

After all, hospitals aren’t fighting over whether to start or staff programs, but over how they can outbid each other for available physicians.

That’s why a debate that played out in the pages of the June 23, 2008, Archives of Internal Medicine may have come as a surprise. The point-counterpoint brought together two internal medicine luminaries: Mark Williams, MD, who for years headed up the hospitalist program at Atlanta’s Emory University and is now chief of hospital medicine at Chicago’s Northwestern University Feinberg School of Medicine, and Robert Centor, MD, chief of general internal medicine at the University of Alabama at Birmingham.

Each contender addressed a simple yet far-reaching question: Is hospital medicine good for patient care? Given hospitalists’ ability to respond to patient needs and to coordinate care, there’s no doubt that hospital medicine has been a boon for patients, Dr. Williams argued.

Not necessarily so, Dr. Centor countered. There’s too much variety in coverage and services to talk about a single hospital medicine “model.” And according to Dr. Centor, we still don’t know what the long-term effect of hospitalist care is, nor what number of patients physicians need to treat or what kind of training they need to be considered skilled in hospital medicine.

Today’s Hospitalist talked to Dr. Williams about why the points raised in the opinion duel are still relevant.

Whose idea was it to hold the point-counterpoint?
It’s a format that Archives runs periodically. Each of the two parties is given a topic to write about, and you don’t know who the person is whom you’ll be debating. I understand that Archives had some trouble finding someone to take the “con” side of the debate.

Hasn’t the issue of hospital medicine being good for patient care been settled?
That has been settled, and the answer is an unequivocal “yes.” The question we should be debating is not whether to use hospitalists but how to best optimize their use.

I think Dr. Centor was trying to touch on those questions and not have people just accept hospitalists wholesale “and I don’t entirely disagree with him. It is critically important that as we establish hospitalist programs, we establish them properly.

Dr. Centor raised the issue of variability in programs staffing and coverage.
He certainly identified issues that some programs need to figure out: What is the optimal patient census, schedule, support staff and approach? Should it be a nurse, a hospitalist and a pharmacist rounding together? Those are the questions that we need to address.

At the same time, I think it’s disingenuous to raise those questions as the reason why hospitalists “are not a good idea,” just because some programs are not following optimal approaches and lack adequate leadership. These are growing pains and symptoms of the rapid expansion of the field.

But the fact that we’re asking these types of questions means the field is maturing. We’ve passed out of adolescence and we’re heading into our late teens, although some programs are remarkably mature. If you look at Kaiser Permanente’s hospital medicine models, for instance, some have been in place for 16 years.

Dr. Centor also used some pretty loaded terms, like “complete internist,” to describe a doctor who provides both inpatient and outpatient care.
Well, Dr. Centor is coming from an academic medical setting with housestaff who serve as his personal hospitalists. I certainly wouldn’t describe him as a “complete internist” who’s willing to get called in at 2 a.m. to admit patients or to deal with weekend admissions while also staffing a busy outpatient clinic. Given that he exclusively supervises residents on a teaching service, I’d describe him as an academic hospitalist and have told him this!

I think the concept of a “complete internist” is an anachronism that may have applied 20-plus years ago. While there may be a few internists still like that in rural private practice, it’s clear that optimal care for hospitalized patients is having a hospitalist on-site who’s available to respond to emergencies.

And here is a critical issue. A hospitalist not only delivers patient care, but is dealing with a second patient: the hospital. Hospitalists are trying to figure out how to optimize the entire system of care delivery, and that’s what makes hospital medicine a true opportunity.

The Wall Street Journal’s Health blog covered your debate. At least a few comments about hospital medicine from readers seemed quite bitter. Were you surprised by that backlash?
No, there are a lot of internists in their 50s and 60s who might wish to turn back the clock. But the model of community physicians following patients into the hospital meant that there was no inpatient doctor at night to see patients. I think a lot of medical errors occurred as a result.

That backlash is also being driven by a small portion of hospitalist programs that aren’t run right. Some hospitalists see between 25 and 30 patients a day or work two- or three-day blocks at a time, so a patient may come in and see three different hospitalists in three days. That’s not acceptable to me as we develop this model.

One controversial point raised was that financial and lifestyle considerations, not quality issues, have spurred the rise of hospital medicine. Your comments?
I don’t think lifestyle concerns are driving the model per se, although I think that’s a recruitment issue for the current generation. It’s no secret that specialties like radiology, dermatology or even emergency medicine enjoy significant popularity because new medical graduates enjoy the lifestyle of defined hours. Being a hospitalist provides that opportunity.

The issue is: How can we optimize quality of care and best utilize our most important resource “hospitalists? This plays into the evolution of scheduling. We’re trying to balance this out with what’s ideal from the patients’ perspective.

I think patients want to have a hospitalist living in the room next to them 24/7 from the time they arrive until they leave. Of course that’s not realistic, so we need to figure out how to meet their continuity needs while enabling human beings to do this job.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.