Hospitalists and family physicians: Understanding opportunities and risks

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Original Research

Hospitalists and family physicians: Understanding opportunities and risks

J Fam Pract. 2004 June;53(6):473-481

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References

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Despite the debate in the literature and the media, it appears this inpatient care model is here to stay.^1,13,16 Major medical organizations, including the American Academy of Family Physicians and the American College of Physicians–American Society of Internal Medicine, now note that hospitalist programs are acceptable as long as they are well designed and implemented voluntarily, and this consensus has helped spark program growth.¹⁷

However, the increasing presence of hospitalists in hospitals and academic medical centers is forcing many family physicians to choose how involved they want to be in inpatient medicine. The goal of this study was to synthesize available information in the literature regarding the practice of hospitalists and their effect on family physicians, and to provide a discussion about future research opportunities to further evaluate the hospitalist model and its influence on family practice.

Methods

A comprehensive review of the literature was conducted by database searches, by hand, and the Internet. Medline, Lexis-Nexis, and Academic Universe were used as the primary databases for the literature search. Key words such as hospitalists, inpatient physicians, hospital medicine, primary care physicians, and family practice were used to focus a search. Furthermore, references in each article were reviewed to find related literature.

Literature was largely concentrated within the past 5 years and included both peer-reviewed and descriptive articles on hospitalists and their effect. Internet searches used Google as the primary search engine; results supplemented findings in other published material.

This literature review continued until saturation was achieved with respect to considering the possible issues and implications of the expansion of hospitalists, with special attention paid to the risks and opportunities to family physicians.

Findings

This integrative literature review revealed 3 major themes of interest to family physicians regarding the emergence and expansion of hospitalists in the US: descriptions of the hospitalist role and responsibilities; hypothesized benefits and risks of the hospitalist model; and reported research results evaluating the effect of the hospitalist model. Synthesis of this literature also uncovered 2 major opportunities related to hospitalist practice: opportunities to conduct future research to study the impact of hospitalists on family physicians; and opportunities to leverage relationships with these new practitioners.

Hospitalist roles and responsibilities

A hospitalist physician is a new type of medical specialist who combines the roles of acute care subspecialist and medical generalist in the hospital care setting.¹⁸ Hospitalists do not replace primary care physicians, surgeons, or specialists, but, instead, are concerned with managing hospital inpatients, from admission until discharge. They act somewhat as a case manager for a patient’s hospital stay, working and communicating closely with other physicians involved in the patient’s care.

Patients are assigned to hospitalists upon admission, either when an outpatient provider such as a family practitioner transfers inpatient care responsibilities to the hospitalist, or when patients arrive at the hospital unassigned to any other provider. The clinical and organizational responsibilities of hospitalists are in Table 1.

TABLE 1
Typical responsibilities of hospitalist physicians

Clinical
Patient admissions, daily inpatient rounds, and medical care attention
Ordering consultations, requesting tests, managing medications
Assisting other physicians with medical consultations
Helping with preoperative care and evaluations
Providing coverage of unassigned Emergency Department patients
Communicating with other involved physicians about patient conditions
Managing patient and family communications
Working with discharge planning, overseeing transfers from hospital, and post-hospital follow-up care
Organizational
Service on committees, involvement in administrative roles
Involvement in hospital quality assurance and utilization review activities
Involvement in disease management, care innovations
Teaching of medical students, residents, fellows
Involvement in hospital operations and systems improvement
Involvement in practice guideline and protocol development
Involvement in clinical information system development
Administrative involvement in hospitalist program including physician recruitment, scheduling, program development
Research responsibilities
Sources: Lurie et al 1999,¹ Wachter et al 1996,⁷ Wachter 1999,¹⁹ and Geehr and Nelson 2002.²⁰

Hypothesized benefits and risks of the hospitalist model

Persuasive arguments have been raised about the advantages and disadvantages of the hospitalist model.^18,19,21,22 A variety of these potential advantages and disadvantages are summarized in Table 2, representing perspectives of 3 different stakeholder groups: hospitals, patients and families, and hospitalist physicians. Each of the listed advantages or disadvantages was discussed in 3 or more independent articles that were reviewed.

For family physicians specifically, the introduction of a hospitalist program at a local hospital has numerous associated potential benefits and risks. Table 3 presents a summary of the issues that were raised in 3 or more articles or studies.

Benefit: focus on ambulatory care. One widely discussed advantage in using hospitalists is the option for family practitioners, who so desire, to limit practice to outpatient medicine because of their interest in ambulatory care or because they feel overtaxed by the demands of the health care system.^12,21 Willing family physicians can relinquish care of their hospitalized patients to a hospitalist so they do not have to travel to the hospital for daily rounds or more frequent patient contact; upon hospital discharge, family practitioners subsequently resume care for their patients.