Important visitors: The second group, whom Dr. Wellikson calls important visitors, has a totally different relationship with the hospital. These are the cardiologists, orthopedic surgeons, and other medical specialties. “They are very important,” he says. “But they use the hospital intermittently and are not as tightly connected to it.”
Even so, they desire a high-quality hospital for their patients and will be willing to help set performance standards to achieve it. But their interest may not extend to patients who are not their own. “If the hospital says you have to also take care of free patients, they may choose not to,” Dr. Wellikson notes. “In fact, sometimes they have their own outpatient centers,” making them direct competitors as their competing practices sap revenue from money-making patients and procedures—all the while sending the sickest and costliest patients to the hospital.
Office-based physicians: The last of Dr. Wellikson’s groups is office-based physicians. These are the doctors who once made daily morning and evening rounds of their hospitalized patients but are now infrequently found at the bedside. “They are the physicians who don’t come to the hospital anymore: primary care physicians, endocrinologists, rheumatologists, neurologists, physicians who do all their surgery as outpatient procedures,” Dr. Wellikson explains.
—Larry Wellikson, MD, CEO of SHM
This upheaval is due to tectonic shifts in both medical economics and lifestyle preferences. “Because the reimbursement for care has gone down, physicians have to see more patients to make the same amount of money,” explains Dr. Wellikson. Turning their hospitalized patients over to hospitalists allows office-based physicians to maximize their income and optimize their time.
“It increases satisfaction, limits the hours you spend in the hospital, and puts some boundaries on your work day,” Dr. Cawley says.
“Doctors want more a predictable lifestyle,” Dr. Whitcomb says. In fact, their absence is already a fait accompli in many community hospitals.
As Dr. Axon succinctly puts it: “The primary care doc has left the building.”
Dr. Cawley believes the new system is a relief to many office-based physicians. “Some do miss going to the hospital and seeing other physicians to network with them. Some miss taking care of their acute in-care patients. But I think most are relieved to not have to go to hospital. They say, ‘No, things are better this way.’”
With so many other physicians withdrawing from hospitals to their offices and clinics, Dr. Wellikson believes hospitalists will become increasingly crucial to the institution’s operation and governance. “Now the home team is going to be more active; how you staff, how you make the hospital more efficient,” he says. “The inside physicians will be much more interactive. That’s why hospital medicine has grown so rapidly.”
The explosive expansion of hospital medicine as a specialty is a direct result of the need to increase efficiency and quality standards in this new hospital atmosphere.
In addition, good home teams create a milieu in which other physicians—the important visitors (cardiologists, surgeons, orthopedists)—will want to work. “My job (as a hospitalist) is to create an environment where you can come in and do your surgery,” Dr. Wellikson points out.
The home team offers something else too: medical expertise. Providing post-operative care is not cost-effective for many surgeons. “The surgical specialists are not paid to manage medical issues,” Dr. Cawley says. “It takes time and if somebody else can manage it, that’s great.” That somebody is often a hospitalist. “There is a quality-control aspect as well,” he adds. “With hospitalists focusing on medical issues, the result is better patient care.”