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Monday, July 25, 2005

Prominent academic hospitalist expects growth driven-in part-by desire for "through-put"

Dr. Robert Wachter, Professor of Medicine at UCSF, gave a "state of hospital medicine" address at the annual meeting of the Society of Hospital Medicine (SHM). Wachter listed 3 reasons he believes hospital administrators will continue to promote the hospitalist movement; resident work-load limits, nurse shortage and retention and hospital efficiency (the through-put issue).

The first is only an issue in academic hospitals which is a tiny minority of the country's hospitals, the second is a issue that only time will tell. We do not know if hospitalists will help nurse retention and I am not sure why that would be the case. Working conditions and salary are major issues with all who work and I don't quite see how salaries would change and working conditions are more under the control of hospital administrators than the doctors. If hospital administrators want more nurses they should pay them more money, that makes more sense than hiring hospitalists.

The third reason is probably the driver which is in keeping with the rarely wrong follow-the-money concept. Administrators want hospital beds filled-briefly-with surgical patients. They want Medicare patients with medical illnesses out of the hospital as soon as possible. This what is meant by efficiency. That is where the profits lie. I have talked before about the degree to which salaried hospitalists may be conflicted with that imperative. It will continue to be a empirical question whether hospitalists make more money for the hospitals than they cost. If they make more, the trend will grow. Talk about efficiency seemed louder than talk about quality of care. Thomas Sowell says if you want to see what a organization is all about, do not look to their stated goals or values but rather to their incentives and constraints. I cannot believe that through-put concern of hospital administrators is all about quality.

Another speaker, Dr. Tom Baudendistal used the term "ambulist" in his statement that hospitalists were ideally suited to the role of "championing efficient care". I mention that seemingly self serving statement only to point out the neologism.

Another item which could be a sign of the success of the hospitalist movement is that reports are appearing of burnout.
Kevin, MD has a post linking to a Chicago Tribune article regarding some of the pros and cons of the hospitalist movement and speaks of the economic forces driving the movement.


Anonymous said...

You are simply wrong to say that the eighty hour work week only affects academic hospitals. There are more residents working in community settings than in academic medical centers. You can hear an interview with David C. Leach, MD, the Executive Director of the ACGME where he addresses this point and many others about private doctors training the next generation of doctors at www.soundpractice.net.

james gaulte said...

Thanks for the heads up. I listened to Dr. Leach's podcast and got a better sense of the degree to which residents are trained, at least in part, outside of academic centers.To the extent this happens the impact of the 80 hr. resident week on demand for hospitalists would be greater.I apologize for relying too much on observations in one large southern city with 2 medical schools and not doing a little more research into that point.

Anonymous said...

As a private community physician who still manages most of his hospitalized patients, here's my perspective. It is not terribly cost-effective for me to do hospital care. I have a personal economic incentive to get the patient out of the hospital as soon as possible. However I am also familiar with what goes on after hospital discharge. Many patients are discharged to nursing homes which are not staffed adequately to care for the ill, unstable patients sent there. Home care is available, but physician supervision is lacking because most doctors will not do house calls. If the patient is too weak or unstable to come to the doctor's office, there is no physician care. More and more it seems that hospital care is about doing less and less faster and faster and then dumping the patient on someone else's lap. The hospitalist may get the patient out of the hospital sooner because there is no incentive to worry about what happens after discharge.

Anonymous said...

"The hospitalist may get the patient out of the hospital sooner because there is no incentive to worry about what happens after discharge. "

after doing primary care work, inpatient and outpatient, for several years and now just inpatient hospitalist work....I can see little difference in my style. I try not to send patients home or to a nursing home until I think they are ready medically. It does no good for the patient or myself to send some home too soon.

The worst scenario I had in primary care was usually in caring for the mandatory unattached hospital patients who I admitted on medical back-up call. It takes a lot of effort and time , away from my esttablished patinets, to care for patients who you meet for the first time in the Emergency department. Now , as a hospitalist about 50% of my patients have no physician and many after discharge will not be able to or care to find a physician.

The biggest difference I find in hospital vs primary care work is not the stress of work (both have their unique stressors) but rather the lack of stress when I am not working. In primary care I never felt like I had time off...always worrying about details and risks my patients might face especially when they presented with a problem that I could not readily solve. I tended to work in the office on the weekends or come back late at night or cut short vacation time so I could improve my patient care or slog through the mounds of paper work I needed to do on behalf of my patients. As a hospitalist... when I'm off, I can actually relax and enjoy life without worrying so much. It is this sentiment, repeated often times among my hospitalist colleagues ( who did primary care first) that seems to come up repeatedly.