US-style hospitalists are unlikely to improve delivery of patient care in the NHS
Editor – Over the last 15 years, I have watched the increasing impact of physician specialists, known as hospitalists, on the delivery of patient care at the institution where I have my principal appointment. More recently, I have had the opportunity to interact with hospitalists at two other medical centres (one a university hospital, the other a community hospital). Accordingly, I read with great interest Kirthi et al's recent paper advocating a clinical leadership role for hospitalists in the National Health Service (NHS) (Clin Med August 2012 pp316–9) as well as your accompanying editorial (Clin Med August 2012 pp 307–8).
Few hospitalists in the US have trained specifically for hospital medicine. Indeed, in a recent survey, it was found that only 1 in 50 hospitalists had either completed or were currently involved in a hospital medicine fellowship.3 The typical hospitalist's postgraduate training is limited to three years (most often in general internal medicine). In addition, 55% of the current pool of US hospitalists have only been practising as hospitalists for five years or less.1 Accordingly, Kirthi et al's attempt to equate US hospitalists with NHS general physicians is somewhat misleading, at least with regards to depth of training and experience.
There have emerged national hospitalist management companies that individually employ often hundreds of hospitalists in facilities throughout the US. One particular company employs physicians in 900 facilities (including the three medical centres at which I work) in 27 states.2 Such private companies provide intense instructional programs, teaching billing and coding, medical record documentation, risk management and health care economics for every new hospital recruit. Several years ago I met a former resident who had just completed one of these courses. ‘I've become a billing machine!’ he told me proudly. In the US fee-for-service environment these skills are vital. The hospitalist is often under the gun from his or her employer (whether a hospital, a national chain or a local group) to consistently bill to the highest level that can be supported by their notes (electronic health records have been an enormous help) and to see as many patients as possible. For most hospitalists, a part, if not all, of their salary is determined by the number of fee-for-service relative value performance units (RVUs) they clock up.3
Like emergency room physicians, hospitalists are shift workers who generally do not have the opportunity to form significant personalised bonds with patients. They manage only hospitalised patients and have absolutely no outpatient responsibilities. They work in a very focused and efficient manner, recording medical history, carrying out physical examinations, writing discharge summaries and progress notes, checking results of investigation and carrying out the suggestions of the various consultants on the case. However, there is, quite frankly, no expectation of the hospitalist consistently providing significant clinical insight into individual patients. Moreover, when a patient needs to be transferred from the regular medical ward to an intensive care unit, hospitalists are generally out of their depth, and provision of comprehensive clinical care is transferred to the intensive care specialist.
In the past, hospitals looked to hospitalists to shorten length of stay. Now, as the Affordable Care Act starts to roll out, the key missions for the hospitalists will be to keep readmission rates as low as possible and to achieve, in every patient, compliance with ‘core measures’ (such as making sure that every heart failure patient is on a beta blocker and ACE inhibitor at the time of discharge). Hospitalists are very good at achieving the latter goal; their effectiveness in reducing readmission rates is less certain.
Accordingly, and in full agreement with the opinions expressed in your editorial, I feel that US-style hospitalists are unlikely to improve delivery of patient care in the NHS.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2012 Royal College of Physicians
References
- ↵Compensation and Career Survey Results, 2011. www.todayshospitalist.com/survey/11_salary_survey/index.php [Accessed 16 August 2012].
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- Gesensway D.
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