Hospitalists: the missing link incomplex patient care

The Evolution of Hospitals: Specialization and Fragmentation

Throughout history, the growth of medicine and hospitals has been interconnected. As new knowledge and treatment methods developed, they were rapidly adopted within hospital settings. Originally, hospitals were sanctuaries for the sick and frail, but over time, they evolved into centers for cutting-edge medical techniques. With each medical advancement, hospitals required more specialized knowledge, equipment, and professionals, driving the trend toward increasing specialization. This focus on specialized care led to institutions and professionals concentrating on specific medical conditions and procedures.

Around 25 years ago, a new concept emerged: the hospitalist. Though it didn’t initially cause a major shift, the role gradually changed how doctors work in hospitals. In 1996, physicians Wachter and Goldman proposed the hospitalist model, advocating for the creation of a “generalist” doctor who would oversee patients’ overall care and coordinate treatment among various specialists. Their vision focused on hospital-based generalists who could understand a wide range of medical conditions, meet patients’ complex needs, and streamline comprehensive treatment plans.

A hospitalist is a physician dedicated to the care of hospitalized patients. These doctors usually have completed residency training in areas like general internal medicine, pediatrics, neurology, or related fields and may be board-certified in hospital medicine. They are responsible for timely diagnosis, treatment, and coordination of care during a patient’s hospital stay, ensuring all needs are met across various specialties.

The hospitalist role arose from the need to improve the coordination, quality, and cost-effectiveness of patient care. After decades of increasing specialization, which led to fragmented care, no one was responsible for overseeing the patient’s overall well-being. Health care leaders recognized the necessity of integrating different areas of medical expertise and treating patients as whole individuals rather than a collection of separate medical conditions. As a result, the hospitalist model was developed to address the complexity of modern patient needs in a more holistic and efficient way.

Hospital Medicine: A New Paradigm and Role

The increasing fragmentation of care in hospitals made it challenging to manage patients with multifaceted, complex conditions. Specialists, despite their expertise, often found it difficult to provide the comprehensive care these patients required. As a result, patients began to experience the negative consequences of over-specialization, with care becoming less coordinated and patients themselves becoming less visible in the system. Addressing this fragmentation and improving patient care demanded a new approach—one that recognized patients as whole individuals with both medical and non-medical needs, requiring integrated care systems to ensure effective treatment in the 21st century.

The Shift Toward Specialization and Its Consequences

As medical professionals increasingly narrowed their focus to specific diseases, the standard of care for individuals with complex needs declined, while hospitals faced escalating operational strain. Many specialists were forced to manage issues outside their expertise, leading to compromised care even for less complicated cases. The introduction of the hospitalist role marked a turning point. It allowed patients to receive more comprehensive care, optimized hospital workflows, and freed specialists to focus on their areas of expertise.

Over 25 years later, the success of hospitalist programs is evident, with the Society for Hospital Medicine (SHM) boasting approximately 15,000 members, most of whom are physicians, and estimates indicating that 50,000 to 60,000 hospitalists currently practice in the U.S. Hospitalists, who focus exclusively on in-hospital care, have revolutionized patient care by ensuring that skilled clinicians are present in real-time to meet patients’ needs. As one of the founders of SHM, Winthrop P. Whitcomb, remarked, “We saw a need, and we were lucky to be the ones who addressed it. The biggest legacy is for all the patients who benefitted from having a doctor present at their time of need.”

Why Did Hospital Medicine Emerge Primarily in North America?

Despite its success in the U.S., hospital medicine has not expanded significantly beyond North America. This raises the question: why? The challenges of narrow specialization and fragmented care are not unique to the U.S. Patients with multiple comorbidities or those requiring coordinated, multidisciplinary care exist worldwide. However, several factors explain the limited global reach of the hospitalist model.

A major reason lies in the emphasis on quality and financial outcomes in U.S. hospitals. In the U.S., hospitalists are used to reduce patient stays and costs while improving care quality, driven by a focus on efficiency. In many other countries, where this focus is underdeveloped, it’s difficult to measure the impact of hospitalists on costs and outcomes. As a result, hospitals in these countries often rely on younger or part-time doctors who may lack the decision-making autonomy necessary for the hospitalist role.

Additionally, in many countries, generalists are undervalued and undercompensated, which limits the appeal of the hospitalist role. There is also a societal bias favoring specialists, making it harder to attract and retain hospitalists. Furthermore, traditional medical education in some regions does not prepare physicians to be part of care teams or to lead initiatives in cost containment, quality improvement, and patient safety, which are essential for successful hospitalist teams.

The Role of Hospitalists in Caring for Complex Patients

Hospitalists play a crucial role in managing care for complex patients, but challenges arise from congestion in healthcare systems. In the U.S., the high cost of hospital care has driven the development of alternative care settings for patients who are medically stable but still require attention. However, in countries lacking defined long-term care models, patients often remain in hospitals long after their acute issues have been resolved, awaiting appropriate placement. This undermines the role of hospitalists, whose purpose is to expedite hospital processes, reduce costs, and improve the quality of care.

In addressing the question of what hospitalists mean for complex patients, we encounter a paradox. While high-quality care for complex patients requires well-trained, competent hospitalists who understand both the medical and social needs of their patients, the absence of such professionals leaves these patients vulnerable. Without addressing their full range of needs during hospitalization, these patients are likely to be readmitted for the same issues, perpetuating inefficiencies in care and failing to provide the comprehensive support they require.

The absence of hospitalists can create a cycle of fragmented care for complex patients, further exacerbating their conditions. Without a coordinated, holistic approach—one that integrates hospitalists, organized care for complex patients, and long-term care—these challenges persist. A cohesive system is necessary to break the cycle and improve care outcomes for these vulnerable patients.

References:

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-7. doi:10.1056/NEJM199608153350713
2. MacMillan C. What is a hospitalist? Available from: Yale Medicine. Accessed: October 2, 2023.
3. McGill University, Department of Family Medicine. Enhanced skills program in hospital medicine. Available from: McGill Family Medicine. Accessed: October 2, 2023.
4. Beresford L. SHM celebrates 25th anniversary as the home for hospital medicine. The Hospitalist. Available from: The Hospitalist. Accessed: October 2, 2023.
5. Kisuule F, Howell E. Hospital medicine beyond the United States. Int J Gen Med. 2018;11:65-71. doi:10.2147/IJGM.S151275