Hospitalist Medicine – Changing Standards of Practice, If Not Standards of Care

Since the word “hospitalist” was coined by Dr. Robert Wachter in 1996, the field of hospitalist medicine has undergone unparalleled growth when compared to other medical specialties.¹ Experts estimate there are more than 20,000 hospitalists working today, a number projected to exceed 30,000 by 2010.² Such a rapid expansion of physicians who practice only hospital medicine has, without question, brought about unprecedented change in the way health care is delivered in hospitals throughout the United States.

We embrace increasing specialization in medicine because of our prima facie assumption that a more specialized knowledge base leads to better patient care. Yet this belief requires rigorous objective data, as may be indicated by a recent study on increased mortality and worse outcomes in patients cared for by intensivists.³ Hospitalists have demonstrated modest improved efficiency in terms of resource utilization and length of hospitalization, and higher quality of care as measured by slight overall improvements in mortality and morbidity.^4,5 The academic community has vigorously debated the significance of the current collective data that compare the hospitalist model to the traditional one of a practitioner who maintains both an office and a hospital practice.^6,7,8

What is not subject to debate is hospitalist medicine is here to stay. While the field may never completely replace the more traditional model, it is rapidly becoming the standard model of hospital care. The reasons for this go beyond the constant pressure to improve the quality and efficiency of care. Indeed, some have argued perhaps what is really driving hospitalist medicine are issues of economics and physician lifestyle.⁹ For better or worse, younger physicians tend to seek a more equitable balance between life and work that previous generations of physicians would find unfathomable. By and large, hospitalist medicine, with its relatively consistent and regular hours, facilitates this balance. That life-work equilibrium appeals just as much to primary care physicians who can offload their hospital responsibilities when hospitalists are on the clock.

The American Board of Medical Specialties (ABMS) defines the meaning of board certification as “exceptional expertise in a particular specialty and/or subspecialty of medical practice.”¹⁰ “Exceptional expertise” has largely become synonymous with the prerequisite knowledge needed to practice standard of care. What makes the rapid development of hospitalist medicine curious when compared to other specialties, is that this growth has not had a clear analogous effect on what defines “exceptional expertise” in the practice of hospital medicine. For example, board certification in emergency medicine has largely become a precondition for working in an ER, and spine fellowship within orthopedics is a similar requirement for doing discectomies. Not true for those who practice in-patient medicine. Despite the aforementioned evidence for hospitalist medicine's ability to improve patient care, the claim that hospitalists have changed the standard of care for inpatients is unproven. Few would conclude that a busy internist or family practitioner deviates inherently from standard practice when he or she leaves the hospital to attend to a busy office practice after morning rounds, all the while tethered to hospital patients by way of a pager.

Tort law defines standard of care as the degree of care a reasonable person would take to prevent an injury to another person.¹¹ For a physician, the definition has evolved as follows: “the quality of care that would be expected of a reasonable practitioner in similar circumstances.”¹² That standard assumes that this “reasonable practitioner” possesses the expertise necessary to execute said quality of care. Clearly, then, the growth of hospitalist medicine has not depended on its ability to change medical standards of care to the same extent as in other more recently evolved sub-specialties. That distinction is underscored by the fact the ABMS has declined to set up a separate subspecialty certification for hospitalists. Additionally, I know of no imminent plans to create a separate residency or fellowship curriculum requirement for the practice of hospital medicine.

That said, it strikes me that hospitalist medicine has in fact changed an important standard of care in the practice of hospital medicine. This change is not a change in the cognition knowledge base or clinical skills required to practice in the hospital. Instead, the transformation is what I call the end of “telephone medicine.” By this, I do not mean phone orders for Tylenol and sleepers, although that constitutes a practice of medicine by phone. Rather, I refer to caring for an acutely ill patient based on a conversation with an allied health care professional. This may sound foreign to those in academic medicine, given the prevalence of young doctors in training available to attend to patients at the bedside. Yet for the majority of community hospitals, which constitute the majority of hospitals, telephone care has been the standard of practice once a physician had left the building, until relatively recently. This is no surprise, given the diurnal practice of medicine which results in no shortage of doctors during the day, but a real dearth at night (and, for that matter, on weekends).

Recent studies that have demonstrated increased mortality for cardiac arrests,¹³ myocardial infarctions¹⁴ and strokes¹⁵ at night and higher mortality for all seriously ill patients on weekends¹⁶ have confirmed the importance of similar standards of care in the hospital 24/7. The growth of rapid response teams (RRT) throughout the country also buttresses the argument that hospitalized patients need to be seen by a physician regardless of the time of day. While not all RRT programs are universally run by hospitalists or accepted as standard of care,¹⁷ my experience at three separate health care networks leads me to believe that this innovation has been a vital improvement in the care of hospitalized patients.

Of course, not all hospitalist programs practice 24/7 in-house medicine, although the specialty is certainly moving in that direction. Moreover, many physicians demonstrate such dedication that they do not hesitate to leave home for the hospital at any hour, to treat patients face-to-face rather than risk treating them over the phone. And I am of course assuming that the regular presence of a doctor at the bedside leads to better care in the first place versus talking to a physician at home who has been yanked out of REM sleep in the wee hours of the night. Just as we do not need placebo-controlled trials to prove the effectiveness of parachutes from 20,000 feet, the superiority of bedside medicine seems to me to be a matter of common sense. As further proof, one should use what I call the “Doctor, is it true …” scenario when deciding what is standard of care for the patients they treat. As an example: “Doctor, is it true that you ordered a bolus of fluids on Mrs. Smith from the comfort of your own home at 2 a.m. without personally examining her and relying solely on what the nurse told you prior to her dying of a massive pulmonary embolism? And, is it not true that General Hospital is populated by physicians called hospitalists who work in-house 24/7, specializing in hospital medicine, who would have without doubt evaluated the deceased at her bedside rather than managing her care over the phone?”

Hospitalist medicine has undeniably transformed hospital medicine, if not obviously led to a momentous change in inpatient standard of care. The litmus test needed to authenticate a new stand-alone specialty has traditionally been a newly defined knowledge base of “exceptional expertise.” But it just may be that because of the growth of hospitalist medicine, for the reasons described, we may need to reconceptualize the very definition of a new specialty, making sure that the criteria we use to establish a “best practice” are suited to keep pace with today's changing health care landscape.

• Copyright 2008 Federation of State Medical Boards. All Rights Reserved.