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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Given the pressures of managed care to increase office productivity,⁴⁸ this delegation of responsibilities can create an important practice advantage.¹⁵ Even for those family physicians who choose to visit their hospitalized patients, shifting overall responsibility for inpatient care to hospitalists can make hospital visits more efficient and thereby free office time for outpatient practices.⁴⁹

Risk: lack of patient familiarity. Research has shown that a lack of familiarity with patients can increase the risk of errors and poor outcomes in medicine, and the use of a hospitalist as a new provider indeed introduces this risk.^50,51

Without dedicated effort on the part of the family physician, the treating hospitalist may have limited appreciation of a patient’s situation. Hospitalists focused only on inpatient care may not know where patients come from or where they return to, and are less likely to be knowledgeable about needs for psychosocial support or for such patient preferences as end-of-life care.^14,21

Risk: reduced political leverage. In addition, a political issue for family physicians may arise if hospitalists become providers of choice for inpatient internal medicine, thereby defining a smaller role for community-based family practitioners.²¹

Risk: communication problems. Another major risk of hospitalist programs is poor communication, an issue raised in nearly every article discussing the hospitalist model. The involvement of a new physician provider and the process of patient care transfers between outpatient family physicians and inpatient hospitalists can lead to missed information, gaps in communication, and misunderstandings.^19,22,35,37

Recent studies of discontinuity of care when patients are hospitalized reported that inpatients specifically wanted both contact with their primary care physicians and good communication between their established primary care physician and hospital-based physicians.⁴⁹ Guidelines created by the American Academy of Family Physicians (www.aafp.org/x6873.xml) support communication and interaction between community-based physicians and hospitalists for excellent patient care,¹² but the burden may fall on family physicians to ensure communication.

TABLE 2
Stakeholder perspectives of hospitalist model: Advantages and disadvantages

Stakeholder perspective	Potential advantages	Potential disadvantages
Hospital	Efficiency improvements^3,16,23,24 Quality of care improvements^16,25 Inpatient continuity of care improvements²⁶ System improvements¹⁸ Better control of formulary purchased goods, procedures²⁷ Involvement of hospitalists in administrative activities^2,28 Additional clinical coverage possible from staff hospitalists^29,30 New referral source from distant, nonaffiliated primary care physicians; strengthen relationships with rural physicians³¹	Discontinuity of care³² Loss of diversity of physician involvement in hospital affairs Reduced contact with community-based physicians Effects may vary based on hospital type, hospitalist model¹⁶ Lack of buy-in from primary care physicians may hinder program³³ Reduced loyalty from primary care physicians who do not care for inpatients³¹
Patients and families	Improved communications with providers, families^34,35 Improved access to hospital-based physician³⁰ Quicker response times for test results and clinical findings²¹ Rapid emergency response²⁷ Better end-of-life care^18,36	Communication gaps within patient-hospitalist-PCP triad^19,22,35,37 Lack of patient familiarity^14,21,38 Reduced access to PCP²² Reduced patient autonomy²²
Hospitalist physicians	Ability to develop specialized inpatient care expertise Improved ability to negotiate hospital system¹⁸ Dedicated time to teach, perform research, improve hospital systems of care¹⁸ Satisfying new career path^20,26,39,40	Conflicting incentives for patient care and efficiency^6,41,42 Physician burnout possible²⁶ Malpractice risk may be increased Inability to recognize that both patient and referring physician are customers will be problematic
PCP, primary care physician.

TABLE 3
Potential benefits and risks of the hospitalist model for family physicians

Potential benefits for family physicians^15,33,47-49
Increased office productivity, less disruption of office schedules
Career development option limited to outpatient care setting may be desired lifestyle hoice
Extra time for outpatients
Reduced travel time, especially for physicians in distant practice areas
Improved outpatient satisfaction
Increased provider satisfaction with ability to specialize in outpatient care
Can offset lost inpatient revenues with increases in office volume
Reduction in life stress and potential burnout
Potential risks for family physicians^12,32,50,51
Discontinuity in care for patients
Communication problems regarding patient care
Loss of information about patient wishes
Reduced contact with hospital-based professionals, specialists
Loss of influence at admitting hospitals, loss of hospital privileges
Decline in acute care skills, changes in continuing medical education
Shift in professional identity
Loss of status for outpatient practice
Reduced variety in medical education
Loss of variety in scope of family practice

Assessing the effect of the hospitalist model

Research evaluating the impact of hospitalists has largely focused on hospital-based outcomes. Recently, Wachter and Goldman’s review of 19 published studies showed that hospital costs decreased 13.4% on average and hospital lengths of stay decreased 16.6% on average after a hospitalist program was initiated.²³ These efficiency improvements were apparently gained while patient satisfaction was preserved.

However, results indicating improved outcomes, such as mortality and readmissions, were reportedly inconsistent among the studies evaluated.²³ Additional studies^3,24,52 of hospitalist programs have shown similar reductions in hospital costs and lengths of stay, and have also reported preservation or improvement of quality of care as measured by reductions in mortality^3,24 and constancy of readmission rates.⁵²

Study of the effect of hospitalists specifically on family practice has been limited. As noted by Smith and colleagues,⁵³ methodologic constraints limit the reliability of many reported results, and the focus of most studies does not extend beyond the hospital setting.