Fifteen years ago, the concept of the hospitalist was a revolution in medicine. Now a slew of subspecialties are getting into the mix, with neurologists, obstetricians, orthopedists, and even dermatologists calling themselves hospitalists.
Some of the factors fueling the rise of these new programs are the same ones that caused so many internists to become hospitalists in the 1990s. Across specialties, physicians are so busy with their outpatient practices that they don’t have the time or inclination to see patients in the hospital.
Courtesy Dr. S. Andrew Josephson
Neurohospitalists like Dr. S. Andrew Josephson have made the lives of both neurologists and hospitalists a little easier.
But traditional medicine hospitalists can’t fill all those needs, said Dr. S. Andrew Josephson, director of the neurohospitalist program at the University of California, San Francisco. In neurology, for example, medicine hospitalists have increasingly been asked to take on more of the neurology cases that come in through the ED, but they lack the training to feel comfortable managing the broad spectrum of neurological disorders in the hospital, he said.
The creation of neurohospitalist programs has been a way to take the pressure off of both outpatient neurologists as well as medicine hospitalists, Dr. Josephson said. And so far, very few physicians seem to mind handing off the work. "There’s not a lot of turf battles here," he said.
Hospitals benefit too, he said, because having a neurohospitalist available 24-7 to cover the ED makes it easier for hospitals to be experts in neurologic care and be certified as Primary Stroke Centers.
Similar trends can be seen in orthopedics, where hospitals are also having a tough time getting orthopedists to take call. Dr. Kurt Ehlert, an orthopedic hospitalist and the national director of orthopedic services for the physician staffing firm Delphi Healthcare Partners, said that they have largely been able to defuse turf concerns among community-based orthopedists by firmly establishing that the hospitalist group will not take elective cases. The orthopedic hospitalists mainly handle fracture care and when an elective case comes their way, they get the patient started on therapy and refer them to a physician in the community.
"The center of gravity for physician practice in almost every specialty is moving away from the hospital," said Dr. John R. Nelson, a traditional medicine hospitalist in Bellevue, Wash., and a cofounder and past president of the Society of Hospital Medicine.
More and more physicians are realizing that by focusing on the outpatient setting they can generate more income, are less likely to be sued, and don’t have to work nights and weekends, Dr. Nelson said. Because of this, they are limiting their hospital work as much as possible. "We need to fill the hole," he said. "We’re filling the hole with hospitalists in some cases."
In specialties like obstetrics and gynecology, the hospitalist trend is catching on fast, said Dr. Rob Olson, an obstetric hospitalist in Bellingham, Wash., who was recently elected to be the first president of the Society of Ob/Gyn Hospitalists. The exact number of ob.gyns. practicing as hospitalists is unknown, Dr. Olson said, but he estimates that there are currently 142 programs in hospitals around the country. The growth in obstetrics and gynecology hospitalist programs has been explosive, growing from about 15 programs only 5 years ago, according to Dr. Olson.
While there are a variety of models for how to run an ob.gyn. hospitalist program, the major driver for all of them seems to be the enormous malpractice exposure in obstetrics. The idea behind having an obstetric hospitalist program is that there is always a qualified physician in the hospital to handle obstetric emergencies and deliveries. Theoretically, that reduces bad outcomes and therefore brings down malpractice litigation and settlement costs.
There is already some evidence to support that idea. In one study, researchers analyzed perinatal malpractice claims and found that most of the money paid out in obstetric malpractice cases is the result of "substandard care." The researchers concluded that more than half of hospital litigation costs could be avoided with a few changes, including 24-hour in-house obstetric coverage (Obstet. Gynecol. 2008;112:1279-83).
But even with studies supporting the premise of the ob.gyn. hospitalist movement, there is still a great need for more data on cost, quality, and patient satisfaction with these programs, Dr. Olson said.
Unanswered questions abound in other specialties too. Dr. Nelson said he’s optimistic that hospitalists from across specialties will embrace the quality improvement example set in medicine and pediatrics, but the idea that setting up hospitalist programs in a variety of other specialties will definitely lead to better care for patients is still unproven. And it could take another 5-10 years before that evidence is available, leaving hospitals to make a business decision before all the evidence is in, he said.