Society of Hospital Medicine President Dr. Jeff Wiese Responds to Four Criticisms of Hospital Medicine

As the field of hospital medicine grows and more hospitals implement hospitalist programs, critics wonder whether hospital medicine will hurt quality of care or draw medical students away from primary care. Here Jeff Wiese, MD, president of the Society of Hospital Medicine, responds to four oppositions to hospital medicine.

Criticism: The transition from primary care provider to hospitalist hurts patient care.

Response: Dr. Wiese says the biggest opposition to hospitalist medicine has "everything to do with transitions." He says, "I'll be first to point out, if you've got a perfect primary care provider clinic and a perfect inpatient hospital environment, but those two are not communicating back and forth, there's a risk that the patients will fall through the cracks between the two." Because the hospitalist model rides on the relationship between PCPs and hospitalist, he says hospitalists have to improve transitions of care.

According to Dr. Wiese, hospitalists and PCPs need to work together to improve transitions into and out of the hospital. Hospitals need to communicate with PCPs to ensure they have information about the patient's history, preferences, disease management plan and especially medications. If a hospitalist is unaware that a patient is taking a certain medication, he may prescribe a new medication without giving instructions to discontinue the old one.

The other component of successfully transitioning a patient is providing education, Dr. Wiese says. "You need to make sure the PCP and hospitalist are on the same page in respect to the goals of therapy that are appropriate for each individual patient," he says. If a patient's PCP and hospitalist never communicate about the patient's history, preferences and future treatment, then hospitalist medicine will be unsuccessful, but it doesn't have to be that way. With enough communication, both providers can save time and give the patient the kind of one-on-one attention that a PCP can't always provide at a moment's notice.

Criticism: Hospitalists make primary care less attractive for future physicians.

Response: Though the healthcare industry is seeing a decrease in residents choosing primary care, hospitalists are not to blame, says Dr. Wiese. In fact, in a functional relationship between hospitalist and PCP, each role compliments the other and cannot function without its counterpart. A study by the University of California on hospital medicine showed two-thirds of primary care physicians supported the hospitalist movement, indicating PCPs believe the presence of hospitalists will give them more time to see patients and less hassle moving back and forth from the office to the hospital.

Dr. Wiese adds that when 32 million Americans gain health insurance for the first time, the relationship between hospitalist and PCP will be essential to freeing up the primary care provider's time. "It's a tremendous waste of resources to use a primary care provider for [a hospital visit]. We need to move into proactive mode, not reactive mode," he says. "More PCPs are going to need even more time in the clinic to handle the increased number of patients, and you lose the luxury to run back and forth between the clinic and the hospital. For those that can develop a trusting relationship with a hospitalist, you can work together to see more patients and provide more care."

Criticism: Hospitalists work for the hospital, not for the patient.

Response: Hospitalists are first and foremost physicians, Dr. Wiese says. "The primary responsibility of a physician is to the patient, and it's ultimately bad business for the hospital if physicians are doing anything other than providing the best possible care," he says. The hospitalist may work for the hospital, but the hospital works for the patient, he says. Payment structures for hospitals vary from institution to institution, but the predominant pay arrangement makes hospitalists salaried employees.

Criticism: Hospitalists will burn out because of stressful hours.

Response: A well-thought-out job structure can prevent burnout, says Dr. Wiese. He outlines two components to burnout: work intensity and fulfillment. "If they have the right work intensity, not doing overnight every other day throughout the year, they should be fine," he says. Equally important, he says, is fulfillment. If a hospitalist is embraced by the C-suite and treated as a partner in the overall mission of the hospital, he or she gets to see his or her ideas improve the system.

Dr. Wiese recommends that hospital executives treat hospitalists as "system architects." This means that a hospitalist is more than just a practitioner who happens to practice in the hospital. Instead, the hospitalist is a provider who's uniquely familiar with the hospital system, who spends all his time learning the ins and outs of hospital life and who can provide valuable feedback about hospital processes. By involving hospitalists in the strategic goals of the hospital, you can prevent burnout and make them feel like more than a geographically convenient provider.

Learn more about the Society of Hospital Medicine.

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