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'Hospitalists' Begin Taking Over Role of Personal Physician in US Hospitals - 2003-08-20

Most Americans who find themselves in a hospital will see their personal physician once or twice a day during rounds. But that pattern is changing as a new specialist begins to take over hospital duties. The hospitalist is meant to make patient care more efficient and accessible, but not all family practitioners are ready to give up their hospital privileges.

Dr. Bipin Mistry is a hospitalist. He has no private practice and no regular patients; he treats anyone who's admitted to Mercy Hospital in Springfield, Massachusetts in the American northeast. So when a typical patient comes in, such as Miguel Flores, who complained of chest pain, the doctor had to quickly absorb his medical history from a chart.

Dr. Mistry was trained in England, where the hospitalist model has a long history. Doctors work in an office, or in a hospital, but rarely both. "I like the acuity, the variability. It's just interesting to establish a bond with a patient in a short period of time," he said.

Ten years ago, Mercy Medical Center was one of the first American institutions to use hospitalists. Now, two or three are on call any time of the day or night. Chief hospitalist Win Whitcomb says it's a win-win situation. Patients get 24-hour access to a doctor, and primary care physicians get some relief. He speaks from experience. He spent two years in family practice.

"You had a long day in the office and unexpectedly, you'd have to go back to the hospital for two hours to take care of a patient, or a patient would become unstable in the hospital and I was physically unable to get there," he said. "I would order a whole bunch of tests, which may or may not have been necessary, all as a surrogate for me being able to personally get to the patient."

Back then, Dr. Whitcomb says, it was unusual to have a fully trained doctor around the clock at any U.S. hospital. But administrators began to notice that hospitalists saved them money.

"If you come in for pneumonia, a hospitalist will take care of you for roughly $700 less than a traditional primary care doctors would," he said. "We're not sure exactly why, but I think the essence is, we can get to the bedside in real time, as their condition demands."

The number of hospitalists in the United States has jumped from a few hundred in 1993 to about 9,000 today. Eventually, that number could double. Some of these physicians work directly for a hospital; others are hired by family practitioners to see their patients who've been admitted. Journal studies have shown that in-patients are as satisfied with treatment from a hospitalist as from their regular doctor. But there are skeptics.

"I like to be able to say to somebody, I think you need to be in the hospital, and I'm the one who's going to take care of you," he said.

Patrick Coghlan is a Springfield family practitioner who only contracts with hospitalists at night and on weekends. Doctor Coglin says he feels a responsibility to visit his regular patients when they're at their most vulnerable.

"A fellow is in the hospital who's sick and in the ICU and on a ventilator," he said. "I see him every day and I talk to his family and I think they like to hear from me what's going on. Hopefully, he's going to get better and come back to the office, and this way, I'm really going to know what happened to him."

Moreover, Dr. Coghlan worries that family practitioners could lose important skills if they no longer work in an acute care environment.

"I think over time you'd lose contact with hospital systems, because it's changing all the time," he said. "You see a different mix of illnesses. There are newer technologies that get used to get to continue to get familiar with."

But he concedes that for many doctors, avoiding hospital rounds makes their schedules more efficient and lucrative.

"The hospitalized patients are more difficult to take care of, they take more time, and in a lot of ways, your time would be more efficient spent seeing people in your office from 8 to 9, instead of making rounds in the hospital from 8 to 9," he said.

For now, individual doctors decide whether or not to use hospitalists. But Patrick Coghlan and other physicians worry they could lose their hospital privileges if the hospitalist trend accelerates. Meanwhile, the specialty is gaining legitimacy. At Mercy Medical Center, Dr. Whitcomb is working to develop a residency program and board certification specifically for hospitalists.