Freelance Physicians

When introducing himself to new patients, Robert W. Goldmann, MD, usually says he is “their doctor’s eyes, ears, and feet” while they are in the hospital. Goldmann, who might be termed a “freelance physician,” is not employed by a group practice or a hospital, but takes referrals from several doctors in various private practices to manage their inpatient cases.

“There are some physicians who, with all the pressures and complications, simply cannot, and don’t want to try to, keep up with the way hospital medicine works today. I can’t say I blame them,” he says. “Trying to keep up with inpatient and office medicine and make it all balance is extraordinarily difficult.”

Enter the “hospitalist” - someone, like Goldmann, who is at the hospital full-time, doesn’t have an office practice to manage, and who thoroughly understands the insurance issues and the way the hospital system works. Such an ally can relieve a busy physician of an enormous amount of responsibility and work.

Not surprising, the concept is catching on in the medical profession. According to figures from the National Association of Inpatient Physicians (NAIP), formed in 1997, there are more than 5,000 hospitalists working in the United States and the number is growing every day.

Defining the role

So are the success stories. Richard Olds, MD, chairman of the department of medicine at the Medical College of Wisconsin (MCW) who also oversees the 180 physicians practicing through MCW at two major hospitals in Milwaukee, has a history of working with hospitalists. In his former position with Metrohealth Medical Center, one of the teaching campuses of Case Western Reserve University in Cleveland, Ohio, he oversaw what he describes as a “fairly robust hospitalist program.” That, he says, is the reason he is in the process of bringing a hospitalist program to MCW, planning to hire five hospitalists this summer and use them as the building blocks for a program to train hospitalists through the college.

Despite his optimism about the program, Olds admits that the role of the hospitalist is not yet completely defined.

“If you ask five people what a hospitalist is, you will get five different answers,” he says. “Some people are trying to define hospitalist as a distinct career path that will lead to either board certification or a specialty certification. In some areas, hospitalists are really glorified house officers doing a job not much different from what residents do in teaching hospitals.” He says that, as the hospitalist model spreads, the standards will become clearer.

Olds isn’t the only one in the process of weighing the pros and cons of the hospitalist model. Individual practitioners, large multi-specialty practices, and hospitals themselves are all finding many advantages to such a program, and, as with all new endeavors, turning up some disadvantages also.

Economic issues

“Without question, the insurance industry has been the driving force in this area,” says Olds. “[Insurers] create very complex rules that most physicians are not aware of. Hospitalists are highly trained in this area because they are expected to be the managers of the inpatient service by both the hospital and their group practice.”

The hospitalist not only removes the burden of the paperwork from the private practice physician, but he or she also can work the regulations more efficiently, allowing better care for patients.

“There are many specific disease management pathways,” says Olds. “Knowing the most expeditious way to make a diagnosis, which tests to do and not do, the most efficient ways to get patients in and out with the best outcomes is a skill that most physicians don’t have, since they spend 90 percent of their time in outpatient settings.”

On the other hand, because they spend all their time developing inpatient skills, hospitalists can handle those issues more efficiently. Hospitalists also improve time management for busy outpatient physicians.

“In the old days, [because] people were admitted for days or weeks, there was time for the doctor to come in once a day and make decisions for the next day,” Olds says. “The pace of decision making doesn’t allow for that anymore.”

The hospitalist can make decisions immediately, several times a day, and can take the necessary time to explain them to the patient and family. A hospitalist also can counsel other physicians.

“One of the drawbacks in a teaching hospital is that the house staff is trying to manage patients with a variety of doctors giving them instructions, and some of them may conflict,” says Olds. “One of the solutions is the hospitalist, who doubles as the major teacher of inpatient house staff and the manager of patients. The person responsible for the teaching is then also responsible for the patient care.”

There are drawbacks

Using a hospitalist isn’t a panacea, however. There are some drawbacks that physicians should consider before contracting with one. For instance, there is the possibility of jeopardizing the doctor/patient relationship when turning patients over to a hospitalist.

“If a patient has seen a family doctor for many years, he would like that doctor to be at his bedside during a crisis,” says Charles Waisbren, MD, a board-certified internist who uses Goldmann’s services for his inpatients. “But using a hospitalist doesn’t mean we can’t see the patient. I stop in, reassure the patient, but the responsibility is not with me to do the day-to-day care.”

Goldmann feels this problem can be overcome with good communication. 

“If you don’t let the patient understand who you are and how you relate to them, they may get defensive,” he says. “Then you get the person saying, ‘Who is this stranger and why is his name on my arm?’ But if you lay the groundwork, most patients are appreciative of having someone right there.”

Another issue for some physicians is loss of billings for hospital visits. 

“The economics is that you lose income from the admission and the follow-up visits,” Waisbren admits, but he says it’s less of a loss than many doctors would expect. “Under the insurance rules today, if more than one doctor is following a patient in the hospital, the insurance will pay for only one anyway. The extra office visits I can do during the time I would spend traveling to the hospital balance it out.”

A related worry among physicians is that they will lose their hospital skills by not doing any inpatient management. Yet, say the experts, so much of what used to be inpatient medicine is now done on an outpatient basis that doctors stay in touch that way. In addition, some large group practices will have their individual doctors act as hospitalists for two weeks a couple of times a year. 

“Doctors will hone their skills better by taking a two-week shift than by trying to squeeze it into a 95 percent ambulatory practice,” says Olds. 

Some physicians fear that a third-party payer will force them into using a hospitalist against their wishes. That is why the American College of Physicians–American Society of Internal Medicine affiliated with NAIP last year; they both oppose mandatory hospitalist programs.

High burnout rate?

Another possible disadvantage to hospitalist programs is the intense nature of the job, says Olds. 

“Some of the benefits are lost if the [hospitalist] isn’t there 24/7,” he says. “When the person is off, the continuity is lost. That makes the burnout rate potential very high.”

He points out that big hospitalist operations, such as the one he headed in Cleveland, don’t let one person do the main job constantly, but assign the physicians somewhat lighter duties when they’re not serving as a hospitalist.

“You have to be very careful with workload management,” Olds says. “That’s often the fatal flaw in these programs; people don’t recognize that.”

Despite some disadvantages, most outcome studies show hospitalist programs have reduced the length of stay and cut hospital costs while maintaining and even improving quality. Robert M. Wachter, MD, who coined the term “hospitalist” in a 1996 New England Journal of Medicine article, says that hospital costs and lengths of stay are consistently declining in hospitalist programs around the country.

“I love having a hospitalist,” says Waisbren. “The benefits are fantastic. Talk to any primary-care doc - they hate dragging in on Saturday or Sunday to do hospital rounds. It’s frustrating to them because if something is happening at the hospital and they are at home or at the office, it’s so hard to take care of over the phone. I think we will see more and more hospitalists in the future.”

Kathleen Winkler can be reached at editor@physicianspractice.com.

This article originally appeared in the March/April 2001 issue of Physicians Practice.