Thursday, June 09, 2005

more and more issues surface in the hospitalist saga

A comment to Kevin, MD speaks of his hospitalist group contracting with a hospital to shorten hospital stays. I realize this is heresay but it is troublesome if true. Obviously this would place the hospitalist in a conflict of interest position, if shorted stays become a contractually obligated,determinative clinical management imperative.
Several other issues in the hospitalist saga are brought out in the June 1, 2005 issue of Internal Medicine News. These include:
1.With the rise of hospitalists, what about the credentialing of those internists who now no longer go to the hospital, can they get it , do they want it ?.
2.If docs loose credentialing what about their loyalty to the hospital?.
3.Will it be defined as a specialty, or remain as a major part of what an internist does ( or did)?
4.Will the hospitalists be in an economic bind if the hospitalists are pressured or contracted with as alleged above to achieve cost savings and their income depends on the hospital. Does this raise issues that have been part of the corporate practice of medicine which in some states continues to be legally not allowed?
5.The Society of Hospital Medicine is working on a core curriculum which raises numerous questions. Dr. Michael Pistoria, Chair of the curriculum task force commented "The concept of the core curriculum was really one of trying to find out who we are and what we are..." wow! I'll bet orthopedic surgeons don't have have that problem.
6.At the recent meeting of the Society of Hospital Medicine, Dr. David Melzer reported on the largest study on the outcomes and costs of hospitalist programs. Taking all six academic centers in the study the investigators apparently concluded that hospitalists did not affect the average length of stay or costs or outcomes. In 2 of the 6 there was savings.If this an accurate assessment of such programs, you have to ask what is it all about anyway? In an apparent rebuttal to his own paper, Dr. Melzer is also quoted by Internal Medicine News as saying the evidence for improvement resulting from hospitalists remains robust with more than 20 studies show average cost and length of stay reductions of about 15%. I would like to see a study comparing internists who call themselves hospitalists with internists who take care of patients in the hospital but don't self designate as hospitalists. Am I wrong here or is it true that- with the exception of pediatric care- hospitalists are internists who don't see outpatients.
7.There are now 3 defined IM residency tracks said to be generally accepted; general internist, sub specialist and hospitalist. An article by Arora V et al "Closing the gap between internal medicine training and practice." AM J Med. vol 118, no 6, pg 680, june 2004 discussed-among other issues-the possibility that hospitalist led teaching of IM residents may influence career choice of house officers as they have less contact with general internists and subspecialists, the implication that fewer residents might choose those 2 paths. ( With the current delta between general internists and specialists, I doubt fewer wil choose the speciality route)
A flippant summary would be:hospitalists are not sure who they are, their compensation may be an issue, there is a real question regarding if they save money or decrease hospital stays, too many hospitalists teaching residents might not be a good idea, and will their interaction with hospital administration pose a conflict of interest.

No comments: