Hospitalists play rising role in health care
Hospitalized patients across the country can no longer assume that their regular doctors will check on them during daily rounds.
Reflecting today's changing medical practices, some primary care doctors don't set foot inside their patients' hospital rooms at all -- leaving their care to physicians called hospitalists.
The specialty of hospitalist -- a doctor employed by a hospital to care for admitted patients -- began emerging about 15 years ago and stems from a variety of factors that include health care reform and soaring medical expenses, experts and officials said.
Hospitalists track the condition of patients after they are admitted -- arranging for tests and specialist care instead of having primary care doctors attend to them.
Those who advocate the expanding use of hospitalists say their presence means hospitalized patients don't have to wait for their own doctors to appear to check on them and give orders for their care.
But some experts contend that the move toward hospitalists may be a disguised attempt to churn patients in and out quickly so hospitals can make money on their stays but still avoid expensive testing that drives up costs.
Brendon Shank, a spokesman for the Philadelphia-based Society of Hospital Medicine, said based on the American Hospital Association's annual survey of hospitalists, his group estimates there are now more than 40,000 hospitalists in the United States.
"The entire American health care system is becoming increasingly interested in the cost of medicine in the United States," said Dr. Shaun Frost, president of the hospital medicine society. "The goal is to improve the quality of care that patients receive from hospitals in this country."
An emerging specialty
A 2012 report by the hospital medicine group based on statistics provided by the Medical Group Management Association in Englewood, Colo., sampled 3,402 hospitalists across the country and found their median compensation was slightly more than $233,000 in 2011. In the Eastern region, the median salary was just over $227,000.
Some patients first encounter a hospitalist when they enter an emergency room. But more and more, primary care doctors who admit patients to hospitals for various medical conditions are arranging ahead of time for a hospitalist to take care of them during their stay.
By monitoring a patient's condition throughout the day, a hospitalist can sometimes provide treatment more quickly than a primary care doctor who holds office hours in addition to visiting patients in hospitals.
At South Nassau Communities Hospital, Dr. Haiwen Ma directs the hospitalist program, which has one part-time and 12 full-time physicians. The full-time hospitalists work eight-hour days and handle 11 to 12 patients daily, Ma said.
"I just like the challenge of it," Ma said. "I like the busyness and trying to make decisions. We're on the front line."
Ma noted that 77 doctors send their patients to South Nassau to be cared for by hospitalists. "My goal is not to shorten length of stay, my goal is to get the patients better," she said.
Most hospitalists keep in touch with patients' regular doctors about their conditions during their stays and inform them of their plans for discharge.
Primary care physicians can benefit from the new model, too, some hospital officials say, since they can concentrate on seeing more people during office hours.
Dr. Robert Wachter, a former Long Island resident and now chief of the division of hospital medicine at the University of California, San Francisco, and Dr. Lee Goldman, dean of the faculties of health sciences and medicine at Columbia University, are widely credited with planting the seed for a new hospitalist specialty in a 1996 New England Journal of Medicine article.
"These places [hospitals] are so complicated that you need doctors who specialize in the place," Wachter said in a recent interview.
Wachter said it was inevitable the health care system would "be pushed kicking and screaming to figure out" the best care for the lowest cost.
Goldman said the fact that hospital savings are often mentioned when discussing hospitalists isn't a surprise. "We did this for quality [care], not for saving costs," he said.
Dr. Andrew Goldstein, an internist who is a solo practitioner in Merrick, says South Nassau's hospitalist program has freed him to concentrate on patients in his office while being assured his hospitalized patients get round-the-clock care.
In the past, Goldstein said, "I would not get to the hospital until I was done with my office hours, which was often around 8 o'clock."
Now, Goldstein said, if a hospitalized patient needs care, a hospitalist is there to provide it.
South Nassau keeps track of all the specialists Goldstein uses and if one of his patients has an emergency, the hospital will call those doctors.
Goldstein said the feedback from patients has been "very good because the program is very good."
Dr. Glen Stream, a family physician in Spokane, Wash., and board chair of the American Academy of Family Physicians, said the use of hospitalists "can be a good thing but it should be by choice."
Some hospitals demand that family doctors with hospitalized patients give up control of their care to hospitalists, Stream said.
But officials at South Nassau, Huntington and North Shore said that is not the case at those hospitals.
"We want to preserve the opportunity so if they choose to visit their patients in the hospital, the hospital is not prohibiting them from doing that," Stream said. "We really sort of prefer the ideal model where the person's physician was able to care for them in the hospital."
Dr. Anthony Intintoli, director of hospitalist services at Huntington Hospital, says physicians become hospitalists because "they like the action or the intensity of taking care of sick patients in the hospital. We get the satisfaction of getting them better and having them leave the hospital."
Intintoli said Huntington Hospital has about 20 full-time hospitalists. He said the specialty provides regular shifts for doctors -- allowing them more free time.
And, Intintoli said, hospitalists don't have to worry about buying expensive malpractice insurance because the hospital provides that.
In office practices, Intintoli said, "They're worried about malpractice, having to see a certain amount of [patient] volume, a certain income."
Debate over costs vs. care
Dr. Nick Fitterman, who preceded Intintoli in his job, said at Huntington, about 85 percent of the patients are cared for by hospitalists rather than their regular doctors. Fitterman is now medical director of group health management for the North Shore-LIJ Health System, which includes Huntington Hospital.
Bioethicist Arthur Caplan, head of medical ethics at the NYU Langone Medical Center, says because hospitalists are hospital employees, they must balance their employers' desires to lower costs against the needs of patients.
"I think hospitalists have a bit of a conflict of interest on their hands," Caplan said. "If the hospital can maintain its volume by churning people through relatively quickly, they can do fewer expensive tests but still make money. All of this must be balanced by the obligation to do the right thing for each patient."
Because the hospitalist specialty is designed to make hospitals run efficiently and to cut down on costs by discharging patients as quickly as possible, experts like Caplan have raised concerns that some patients might be released too early.
Linda Novick, a school nurse in Great Neck, believes she's a good example of that.
Novick said she first encountered a hospitalist when she entered Huntington Hospital's emergency room in January 2012 with a urinary tract infection. She said she received an intravenous antibiotic and was sent home the same day.
Two days later, Novick said, the hospital called her to say test results showed she had sepsis, described on the Mayo Clinic website as "a potentially life-threatening complication of an infection."
Novick was readmitted, but the next day, she said, a hospitalist and an infectious disease specialist wanted to send her home. She insisted on staying and was released four days later.
"I was feeling absolutely horrible and not well and I was astounded they wanted to send me home," Novick said. "I felt they were rushing me out."
Novick said the hospital didn't contact Dr. Robin Thompson of Huntington, her primary care physician. Thompson confirmed that.
"That's unusual," Thompson said. "Usually the hospital does notify primary care doctors. Huntington Hospital does a good job of keeping primary care involved."
Intintoli had no comment on Novick's case.
However, Terri Morris, 59, of Northport, said she had good experiences with hospitalists during multiple stays at Huntington Hospital for treatment of her chronic anemia.
"They give me a lot of attention," Morris said. "They come by frequently. I have had just a marvelous experience with them. I feel like I'm a regular patient of theirs."