Doctor Knows Best--but Which Doctor?

Anurita Mendhiratta leaned close to the bedside of stroke patient Richard Bryan and asked him whether his right side still felt numb. Then Mendhiratta, an internist with Kaiser Permanente, told the 72-year-old Rockville, Md., resident that he would need to spend several more days in the hospital, so that doctors could carefully monitor the levels of a blood-thinning drug he was taking.

“I’ll be here every day for the rest of your hospital stay,” she said, handing a business card bearing her beeper number to Bryan, whom she had just met, and telling him she would stop by later to see him.

Bryan has a regular Kaiser internist, but she did not take care of him when he was admitted. Once the retired federal worker was hospitalized, his care became the responsibility of Mendhiratta and her colleagues--members of a new medical specialty known as hospitalists.

Like Mendhiratta, most hospitalists are internists who treat and manage the care of other doctors’ patients only while they are in the hospital. When patients are discharged, the hospitalist transfers their care back to their regular physician.

Generations of internists and family practitioners have shuttled between their offices and hospitals to care for patients in both settings. For years doctors have been taught that this duty is sacrosanct and that their patients are their responsibility.

“The idea of having a [hospital] physician principally responsible to inpatients who don’t have a physician is not a new idea,” said John M. Eisenberg, an internist and director of the federal Agency for Health Care Policy and Research.

Patients who show up in an emergency room without a doctor long have been assigned one by the hospital. “What’s new is transferring the care of patients who do have a primary-care physician to another doctor while they’re in the hospital. Most internists have been taught that once a patient comes to see you, you are that person’s shepherd, guide, whatever, and that this is a very special relationship which may last a lifetime.”

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That notion, like much else in health care, is changing rapidly as managed-care companies, hospitals and growing numbers of primary-care doctors embrace the hospitalist concept, long employed in Great Britain and Canada.

Armed with data showing that hospitalist programs can reduce the length of hospital stays without triggering an increase in readmissions, some of the nation’s largest managed-care companies are instituting such programs as a way to improve efficiency and cut costs. Hospitalist programs also enable doctors who choose office-based primary care to see more patients because they no longer have to divide their time between their offices and one or more hospitals.

There can be advantages for patients and their families as well.

“When I give patients my card with my pager number, they say, ‘You mean you’re here all day?’ ” said Paul Aronowitz, a hospitalist at California Pacific Medical Center in San Francisco. “The advantage is that they have a doctor readily available.” Most physicians with an office practice make rounds once a day, often at dawn, then head for their offices, where they are difficult to reach because they are seeing patients. Aronowitz said he sometimes meets with patients and their families three or four times a day.

A fledgling organization for hospitalists, the National Assn. of Inpatient Physicians, founded last year, now claims about 1,500 members, says co-founder John R. Nelson, a Florida hospitalist. The burgeoning demand for such doctors has prompted UC San Francisco, one of the pioneers of the hospitalist movement, to launch a training program for residents interested in hospital-based careers.

In the past few years, hospitalist programs have sprung up in a score of cities, including Washington, D.C.; San Francisco; Tampa, Fla.; Philadelphia; Baltimore; Atlanta; and Chicago. Some insurers, among them Kaiser, Humana and Aetna-U.S. Healthcare, are requiring that in certain cities primary-care doctors hand over their patients to hospitalists. Such requirements typically have met with staunch resistance from some physicians who say they fear being squeezed out of hospitals and worry that care of their patients will suffer.

“My expectation is that many, many hospitals will be doing this in the next few years,” said Hernan Padilla, executive director of Kaiser’s Hospital Services Management Division.

Eisenberg, whose agency is funding a study of the impact of the hospitalist system at UCSF, has mixed feelings about the concept. “I’m very concerned about what it does to communication and the continuity of care,” said Eisenberg, formerly chairman of the department of medicine at Georgetown. “Losing that personal physician and that continuity is a serious risk to the quality of care provided in the hospital.”

Proponents of hospitalist programs say they share those concerns but believe systems that promote improved communication can overcome these problems. Kaiser officials point to the extensive computerized records they maintain on all patients and say their hospitalists sometimes follow up with a phone call to the community-based primary-care physician after a patient is discharged.

John Nelson, who has worked as a hospitalist in Gainesville, Fla., since 1988, said he believes that a hospitalist system will benefit patients.

“I think the continuity of care is so poor now that [hospitalists] will improve it,” Nelson said. These days, many patients do not have a long-term relationship with a doctor who knows them well, Nelson noted. “People move in and out of health plans, and doctors do too.”

But Eisenberg is not optimistic that adding another doctor will improve communication, which he noted has traditionally been sketchy, at best, between specialists with a hospital-based practice and internists. “The telephone has been around a long time,” he said, “and the most common complaint among community-based physicians about hospital physicians is that [community-based physicians] never know what happened to their patient in the hospital.”

Michele Ricard, a Massachusetts internist who specializes in geriatrics, deplores the trend to bifurcate internal medicine as “an abrogation of our duty and dedication.”

“You may have a fax or a data sheet, but it doesn’t give you the rapport or that comfort with the person that comes from a relationship,” she said. “Medicine is not just science, it is art. You can only work with patients if you know them. And you can’t know them if you just met them. If you can’t get the patient to buy into what you’re recommending, you’re going to get nowhere, no matter how good you are.”

“For me,” Ricard added, “medicine is following someone all along, not just in the office.”

Ricard and other critics worry that the quality of care will suffer if community-based doctors are squeezed out of hospitals by the new system. “A great deal of the education of physicians occurs in the hospital setting,” said Neil Brooks, president of the American Academy of Family Physicians, which is concerned about the hospitalist movement. “It may be formal, like grand rounds, or informal,” such as consulting with colleagues about patients.

Brooks said his group has received complaints from members who have been discouraged by managed-care companies from seeing hospitalized patients. “They don’t say, ‘You can’t see a patient,’ ” Brooks said, “but they have said, ‘We’re not going to pay you for it.’ ”

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Supporters of the hospitalist movement say its ascendance reflects the realities of health care and the enormous changes in medical practice that have occurred since the mid-1980s. In the past decade, the number of patients in the nation’s hospitals has been halved and the length of hospital stays dramatically reduced. Hospital patients in 1998 are dramatically sicker than those who were on the wards as recently as six years ago, because so many serious illnesses for which they were once routinely hospitalized--cancer, AIDS, serious heart disease--are being managed in outpatient settings.

Mendhiratta’s caseload on Jan. 20 illustrates this trend. That day she was in charge of eight hospital patients. They included, besides Bryan: a 48-year-old woman terminally ill with a rare uterine cancer who was suffering from a bowel obstruction, a man in his 60s with lymphoma and prostate cancer that had spread to his brain, a 42-year-old woman in the final stages of pancreatic cancer, a lung-cancer patient in his 60s with complications, a kidney-dialysis patient with such bad leg ulcers that doctors were considering amputation, and a man in his 40s with heart problems who was a candidate for cardiac catheterization. She discharged one patient: a man with gallbladder disease who had been scheduled for surgery in February.

“This is a good day,” said Mendhiratta, 39, referring to her caseload, which has climbed as high as 15 patients. Before becoming a full-time hospitalist, Mendhiratta spent four years working in Kaiser’s outpatient clinics, followed by a brief, unsuccessful stint in solo practice.

“It was just too hectic,” said Mendhiratta. “I was making rounds at four different hospitals and trying to see patients in the office too,” she said. She said she finds hospital work more interesting and more manageable than outpatient practice, although she adds that it is often more stressful.

As recently as 15 years ago, notes Eisenberg, a typical busy internist had 10 or 20 patients in the hospital, each of whom spent between 10 and 14 days there. Doctors typically spent a few hours in the morning making rounds and seeing those patients, then showed up in their offices around 10 a.m. and spent the next six or eight hours seeing patients. Some also made rounds at the end of the workday. Today, he notes, most internists have at most one or two patients in the hospital and a score in the office.

“If you’re an internist and you’re in the office at noon seeing patients and one of your patients in the hospital [has a heart attack], you’ve got to run out the door and make your office patients wait two or three hours,” said Nelson. “That’s not really an option anymore, because for one thing most office patients don’t tolerate that very well.”

Nelson and other hospitalists say they provide better care for patients for two reasons: proximity and experience.

“If a family comes in at 3 p.m. and the patient is not doing well, I’m here to meet with them,” said Aronowitz. “If a test comes back at 10 a.m., I can be there to take it to the radiologist and discuss it. Under the old system that test might sit around until the doctor came in after office hours at 8 p.m. and rifled through the files in radiology and said, ‘Oh, my gosh, we need another test,’ which would then wait until the following day. The advantage is rapid response.”

Hospitalists, Aronowitz continued, also figure out the byzantine culture of the hospitals in which they must work, unlike a community-based physician who makes brief or infrequent visits. Hospitalists learn how to get test results fast, which specialists are good and which to avoid, and which nurses will reliably carry out their orders.

That is likely to be good for patients. Michael S. Verhille, a San Francisco gastroenterologist who was initially leery of the hospitalist concept, said he has changed his mind. “It seems that people move through the system much more smoothly with the hospitalist there,” said Verhille, who practices at California Pacific. “With a hospitalist in the house, the nurses have much better communication with the doctors.”

The other advantage, proponents say, is that they have considerable experience dealing with problems that office-based doctors treat infrequently. Studies of AIDS and heart-disease patients have found that patients fare better if they are treated by specialists.

“In the office a doctor might see one pulmonary embolism a year,” said Atlanta hospitalist Gregory Miller. “Well, I probably treat three a month.”

Arthur Leibowitz, medical director of Aetna-U.S. Healthcare, said his organization’s hospitalist program was started several years ago after a group of U.S. Healthcare’s primary-care doctors in Philadelphia said they no longer felt comfortable practicing in the hospital.

“I think a well-trained doctor can do both [inpatient and outpatient medicine] quite well,” Nelson said. “But my view is that it’s just harder to be good at both, and also a little bit impractical.”

Patients who are accustomed to seeing specialists do not seem fazed by the hospitalist system, supporters say. That is especially true of patients in large academic medical centers, where phalanxes of residents, interns and medical students typically troop in and out of a patient’s room and are responsible for care.

Brian Reagan, chief of Kaiser’s Washington-area hospitalist program, said that most patients seem content seeing one of Kaiser’s 11 hospitalists rather than their primary-care doctor. “As long as I tell them I work with Dr. So-and-So and I’m going to communicate with him or her, most patients seem happy,” Reagan said.

In a teaching hospital that uses hospitalists, one of the chief advantages is that an attending physician is actually on the premises supervising overworked residents and interns.

“Patients like the fact that there is an attending-level physician who’s able to spend more time with them,” said Richard Waldhorn, chief of pulmonary and critical-care medicine who directs Georgetown University’s hospitalist program. “They don’t want their cases to be loosely supervised and rightly so.”

That can be a burden for hospitalists, who are subject to burnout because of the relentless pace and caseload consisting of patients struggling with serious, chronic illnesses.

“We’re here and we’re available all the time and we’re subject to a higher level of scrutiny, and are a target of a lot of the frustrations and uneasiness that families have,” said David Garcia, a Kaiser hospitalist. “There’s a physical and a psychological toll as well.”

Whether hospitalist systems succeed or fail will depend on a host of factors, said Robert M. Wachter of UCSF. He coined the term “hospitalist” in a 1996 editorial in the New England Journal of Medicine and is widely regarded as the guru of the hospitalist movement.

“There will be good hospitalist systems and bad hospitalist systems,” Wachter said, “and good systems will invent ways to ensure communication, to ensure that patients don’t feel abandoned and that doctors don’t burn out. I predict there will be lots of varieties.”

Wachter and Nelson worry about managed-care companies requiring the use of hospitalists, which they fear could alienate physicians and patients.

“Managed-care companies have embraced this with a passion,” Nelson said, “and many doctors see it as the latest gimmick thrust upon us by managed-care bean-counters. This has got to be good for patients; if it just saves the shareholder of an HMO money, then we shouldn’t do it.”

Eisenberg said it is important to make sure that the benefits and risks of hospitalists are fully assessed before the traditional system is scrapped and replaced by a new and largely untested model of care.

“It’s a good enough idea that it should be tried, but it needs to be carefully evaluated,” Eisenberg said. “Divorcing inpatient and outpatient medicine has real risks.”