Letters to the Editor  |   September 2004
The Hospitalist: A Patient-focused Paradigm?
Author Affiliations
  • Jerry F. Cammarata, PhD, ScD, LHD
    Coney Island Hospital Brooklyn, New York
    Associate Executive Director
Article Information
Cardiovascular Disorders / Medical Education / Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Pediatrics / Professional Issues / Headache
Letters to the Editor   |   September 2004
The Hospitalist: A Patient-focused Paradigm?
The Journal of the American Osteopathic Association, September 2004, Vol. 104, 364-365. doi:10.7556/jaoa.2004.104.9.364
The Journal of the American Osteopathic Association, September 2004, Vol. 104, 364-365. doi:10.7556/jaoa.2004.104.9.364
To the Editor:  
To be American means to long for a past that never occurred and to yearn for a homecoming to a place that never existed. There was never a time when every boyhood was a variation of Huckleberry Finn's, every family lived in a rambling Victorian house, a mother's biggest problem was whether to serve ham or roast beef at the family's Sunday dinner, and going to work meant strolling down the block to open a shop on Main Street. There were Americans who had some part of these scenarios in their lives, but for every one of them, there were a million others who did not dare dream of such things. 
Part of our collective fictive memory as Americans is the image of the family physician: Born at about 60 years of age but never reaching 61; plain-speaking and always in good humor but secretly passionate about his patients; possessing “awshucks” simplicity, yet a veritable medical genius; never sleeping (there were babies to be delivered at 2 am in every heavy storm); never taking a vacation, never taking a fee (“Why, Mrs. Smith, that apple pie will be just fine as payment for Tommy's brain tumor operation.”); a surgeon, neurologist, cardiologist, podiatrist, obstetrician (women had no need of gynecologists in those days); a psychiatrist, psychologist, philosopher, and conscience; as adept at curing a cow as he was at healing a headache; who knew his patients better than they knew themselves (“Don't you worry about new Baby Sally. Now, Joe, don't forget, I delivered you're greatgrandmother on just such a night as this.”). 
The old family doctor never existed, of course, but as with all the great myths of mankind, this myth does reflect some bits of reality, some nuggets of fact around which the yarn is skeined. 
The truth is that although physicians did not and could not live up to this image, they wanted to, and their patients wanted it of them. This ideal drove many young men and women to medical school in the first place, and, believing that their doctor could be all this, many patients trusted their family physician without question in matters they might trust otherwise only to a spiritual adviser. 
The practice of medicine has changed significantly through the years, and physicians and patients have changed their expectations of each other. We now live in an age of signs and wonders; promising patients a diagnosis and treatment before there is a disease; patients' expectation to be preserved from mortality. Physicians, straining to keep up with the rising tide of medical information now available, expect patients to trust their judgment, while patients having far greater access to medical information than ever before, expect physicians to provide the latest and greatest in treatment, and sometimes fads. 
One aspect remains the same, however: As in the Ol' Doc's day, patients still want to be cared about, not just cared for, and caring physicians want to serve their patients, not just provide a service for pay. This has always been and continues to be the particular concern and strength of the osteopathic approach to patient care. 
Enter the hospitalist. 
The hospitalist practices a specialty that is now approximately 8 years old and that is becoming increasingly prominent in clinical circles. Broadly speaking, a hospitalist is a physician who specializes in supervising patient care during a hospital stay: he or she receives the patient from the family physician, becomes that patient's primary care physician for the duration of hospitalization, and returns the patient to the care of the family physician on the patient's release. In other words, the concept of a patient's primary care physician as that patient's personal medical adviser and the manager of his or her total health program has received another blow. Primary care has been redefined once again. These physicians' ever-diminishing circle of care will soon discontinue altogether, including oversight of the treatment of patients during hospital stays. 
The stated purpose of the hospitalist is to provide patients with better clinical supervision during a hospital stay, under the care of a physician who has a closer relation to hospital staff and more knowledge of clinical possibilities in the hospital setting than the primary care physician. In fact, almost all the studies done on the hospitalist specialty (and there have been more than a few) focus on one of four areas: Reductions in hospital costs, enhancement of family physicians' incomes, length-of-stay measures, and incidences of clinical complications. Physicians have been queried as to their level of satisfaction with their family physician-hospitalist relationship, malpractice claims have been tallied, and medical students have been queried about their experiences with hospitalists as clinical professors. All seems well except that somewhere in all of that turmoil, patients have been forgotten. 
Studies indicate that the presence of hospitalists has reduced the average length of hospital stays by nearly 17% and has reduced hospital costs by an average of more than 13%.1 The presence of hospitalists has also cut the 14-day read-mission rate by about half.2 There even have been claims that the presence of hospitalists has reduced inpatient mortality by one third.3 However, all these studies are based on either accountants' analyses of costs or on surveys of physicians' experiences and attitudes. Note that physicians have been asked about their comfort level with hospitalists, patients have not. 
A couple of thoughts come to mind. First, despite the efforts of such celebrated programs as “New Pathways in Medical Education” at Harvard University, Boston, Mass, which was designed to introduce a patient-centered approach in medical education (but considered by some to have refocused the medical student's attention on his emotions, rather than on sere logic and scientific knowledge), the culture of medical practitioners remains iatrocentric. 
Second, the trend to hospitalists seems part of the movement away from the holistic big-picture approach to care of the patient that led to a crisis in the ranks of primary care physicians. Lisa Sanders, MD, has noted that although one third of her medical school class (1996) had planned to go into primary care, that number has been cut by one third.4 
“Some doctors and other critics say that primary care is just a remnant of an earlier time in medicine and that we are simply witnessing the end of a type of doctoring, like bloodletting or cupping, whose time is over,” she wrote. Maybe. But there is some evidence that this is not the case. In the United States, people with means are willing to pay for what they want in healthcare, and a recent trend suggests that what people want is my Ol' Doc James. In today's healthcare system, a patient may pay an annual fee of between $1,000 and $10,000 to retain a physician who is available as needed. Sound familiar? It's television's Marcus Welby repackaged as luxury primary care. 
Hospital rounds, requiring travel, extended time, and the annoyances involved in overseeing patients in the hospital setting, cannot compare with having patients file into an examining room all day. Further, though we walk about with videophones strapped to our belts like Buck Rogers able to summon up files, charts, and other information with a touch of a button, we still must ask how a hospitalist, armed though he or she may be with a perfect set of computerized patient files—as though such things exist—can supply the heuristic knowledge that a family physician or a long-time primary care physician brings to the care of a patient. 
“The whole point of osteopathic medicine is the maintenance and restoration of the wellness of the person,” notes Dr Jay Sexter, vice president of International Affairs of Touro University of Osteopathic Medicine in Las Vegas, Nev. He continues, “Almost two thirds of osteopathic physicians choose to go into primary care for that reason. Disease is not a problem to be solved by applying a medical algorithm—the patient is a person to he healed and cared for, and part of that is addressing a disease. That's a very different emphasis, of course, from conventional medicine, and while the hospitalist model may make sense in certain specific types of situations, the idea of an osteopathic physician handing off a file to a hospitalist—the way a car mechanic might send an alternator off to be rebuilt and returned—doesn't seem to fit comfortably into our notion of care for a person's wellness.” 
Americans are a nostalgic lot. We long for a time that was more humane, more personal, a time when each person mattered, relationships meant something, and people trusted, more, believed in their physician. The hospitalist model, as convenient as it is for the family physician in his or her office and the accountant in the boardroom, leaves the patient dependent on the kindness of strangers.