Monday, June 06, 2005

Which would a patient prefer- a hospitalist plus an officist or an officist-hospitalist

If a hospitalist only sees patients in a hospital then a officist (see below for attribution for the term) only sees patients in the office and an officist-hospitalist does both. Officists do not yet have their own unique specialty certification; neither do hospitalists but they are further along to that end. When I was in practice I was an officist-hospitalist (OH). Many internists still are but the trend seems to be away from that. An OH sees the patient pre hospitalization, during the hospitalization and afterwards. This would seem to maximize continuity of care. After hospitalization, the OH gets to see if his plan to have the patient get PT and home help has helped and if his new medication treatment plan is working or not. He gets to find out if the new medication is not on the patient's drug plan formulary for the 3 months refills. He gets to hear how the hospital screwed up his bill.
He gets to see how the patient had to go to the hospital because his treatment program wasn't getting the job done and for some reason the lasix Rx never was filled.Here's the thing;the internist who is a OH takes care of his patient when he is sick and sees him when he is well.That was what a internist was all about.
On the other hand the officist (the O) gets to explain why the H changed all of the medications. "Doctor, why did Dr. H take me off of all the old pills, did he think I didn't need them?"An occasional awkward moment, however, may well be well worth the piece of mind one gets from not getting late night calls from the hospital and not having to make rounds.
Of course, this all may be fanciful satire. I had briefly hoped that I would be immortalized in medical lore as the person who coined the term "officist" but in the google era it took me only a millisecond to be referred to a wonderful piece of medical writing by Dr. Farrin A. Manian in the NEJM in 1999. He talks not only of officists but of other characters in the newest medical care paradigm such as the screenist and the SNFist (doc who takes care of patients in a skilled nursing facility) and his comments are worth saving and should be read by anyone taking either side in the hospitalist issue.
Since we live in the era of evidence based medicine, let's look at some of the evidence.
Articles about H's have documented the efficient and efficacious care they provide. I do not claim to offer a systematic review but there have been at least two studies in the Annals of Internal Medicine in the last few years. Particularly robust is the the offering by Meltser, D et al
( " Effects of Physician Experience on Costs and Outcomes on an Academic General Medicine service"Annal Int Med. 3 Dec. 2002, vol 137 issue 11, pages 866-874) who reported a two year experience of 6511 patients managed by two hospitalists (yes,2, that is not a typo). Costs were decreased by $782 and in the first year the average length of stay was reduced by 0.29 days the first year of the study and by a 0.49 the second year. In the second year,but not the first, nor in both years when added together, the 30 day mortality was lower.
Another study (Auerbach, AD et al "Implementation of a Voluntary Hospitalist service at a Community teaching hospital:Ann Int Med. 3 dec 2002,vol 137 issue 11/p 859 865) showed similar findings with the improvement in terms of shorter stays, lower costs and decreased deaths.
These and other data seem have been sufficient to give the concept of H's momentum and managed care seems enamored with the notion as indicated in the following link
from the managed care literature.Although these two articles mentioned above may not offer the most convincing of data,Dr. Robert Wachter,associate chairman Department of Medicine,UCSF in a succient discussion of many aspects of the hospitalist issue quotes five studies that basically show decreased costs and time in hospital and no change in outcome and patient satisfaction.(Dr.Wachter is credited as co-coiner of the term,hospitalist,in 1996."
A recent report in Internal Medicine News casts some doubt on whether much is really saved by such programs.
However, If it is as good as portrayed by Dr. Wachter, who could complain ?(Although neither of the two articles I quoted above asked the patients what they thought of the arrangement)
Follow the money. It has been claimed the O does better by seeing more patients in the office at a higher hourly rate than seeing patients in the hospital (although in our practice we made rounds before or after office hours) and HMO are claiming savings.Or as Dr. Manian puts it [paraphrasesd]the officist provides cost effective care in his office seeing patients as long as they are well. If money is saved for the HMOs and insurance third party payers and hospitalist groups can earn a reasonable income, there will be more and more of this practice. We are talking about cost effective care and the economic entities that are the movers and shakers in 21st century American medicine are driven by cost effectiveness concerns and protestations of the minor supporting players-i.e. doctors and patients-typically are of little concern.
According to Dr. Wachter, patients are as happy with the hospitalist arrangment as with the older style of care. Dr. Wachter and Dr. Manian offer different portraits of the hospitalist scenario,the later, I would argue, tells it like it is and the former supplies us with an academic presentation of a current movement replete with aggregate data and cost effectiveness concerns. If you read both you get a fairly good idea of what it is all about. My thinking is the OH offers something tha is not equaled by the combo of an O and an H, namely continuity of patient care by a physician of the patient's choosing.There should still be room for both ways of taking care of patients.

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