I admit feeling clueless as I travel on average 100,000 miles per year, listening to physicians tell stories about the ongoing tensions of providing care in a dynamic marketplace.  The word “hospitalist,” referring to physicians who specialize in inpatient care, was not coined until 1996 (Wachter and Goldman, New England Journal of Medicine, 335(7):514-17).  It may also be the most rapidly growing US medicalspecialty, with 20,000 estimated hospitalists by 2010 (Williams MV. 2004. The Future of Hospital Medicine. Am Journal of Medicine. 117(6):446-50).  As the following comments from several regions of the country indicate, rapid growth is only one of many reasons for the instability we currently face:

• A West-coast Emergency Department physician:“When hospitalists first started working here, I initially thought it would be great, and it was for the first few years. Now the problem is they’ve become so overworked and bitter. They’re always looking for us to send people home from the ED, or get another service to admit them. Other times, they’re annoyed if we don’t have the complete workup done in the ED. Isn’t that their job? The whole concept of facilitating hospital stays seems to have been lost. It just doesn’t feel like we’re on the same team any more.”
• A midwestern medical staff President: “So, I get awakened at 2:30 am because a gastroenterologist does not want to scope an alcoholic with a GI bleed until he knows that someone is willing to take the patient and manage the withdrawal issues.  What am I supposed to do? I can’t yank his privileges!  All 6 hospitalists where I work are looking for jobs”
• A West-coast hospitalist: “Other doctors and departments here still think hospitalist is equivalent to resident. It’s not. I’m not here to be on the beck and call of every other physician. I’m here to see my patients and, truth be told, perform billable services. I don’t want to see every patient in the hospital. I need to have a life, too.”
• A 6-year-old daughter of a midwestern hospitalist who had been caring for patients 11 consecutive days: “Daddy, I don’t see you any more.”

The stakes are high as the sociology of care changes.  Hospitalist care frees primary care physicians (PCPs) to focus on caring for patients in their offices.  How hospitalists relate to PCPs affects hospital volumes, revenues, and clinical outcomes (Kripalani et al. 2007. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. JAMA 297(8):831-41).

Hospitalists’ practice environment can benefit from hospital leaders’ timely response to hospitalists’ suggestions (Cohn, Collaborate for Success! 2007. Chicago: Health Administration Press, 26), including:

• Interdisciplinary rounds
• Expedited credentialing for new hospitalist hires
• State-of-the-art information technology resources including computers, peripheral devices, simplified sign-in procedures, web-based storage of patient data to allow access from hospital, office, or home, and electronic health records that allow PCPs to see hospitalists’ notes and vice-versa
• Case-manager availability on weekends and holidays to expedite discharges and decrease length of stay
• Assurance that staff who page physicians have access to and know the results of patient data, including vital signs, problem list, medications, allergies, and laboratory values

Even limits to admissions, inpatient encounters, and discharge summaries are in discussion.  However, everything mentioned above may be necessary but insufficient as care becomes more complex and one person’s actions change the context for everyone else.  With complex issues, formulas have limited applicability, and expertise is important, but relationships are key (Cohn,”Embracing Complexity, in  Better Communication for Better Care. 2005. Chicago: Health Administration Press, 32.).  As the medical staff president above reflected, “We all need to work together and protect one another.”

What do you think:

• Do you feel the bathtub water swirling as old compacts break down?
• What have hospitalists recommended to improve the practice environment where you work?
• What can we do differently to work together and protect and sustain one another while protecting patients and their families from fragmented care?

I welcome your thoughts.