The Problem with the Hospitalist System

As a practicing gastroenterologist, so deeply affected by the implementation of the Hospitalist system that I wrote a novel satirizing medical care in the 21^st century titled "The Hospitalist," I feel compelled to respond to the perspectives offered by Drs. Wachter, Goldman, and Gunderman in the Sept. 15^th issue of The New England Journal of Medicine.  I respect the statistics showing the advantages of Hospitalists quoted by Wachter and Goldman, but as Mark Twain said - "There are three kinds of lies:  lies, damned lies and statistics."  I think far more important than statistics are the opinions of doctors like myself who have been forced to work in the Hospitalist system and even more importantly, the opinions of the people most affected by this change in healthcare that none of us were told about or asked our opinion about, our patients.

I grew up in Huntington, W.V., and was very sick as a child.  I had a pediatrician, Robert Kopp, who saw me in the office, made house calls when I was too sick to leave the house, and visited me at least twice a day when I was hospitalized.  Not only did Kopp's clinical brilliance, commitment, and personality keep me alive, but it also convinced me at the young age of five that I wanted to become a doctor.  I should mention that Kopp did all this even though he was partially paralyzed.  With the advent of the hospitalist, role models like Kopp are lost and we are left with doctors working designated shifts and moving in and out of patients' lives like clouds floating across the sky.

From a doctor's perspective, the major problem with the Hospitalist system is a lack of communication between the Hospitalist and the patient's primary-care doctor.   These doctors need to get to know each other and communicate regularly about the patient, especially if there are difficult problems or life-altering decisions to be made such as DNR status.  In 20 years, I have never seen a hospitalist call a primary-care doctor or vice versa. 

The shift work of the hospitalist is detrimental not only to the patient, but also the consultant.  The patients asks who is my doctor and I read him the name scribbled on the board in his hospital room, only to find out that that doctor left service 24 hours before.  The hospitalists need to give the patients business cards and constantly update the patients, their families, and the specialists about who is in charge of the patients' care.

When the patient is discharged, it is not sufficient to have the hospitalist dictate a discharge summary detailing follow-up appointments and medications to be taken.  The hospitalist service (this can include case workers and nurses) must make calls to the specialists and primary doctors informing them of the hospital course and what is now expected of them on an outpatient basis.  Someone must make sure that the prescriptions are affordable so they are filled and taken.  Far too often, I have seen patients bounce back to the hospital within days of discharge because they could not afford the medication or the doctor was not available to implement the next phase of the treatment plan. 

I think that there should be a large number of hospitalist residencies that teach these doctors not only how to take care of ill patients, but also how to communicate effectively with patients and families who they are meeting for the first time under the most dire circumstances.  These residencies should also teach hospitalists who and when to consult.  Not every patient admitted to a hospital with nausea needs a gastroenterology consult; the over-consulting by hospitalists leaves specialists less time to deal with truly sick patients who need more attention. 

In summary, the Hospitalist system was thrust upon us without any warning and if you ask the patients I see, they don't like it and feel cheated.  Since it doesn't look like it is going away but instead is rapidly growing, there are changes that must be made to make it more palatable for all involved, some of which I have covered in my letter. 

It all comes down to one word – responsibility.  When we become doctors, we take on the responsibility for healing sick patients.  There are still sick patients just like there were thirty-one years ago when I became a doctor, but in many cases the responsibility for healing them has been lost and replaced by having better working hours or being able to make more money by seeing larger numbers of healthy patients in the office.  We as doctors need to take back our responsibility as healers to make our healthcare system great again.

Michael F. Weisberg is a gastroenterologist in Plano, Texas and author of "The Hospitalist"