Wednesday, August 15, 2012
This letter is in response to the Hood River News’ recent news releases promoting the purported benefits of a hospitalist program. “The devil is in the details,” so these articles deserve further clarification.
Hospitalist programs have developed in the past 20 years in response to a number of factors, including physician preferences about practice style and skill focus.
Hospitalists are not specialists, per se, but can be any board-certified family medicine, internal medicine or pediatric physician who prefers to work predictable shifts in the hospital setting as opposed to attending patients in a clinic. Other physicians may choose to part with hospital practice and focus exclusively on their office practices.
However, many physicians love doing both, and often make accommodations in their clinic hours or number of days in the office so that they can care for their patients, when they are hospitalized, in a seamless, more holistic way.
The patients benefit because they are in the care of a physician they trust and who knows them well, and can easily facilitate a solid plan for their care after discharge. Meanwhile, these physicians also have access at all times to any specialty or intensive care expertise their colleagues here and in Portland have to offer.
This is reflected in the most recent evidence in the medical literature regarding the efficacy of hospitalist programs. While it may be true that (at least up front) patients may benefit from “lower initial costs and shorter lengths of stay” under the care of a hospitalist, the benefits appear mixed.
For example, patients cared for by a family medicine physician appear to stay an extra half-day on the average than a patient under the care of a hospitalist. However, those patients under hospitalist care are more likely to “bounce back” to the hospital within the first 30 days of discharge, and are also more frequently discharged to a nursing home to recuperate rather than returning home (Annals of Internal Medicine, August 2011).
The study looked at more than 58,000 patient stays nationally, and estimated that relying on hospitalists solely for inpatient care would actually cost the medical system $1.1 billion in extra spending per year.
Moreover, attempting to measure “quality of care” at all is a slippery proposition indeed. Often “quality of care” becomes reduced to easily measurable substitute indicators for such as adherence to a specific evidence-based treatment for a given condition (which is one important aspect of quality).
But these studies do poorly at quantifying other important aspects of quality more difficult to measure, such as bedside manner, accurate history-taking and physical exams, medical knowledge and understanding of disease, and diagnostic ability. As any medical practitioner knows, there is no quality substitute for knowing the patient and their particular history well. Continuity of that knowledge of a particular patient can potentially be lost in the transfer of care between providers.
The Hood River News article also touts hospitalists as providing “… around-the-clock access to a physician… familiarity with key departments and individuals within the hospital, allowing for prompt connections with other health care personnel…” as if this is a novel concept.
The truth is that the Columbia Gorge has been blessed with this high level of quality service via the dedicated medical community that has been quietly, conscientiously doing these very things for years. Every local practice offers patients 24-hour access to a physician. The circumstances of living in a small community with a small hospital has created a wonderful environment in which every physician working in the hospital has “familiarity with key departments and individuals within the hospital…” and is “facilitating prompt connections…” because your local doctor, colleagues and hospital staff have been laboring together for years as a team, and have been relying on each other day in and day out to provide the most excellent care for our patients.
As a result, our hospital, in partnership with the local medical community, has enjoyed the highest ratings for both patient outcomes and patient satisfaction with care throughout the entire Providence hospital system. This has been true even long before the hospitalist system here was initiated. These surveys included some hospitals that already had a hospitalist program in place.
These excellent historical outcomes reflect well on the dedication and judgment of those physicians who have been providing care, both in and out of the hospital, for decades. Physicians in small communities must always depend on each other’s strengths, and having physicians dedicated to the care of hospitalized patients can potentially expand and strengthen our local care capacity.
But there is an art to practicing medicine well, with each patient and family. Our local primary care and specialty physicians have been doing that work quietly and effectively all along.
Laura Starrett, M.D., Hood River, practices at Summit Family Medicine on the Heights.