In the Norman Rockwell past, patients had one doctor who followed them from home to clinic to hospital, managing their health care over a significant portion of their lives. That sort of doctor-patient relationship in today’s medical world seems about as outdated as a family gathered around the fireplace listening to the radio. Now, patients are growing used to unfamiliar people in white coats, seeing multiple doctors at their clinic and a parade of physicians from their hospital bed.
Part of this shift has been the move toward medical specialization, with more medical students choosing careers in surgery, cardiology, neurology or other specialties. The coincident decrease in primary care or family medicine doctors has reduced the ability of those who remain to visit their patients when they are hospitalized and monitor their care. Into this void has rushed the hospitalist, a physician who spends more than a quarter of their time on inpatient service.
Since the mid-90s, hospitals have increasingly relied on this new class of doctor to handle the work of the wards, and David Meltzer, associate professor of medicine, economics, and public policy, has studied the impact of this cultural change. In his talk for the MacLean Center for Clinical Medical Ethics seminar series, Meltzer detailed the impact of an increased role for hospitalists, for both patient health and the hospital’s bottom line. But with the Affordable Care Act rewriting the rules about how Americans receive and pay for their health care, a new kind of hands-on hospitalist may be a key player in the medical landscape of the future.
Meltzer started his research by looking in his own backyard: at the Medical Center’s hospitalist program that he himself directs. From 1997 to 1999, one of the four general medicine services at the Medical Center was run by two hospitalists rather than the rotating house staff and general internists who normally take in new patients. Time revealed the benefits of the more consistent care provided by the hospitalists – by the second year, patient stays were a half-day shorter in the hospitalist service, survival 30 and 60 days after discharge was higher, and costs per patient were nearly $800 lower.
Why would hospitalists show such a profound advantage? The answer may come down to repetition and experience with commonly encountered conditions, Meltzer said. He compared the improvements on the hospitalist service to the growing efficiency of shipbuilders during World War II as they built more ships.
“The total effect was explained by disease-specific experience,” Meltzer said. “Hospitalists seemed to have shorter length of stay and lower costs not because they spend so much time in the hospital, per se, or have so much more experience overall, but because they actually saw these diseases again and again.”
Meltzer and his team have since expanded the hospitalist research to a multi-center study, with six different hospitals all comparing general medicine services in the same fashion as the original study. The early results suggest that the benefits of hospitalists do not always increase over time.
“Why is it that, as each hospitalist gets more experience, they’re doing a better job, but overall they’re not doing a better job over time?” Meltzer asked. “One part of the answer is they were quitting; these were terrible jobs. This led us and others to try and develop these as much more sustainable jobs.”
For the future, Meltzer proposed an approach that would apply the benefits of hospitalists to the issue of what Atul Gawande called “hotspotters” – frequently-hospitalized patients that account for a disproportionate chunk of total health care costs. One solution is to create a class of doctors that specialize in caring for those patients each time they are hospitalized, what Meltzer called a “comprehensive care physician.” With some of the old doctor-patient relationship restored, continuity of care could translate into lower costs and better care for patients with the most persistent problems. His idea was presented at a recent conference organized by the Milton Friedman Institute at the University of Chicago.
“Congestive heart failure, end-stage renal disease or liver disease, sickle cell disease or chronic-obstructive pulmonary disease might all be reasonable models for such care,” Meltzer told Bill Harms. “Especially if cases could be collected into centers of excellence with sufficient volume to support such degrees of specialization.”
[Each academic year, the MacLean Center for Clinical Medical Ethics organizes a series of lunchtime seminars by physicians, biologists, economists, social scientists and other experts covering the biggest questions in health care and ethics. This year’s theme is “Health Disparities: Local, National, Global,” and the series was put together with the Urban Health Initiative, the Global Health Initiative, and Finding Answers. ScienceLife will carry regular coverage of this unique series, and video of the lectures will be posted when available.]
Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, & Levinson W (2002). Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Annals of internal medicine, 137 (11), 866-74 PMID: 12458986