When I completed my family medicine residency in 1990, the term hospitalist did not exist. The word began to be used in the mid-1990s, when it was described by Robert Wachter and Lee Goldman.1 Back then, I thought I had a good idea of the type of full-service family practice I would have during the next couple of decades. As it turns out, I did not have an inkling of where my career would take me.
When I started my practice, I found the work very interesting and rewarding. I did obstetrics, emergency room shifts, attended at nursing homes, and made house calls. I was able to make emergency medicine part of my career by working regular shifts and achieving Certification with the College of Family Physicians of Canada’s emergency medicine examination.
And today I find myself working as a hospitalist. So how did this happen? I now realize that a certain number of small but noteworthy changes occurred over time.
Inevitable improvement
First of all natural population growth brought traffic, which increased the travel time from my office to the hospital. Moreover, the volume of paperwork at the office seemed to increase substantially, and I found there was less time in a day to make it to the hospital for rounds. The hospital expanded as well, and it took more time to do the rounds when I did eventually arrive. One day I was trying to find a locum and the only physicians available were office-based. They would not agree to do on-call and hospital work. As a result of these and other changes,2–4 my colleagues began to resign their hospital privileges one after the other, leaving fewer of us to care for inpatients. With support from the hospital’s administration, we eventually organized ourselves with a system of well-defined and predictable shifts to cover patient wards. The system grew rapidly and soon most patients in the hospital were being admitted under the hospitalists. This change in the way inpatient care was provided brought with it some noticeable improvements.
The nursing staff found they had to make fewer telephone calls to contact physicians, meaning they had more time to care for their patients. Physicians found that after working a full day in the hospital, they could go home secure in the knowledge that their patients would be cared for throughout the evening and overnight by the physicians who remained at the hospital. All my remaining colleagues with admitting privileges benefited from this system by always having physicians available on-site to deliver care in urgent situations.
The advantages multiplied: The physicians working as hospitalists became more knowledgeable about acute illness in hospitalized patients. Protocols for treating common conditions were developed. Patients were seen as soon as they were admitted from the emergency room, with tests and investigations ordered and followed up the same day. Definitive treatments began sooner and patient flow improved. Patients no longer had to wait all day for their family physicians to arrive (after finishing at their offices). Beds could be cleaned and ready for the next patients hours earlier. The lengths of stay decreased5–7 and the quality of care appeared to improve.8,9
Quelling concerns
Although questions remain regarding the continuity of care within the hospitalist model,10 I believe patients are starting to understand that their family physicians cannot be in 2 places at once and are trusting the hospitalists to assume those physicians’ roles. Hospitalists are able to spend the necessary time helping patients cope with acute illness. They are available to speak with families on the wards at any hour of the day or evening. In some places, hospitalists are working part-time shifts while continuing to practise family medicine in their offices. When they see other physicians’ patients in the hospital, it is no different than covering for an on-call group of family physicians. As far as follow-up is concerned, the hospitalists make contact with the family physicians upon patients’ discharge with a telephone call, by providing a written summary, or both. In this way appropriate care can continue when the patients return to their family physicians’ offices or clinics. For those patients who do not have identifiable family physicians or clinics, hospitalists, with the help of family members, will try to find physicians or clinics to accept the patients for ongoing care. In the future, continuity of care will be improved with hospital electronic medical records that can be accessed by family physicians from their offices. This system of access is currently in place for physicians with hospital privileges and will hopefully be extended to all family physicians.
If I could compare the care delivered by a hospitalist to the care delivered by a dedicated and conscientious family physician, I would say that in the best circumstances there might be no difference in the quality of care delivered to the individual patient. I feel strongly, however, that there is a substantial advantage to the inpatient system because of hospitalist care, and this translates into better health care for all inpatients collectively. And if care for the group is being improved, then all individuals who are or who might become a part of that group benefit too.
Notes
CLOSING ARGUMENTS
Hospitalists allow for physicians to always be available on-site to attend to patient situations as they arise and without delay.11
Repeated exposure to common presentations of disease and complex illness improves the level of skill in the management of these conditions.11
Working as a small group with hand over of care means that physicians rely on each other to provide a higher quality and a higher standard of care.11
System inefficiencies are more readily identified, and, through participation on committees with hospital administration, practical solutions can be achieved.11
Footnotes
The parties in this debate will refute each other's arguments in rebuttals to be published in an upcoming issue.
Competing interests
Dr Samoil is the Medical Director of the Fraser Health Authority Hospitalist Program in Langley, BC.
Cet article se trouve aussi en français à la page 1104.
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