Today’s NEJM Hospitalist Study: What’s the News?

A paper in today’s New England Journal proves what we all know – the hospitalist field is the only thing growing faster than the national debt. Even though that’s not news, this elegant biopsy of the Medicare database offers some new insights about our field, the fastest growing specialty in medical history.

Briefly, the study used a methodology developed by Sanjay Saint a decade ago: by examining evaluation and management (E&M) codes submitted by general internists to Medicare, one can determine which physicians do virtually all their E&M work in the hospital, which have traditional general internist practices (part-inpatient, part-outpatient), and which do virtually no inpatient work (“ambulists” or “officists” – somebody will ultimately need to settle on a term).

The NEJM authors defined a hospitalist as a general internist who cares for over 100 Medicare patients per year and whose E&M codes are at least 90% hospital-based. This is a reasonable methodology for highlighting trends, but it misses vast numbers of hospitalists. Surely, every internist with more than 90% inpatient codes is a hospitalist, but someone with 75% inpatient codes is probably one as well. In some academic centers, for example, hospitalists do 2 half-days a week of pre-op clinic, post-discharge follow-ups, or even traditional outpatient practice, and thus fall below the 90% threshold. For this and other reasons (the study excludes pediatricians, family physicians, subspecialty hospitalists, and those who work in organizations like Kaiser Permanente or the VA, who submit very few Medicare bills), the paper’s estimate of about 14,000 hospitalists is probably low by a factor of two. The actual number of U.S. hospitalists is closer to the American Hospital Association’s estimate of 28,000, making the field larger than cardiology.

But the news is in the growth curve. From 1997 to 2006, the hospitalist workforce increased by 29% a year! In keeping with this growth, the percentage of Medicare patients cared for by hospitalists increased from 9% to 37%, and now exceeds 80% in some high penetration markets such as Austin, Texas and Mesa, Arizona. Paralleling these trends is substantial growth in ambulatory internists (<10% hospital codes), now up to 35% of all internists and rising fast.

As you know, the American Board of Internal Medicine has been developing a certification program to recognize the “focused practice” of hospitalists. Some have fretted about a slippery slope – if we’re going to recognize hospitalists, they say, why not recognize those internists who have taken a particular interest in diabetes, heart failure, or thyroid disease? The Board (which I’m on, BTW) has taken the stance that it will consider for “Recognition of Focused Practice” areas in which large numbers of general internists only do the thing, and large numbers never do it. Hospital Medicine clearly vaults way over that bar. Conversely, clinical areas of focus like diabetes wouldn’t qualify, since virtually every general internist still sees diabetics, even though some have taken a special interest in such patients. (HIV is the only clinical domain I can think of that might pass this test.)

Another interesting trend raised by the paper: In 1995, 46% of all Medicare admissions were associated with a general internist E&M claim. Assuming somebody was taking care of the patient, this means that most hospitalized patients were being managed by subspecialists (cardiologists, gastroenterologists, etc.) or specialists (surgeons, gynecologists). This percentage rose to 61% in 2006, all on the strength of the growth of hospitalists. In other words, hospitalists have not only taken over for PCPs in overseeing and coordinating hospital care, they have taken over for specialists and subspecialists. A 2002 paper demonstrated that specialists caring for patients whose main problem fell purely within their specialty sweet spot achieved good quality and reasonable efficiency… but when specialists cared for patients with other problems (the gastroenterologist caring for the hospitalized asthmatic, for example), they had poor quality and miserable efficiency. So this replacement of specialists and subspecialists with hospitalists as primary managers of inpatient care is an important, and to me a positive, development – particularly since so few of today’s inpatients are cooperative enough to limit their problems to a single organ system.

In a related note, the skyrocketing penetration of hospitalists in the care of patients with “medical DRGs” was matched by that seen in patients with “surgical” and “neurologic” DRGs. This is quite remarkable; it means the chances that a patient admitted to a U.S. hospital with an orthopedic DRG (i.e., hip fracture) or a neurologic DRG (i.e., stroke) will be taken care of by a hospitalist is the same (40%) as one admitted with a pulmonary or GI DRG (pneumonia, GI bleed).

These data portend a future in which hospitalists (if enough can be found) will be involved in the care of virtually every sick patient – medical and surgical – in the building, something I’ve predicted for years. This has major implications for training. Future hospitalists need to be as comfortable helping to manage hip fracture or subarachnoid bleed patients as they are COPD patients. The old residency model of doing a couple of weeks on “med consult” (we come when you call us, we make a few recommendations, you may or may not listen, and we slink away) is increasingly out of sync with modern practice. Accordingly, at UCSF we are blowing up our med consult model – our “consult” residents next year will probably spend more time working with hospitalists co-managing complex patients on our neurosurgery and orthopedics service than they do in more traditional “come when called” consult arrangements.

And since most hospitalists have been undertrained in these areas of surgery and neurology, CME needs to refocus as well. My Management of the Hospitalized Patient CME conference (Sept 24-26 this year) has more neurology than pulmonary content, and attendees of our Hospitalist Mini-College (Sept 21-23) will spend three half-days gaining hands-on experience with neurology, periop, and ICU patients. [More info on these courses coming soon, once the agendas are finalized.]

The final bit of news concerns the career longevity of hospitalists. In the early days, lots of folks worried about the sustainability of a hospitalist career. (I’ll never forget our first hospitalist meeting in 1997. I asked an audience of about 150, “Everybody’s worried about you burning out – that this is a young person’s job. What do you think?” One guy stood up, chuckled, and said, “I was in office practice for 15 years. You want to see me burn out, just make me go back there.”) I’ve always felt that hospitalist jobs that were structured correctly, compensated fairly, and embedded in a strong culture carried no undue risk for burnout. A 2001 study confirmed this impression, and a 2005 Press Ganey survey of physician career satisfaction placed hospitalists second from the top, behind only radiation oncologists. (Fun facts: most medical subspecialists clustered near the mean, CT surgeons were in last place [the consequence of training for 12 years and then having your bread-and-butter procedure replaced by stents], dermatologists were near the top (duh), and radiologists were slightly below the mean – which I interpreted to indicate that they didn’t understand the question).

Anyhooo… today’s NEJM study confirms my impression. In the early years, lots of folks were dipping their toes in the hospitalist pool but weren’t fully committed: of internists identified as hospitalists in 1995, only one-third met the definition two years later. Some tire kicking is natural, of course, since there isn’t a special training requirement and it doesn’t take much effort to leave a hospitalist practice. But the paper found that, of those who met the hospitalist definition in 2004, two-thirds still were hospitalists two years later, a doubling in this surrogate measure of career stability.

The accompanying editorial, written by Mary Beth Hamel, a general internist-researcher at Beth Israel Deaconess, NEJM editor Jeff Drazen, and Harvard health policy guru Arnie Epstein, struck me as another in a long line of articles from those who appreciate that the world has changed but are still not quite willing to trade their Walkman for an iPod. After a thoughtful review of the forces promoting the hospitalist model and a discussion of the benefits and the liabilities of the model (the latter focused on the usual culprits [I’ve blogged about this previously]: discontinuity and potential primary care physician skill loss, dissatisfaction, or attenuated links to the hospital), the authors concede the obvious:

No matter what the balance of benefits versus adverse effects related to hospitalists, the economic and practical forces that promoted the growth in the care of patients by hospitalists are intensifying, not lessening, and hospitalists are here to stay. It is time to focus on how to enhance the value of hospitalists and more fully acknowledge and address the compromises the hospitalist movement has required of patients and primary care physicians.

I couldn’t agree more, and wish the authors had ended there. But they couldn’t quite bring themselves to conclude without resurrecting an alternative model – one I first described in 1999 – in which primary care doctors rotate into the hospital for periods of time. Although they quite correctly state that this rotational model has some advantages over the traditional PCP-based hospital care system (namely, on-site presence of the rotating physician), they gloss over its glaring liability: the physician doing one-week-in-8 in the hospital is spending no more time, in aggregate, caring for hospitalized patients than the PCP who spends 45 minutes each morning (each spends 8-12% time in hospital care overall). Without a focus in hospital medicine, the chances that the PCP-rotator (who is decidedly NOT a hospitalist, in my view) will achieve expertise or efficiency in hospital care or will lead hospital quality improvement efforts are really no greater than they are under the old system (not to mention that the office practice goes to hell during the rotator’s week away). I predicted then and continue to believe that these liabilities will consign this model to a small, perhaps even trivial, place in the world of modern hospital care.

By coincidence, I was visiting professor at Dr. Hamel’s superb hospital, Beth Israel Deaconess, just last week. By all accounts, the hospitalist group there, led by Joe Li, does a great job in clinical management, coordination, quality improvement, and education. Most of the primary care internists hold the hospitalists in high regard, and many – though not all – have become comfortable handing their patients off to them for hospital care. Communication and collaboration seem excellent and there is a palpable amount of mutual respect. In other words, the system is working well, and virtually everybody (including all the trainees and most ambulatory internists I met) agrees that it is a vast improvement over the old model. So it is not entirely clear what problem the rotating PCP model would be trying to fix; it would, in many respects, represent a step backwards.

The bottom line is that the rotating PCP model might work here and there, and it is probably better than the traditional model of every PCP coming in every day at daybreak to see 1-2 very sick patients. That said, I believe that calls for its revival represent wistful longings for a system that has clearly lost in the marketplace of ideas and data that determines the organization of hospital care.

3 Responses to “Today’s NEJM Hospitalist Study: What’s the News?”

  1. chris johnson March 15, 2009 at 3:37 am #

    Similar trends are happening in pediatrics, although the numbers are harder to come by. As a pediatric intensivist I often use hospitalists by the back door: though the hospitalist usually hasn’t admitted a critically ill child to the hospital, when such children are ready to leave the PICU they need a pediatrician for the remainder of their hospital stay. I’ve found that hospitalists are ideal for this, and many of the office-based pediatricians agree — they’re using them more and more. These post-PICU kids typically have complicated issues that are hard to deal with through brief morning rounds alone.

    We also get a much more seamless transition of care when we ask the hospitalists to introduce themselves into the child’s care while still in the PICU or step-down unit. In at least one hospital I know, the intensivists and the hospitalists are essentially members of the same team. Discharge planning is much smoother and comprehensive, too. Overall, I think it results in better care. It’s probably cheaper, too; I’m much more likely to move a child out of the PICU a bit sooner if I know they are going to a hospitalist.

  2. tholt March 16, 2009 at 4:43 am #

    In smaller hospitals there is a limited and valuable role for the rotating PCP model as a transition to the hospitalist model. I am familiar with several medical groups that recognized the inadequacy of having every PCP round on their own patients in the morning and then manage them by phone during the rest of the day. Each group began by developing a rounding service with physicians taking turns managing the hospital patients all day for a week at a time. As you noted this is not the optimal way to manage an inpatient service. However, for these groups it was a good way to identify physicians with an interest and an aptitude for hospital work. Eventually the other rounders want to drop out and the hospital or physician group looks for more dedicated hospitalists. It is a necessary transition step for many groups.

    I imagine that many of your readers became hospitalists as they “tried it out” as a weekly rounder. For me it provided a mid career rejuvenation when I burned out on outpatient clinic work.

  3. ron kirshner March 25, 2009 at 2:51 am #

    At my hospital we also have a rapidly expanding hospitalist program. One of the growth problems we faced was the issue of “mutual respect”. This took the form of individuals (mostly specialists) treating the hospitalist as if they were residents or students or worse. We solved this problem precipitously by empowering our hospispitalists to refer patients to the specialists of their choice independent of call or coverage schedules.”Mutual respect” predictably and rapidly followed.

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