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What the Heck is a Hospitalist?

TASA ID: 3333

Q: I just received a case in which the defending doctor is described as a hospitalist. What does that mean?

A: Hospitalists are doctors who take care of patients entirely or almost entirely as inpatients. They have no office practice (though a few are beginning to work in follow-up clinics for patients they cared for in the hospital), so they and their partners are available 24-7 for newly admitted patients and problems with patients already in the hospital.

Q: What kind of training makes a hospitalist? Is there a board certification?

A: Most hospitalists are pediatricians, family practitioners, of internal medicine specialists. But others may specialize in obstetrics and gynecology, general surgery or even psychiatry. They usually get board certification in one of those specialties, though organizations like the Society of Hospital Medicine (a branch of the national organization for internists) offers a fellowship in hospital medicine.

Q: How did hospitalists become so popular?

A: The movement started in the 1990's, when it became evident that a doctor with an office practice is hard-pressed to manage inpatients as well. Hospitalists are more familiar with the hospital and its personnel, they are present when problems arise, and they work with the people there to make sure that care is prompt, high quality and cost-effective. Many large medical groups find it works well either to separate hospital physicians from primary care providers or to keep a few office doctors available to back up the hospitalists at nights and on weekends.

Q: The plaintiff had been going to Dr. Primary for years. Why did he turn her over to some stranger when she got sick?

A: Dr. Primary is an expert in preventive medicine and in diagnosing and treating problems in the office. But in the hospital it takes him longer to do things as he learns how to use the X-ray viewers, he isn't very skilled at giving orders via computer instead of on paper, and he has to make his hospital visits either before or after his office schedule. The hospital had been encouraging doctors to do their discharging early in the day so that another patient can benefit from the bed. Dr. Primary decided that it was better for everybody to turn the job over to a doctor who knows the hospital better.

Q: Why wouldn't the hospitalist see the patient after discharge?

A: See previous answer. Doctors can't be in more than one place at a time, and arranging for Dr. Primary to get all the necessary information and see her in a timely fashion is intended to ensure that she gets continuous quality care.

Q: What are the disadvantages of hospitalist care?

A: First and most obvious, most patients will never have seen the hospitalist before and may be wary; we have to be experienced and confident enough to gain the patient and family's trust. Second, hospitalists tend to practice in groups, so the same patient may see three or four of them in a long hospital stay. Communications between doctors are critical to make sure nothing gets missed when a weekend doctor takes over or when the patient goes home and Dr. Primary needs to know about a problem that he needs to handle.

Q: Why do hospitalists get sued?

A: Mostly for the same reasons as other doctors: bad outcomes, poor relationship between doctor and patient or family, and "nuisance" suits brought in hopes of making some money off a situation. Because we often hand patients off to other doctors (either because we work a 7 days on, 7 days off schedule or for weekends and vacations), it's especially important for us to keep good records and communicate all a patient's problems to fellow physicians. Similarly, test results and medication changes must be sent to the doctor who sees a patient in the office, even if it means arranging the appointment before discharge.

Q: Is the hospitalist always the principal doctor?

A: Not necessarily. We also serve as consultants when patients are admitted by surgeons or by other specialists. In that situation I often explain to patients that I'm here to make sure nothing slips through the cracks, since specialists tend to look mainly at what's going on in their area of interest. A brilliant cardiologist and a general surgeon may be less experienced than I am at adjusting insulin doses or watching for hospital-acquired infections, but those can still cause major problems.

Q: Are hospitalists' notes part of the medical record?

A: Discharge summaries, history and physical dictations and progress notes certainly are, and should be provided when you request hospital records. Hospitalists' notes to each other; however, are usually non-discoverable--though they may go back and check them to use in defending their decisions.

Q: Do hospitalists work only in acute care hospitals?

A: No, we may also practice in skilled nursing facilities, rehabilitation centers and long-term acute care hospitals.

Q: What kind of pressures may cause problems with hospital care?

A: Hospitals are increasingly cost-conscious, and so are many third-party payers. Electronic charts now allow administrators to keep track of physicians' record for avoiding unnecessary days; many have external reviewers checking for errors in things like observation status. Hospitalists need to be careful in discharge planning and in resisting pressure to send patients home before they are ready.

Q: Do I need a hospitalist expert to review records in hospitalists' patients?

A: It usually gives the best results, though a specialist in the same field who is experienced in hospital care can also give you a good evaluation.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

This article may not be duplicated, altered, distributed, saved, incorporated into another document or website, or otherwise modified without the permission of TASA.

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