For Many Hospital Patients, the Doctors Are In-House

With fewer primary care physicians visiting their patients’ hospitals, one specialization aimed at inpatient care is taking off: the hospitalist.

For patients scheduled to see Joshua Allen-Dicker, MD, the doctor is always in. Four years post-residency, the Boston-based internist still meets with patients every day in their hospital rooms.
Rather than cultivating a roster of patients who set up appointments to describe their ailments to him in an outpatient primary care practice, Allen-Dicker is one of more than 57,000 physicians today who have chosen hospitalist careers.

The specialty represents a radical departure from the traditional medical model in which outpatient doctors come to the hospital to manage treatment for their hospitalized patients.

 “I go from room to room, first visiting patients who may be especially sick and then those who may be ready to leave the hospital that day,” writes Allen-Dicker, describing a typical day at Beth Israel Deaconess Medical Center in a blog post. 

The term “hospitalist” was coined in 1996 to describe physicians who specialize in the acute care of hospital inpatients. The introduction of a medical specialty defined by where the physicians work sprung from an effort to meet the challenges of caring for patients under capitation-based payment models and changes in reimbursement policies that no longer pay physicians for providing a full continuum of care.

Hospitalists: From outliers to insiders

In just two decades hospitalists have become integrated into the country’s health care workforce. While the majority of the country’s hospital-based providers are certified either in internal or family medicine, the hospitalist model is being used increasingly in pediatrics, obstetrics practice, and skilled nursing care settings. 

“Primary care physicians and even specialists are having to see more patients in the office in less time,” says Keith Horvath, MD, senior director of clinical transformation at the AAMC. “This doesn’t always allow for them to care for inpatients, which is why the need for hospital-based physicians has skyrocketed.” 

In 2017 the American Board of Medical Specialties recognized the specialty’s growth by establishing a focused practice designation enabling certification boards to offer training to help hospital-based providers concentrate their continuing education efforts in the specialty. But training hospitalists goes back much farther. The University of California San Francisco School of Medicine launched its hospital medicine fellowship in 1999, and the University of Colorado Anshultz Medical Campus launched its hospital's training program in 2004.

“The primary driver of the growth of hospital medicine has been the desire to have shorter lengths of stay, lower costs, and better outcomes. It’s all value.”  

Ronald Greeno, MD
Society of Hospital Medicine

Three-quarters of the nation’s inpatient care centers have hospitalists on staff and as more inpatient facilities recruit hospitalists to their team, the Society of Hospital Medicine (SHM), maintains a set of core competencies administrators can use to develop standardized curricula for teaching the specialty in medical school, post-graduate, and continuing education programs. 

A 2015 AAMC survey found that 49.8% of recent graduates intending to specialize in internal medicine plan to work as hospitalists. As medical students increasingly express interest in hospital medicine, several academic medical centers have developed programs to train hospital-based providers. 

“For the majority of hospitals of internal medicine there’s no major difference [between primary care and hospitalist training], but there’s a specific skill set that hospitalists need,” says Vineet Arora, MD, assistant dean, associate professor, and academic hospitalist at the University of Chicago Pritzker School of Medicine.  The hospitalist curriculum at Pritzker focuses on research, quality improvement and teaching. 

With demographers projecting a near doubling of the population of older adults over the next two  decades, the skills specific to hospital-based providers reflect the changing demographics among hospitalized patients, who in recent years have been admitted with more serious conditions. 

Taking a leading role in value-based care

Even as some research credits the hospitalist model with increasing productivity for PCPs who hand off care of their admitted patients to hospitalist teams, researchers and clinicians have offered conflicting views of hospitalists’ contributions to care delivery.

“Not everybody does well with a hospitalist,” Arora notes. “If you’re super sick and you have six or seven hospitalizations a year, maybe there is some benefit to having a comprehensive care physician, so to speak, who rounds both in and out of the hospital.”

In addition, some policy experts say growth in hospital medicine has come at the expense of an adequate supply of PCPs. “With an unchanging number of physicians entering primary care specialties, an increased supply of hospitalists means a reduced supply of PCPs in ambulatory settings,” states a 2016 AAMC report, citing a 2015 study in the Journal of General Internal Medicine. 

Not to be deterred, proponents of the model say hospital medicine will play a significant role in efforts to improve health outcomes and shift from fee-for-service to value-based care models. 
“The primary driver of the growth of hospital medicine has been the desire to have shorter lengths of stay, lower costs, and better outcomes. It’s all value,” says Ronald Greeno, MD, president of SHM and a founding member. 

Primary care physicians also have shared concerns about the impact a hospitalist team unfamiliar with a patient’s medical history will have on their treatment and outcome. Some researchers have observed an increase in unnecessary tests when a PCP hands off a patient’s care to a hospitalist who is just meeting the patient upon admission.
“If the primary care physician is not coming to the hospital, you have to develop a systematic way to make sure handoffs occur,” Greeno says. 

Arora, who conducts research how to improve handoffs in hospital patient care and authored the SHM core competencies chapter on best practices for patient handoffs, is exploring ways to respond to critiques of hospital medicine.
“We’ve done a lot of work to improve hospitalists at shift change and service change,” Arora says. Over the years Arora has published several papers examining procedures on hospitalist teams and how to improve them. A patient on a hospitalist service can be passed between doctors an average of 15 times during a single five-day hospitalization.
But even with an increased number of handoffs, patients in a recent study reported a positive experience with their hospitalist physicians compared with their doctors on a traditional in-house teaching services staffed by residents. 

From a unique vantage point treating patients inside hospitals, advocates say hospitalists will be the drivers of innovative patient care models. “This model will be a critical component of the redesign of the American health system,” Greeno says.