Hospitalists: They've made me a believer

September 20, 1999

Once skeptical about inpatient specialists, this doctor has come to love what they do for him. Mostly, they give him time.

Hospitalists: They've made me a believer

The Way I See It

Once skeptical about inpatient specialists, this doctorhas come to love what they do for him. Mostly, they give him time.

I can still remember the morning in 1993 when one of my IPA colleaguessaid we were going to use intensivists (now called hospitalists) to carefor our group's inpatients.

I gulped. "I'm going to lose touch with my patients," I thought."My brain will atrophy. It's the end of an era for primary care physicians--andfor me."

Truly, I wasn't happy. Some guy who didn't know my patients was goingto tell me what was best for them. No way.

But I couldn't argue with my colleague's rationale. The Good SamaritanMedical Practice Association provides care to some 27,000 patients--mostof whom, when they need admitting, are sent to Good Samaritan Hospital inLos Angeles. As one of the IPA's directors, I'm very much involved in itsinner workings. Our multispecialty group was busy, I knew, and our physicianswere overworked. We had more paperwork, more administrative responsibilities,and more pressure from HMOs, and yet it seemed like less money was comingin every month. Medical groups around us were failing left and right. Ifour group was to avoid that fate, we had to find new ways to become moreprofitable.

In theory, it sounded like the use of hospitalists would work. So, withgreat reservations, I decided to give the idea a try.

It wasn't an easy decision. I'm an old-school doctor, one who came froma hard-working lower-middle-class family and grew up in southern Californiain the 1940s and '50s. My mother was from Poland, my father from Russia,and it was their dream that I become a successful physician. By the timeI was 10, I knew that medicine was my calling.

I started my medical career in academia, which taught me to look diligentlyfor answers to complex problems. But as much as I loved research, I feltit lacked the human touch. My father had been hospitalized for cardiomyopathysecondary to periarteritis nodosa, and he'd begged me to take him home,albeit prematurely, because he felt his physician had treated him coldly.When he died in 1968, I moved into private practice--and loved it instantly.

In 1992, with the onslaught of managed care, I decided to join the GoodSam IPA. I felt very fortunate to have found this professional family. Notonly did I have the benefit of belonging to a respected medical organization,where colleagues shared ideas and supported one another, but I still hadthe freedom and flexibility of a solo practitioner.

When we elected to use hospitalists, one reason I could accept the decisionwas that it came from colleagues I liked and respected. Then, the firstweekend I actually got to spend time with my family, came the first indicationthat this approach had its advantages.

Another plus has been the newfound stability in my office schedule. BecauseI no longer have to make early morning rounds, I can start seeing patientsat 8 am. That's a tremendous advantage for my elderly patients and thosewho work. I can see more patients in the office and provide more focusedcare.

Certainly, I don't miss all the hospital paperwork. There's no dictatingof H&Ps, no going to the Records Department to sign off on charts, andnone of the myriad other details and responsibilities.

The new system has also forced me to reconsider my criteria for admissions.In the past, I'd admitted some borderline patients who could have been caredfor outside the hospital. I've looked back on those situations and askedmyself if the deciding factor was financial or medical. Today, our group'scontracts with health plans offer us incentives not to hospitalize patientsunless really necessary. This compels us to sit down and consider what'sbest for the patient.

Having hospitalists has encouraged me to rely more on my own diagnosticand clinical skills in caring for outpatients. More than ever, I feel compelledto think about the mechanisms of disease and to figure out what's causinga patient's symptoms. What's the best method of diagnosis? What are thealternative treatments? In the past, we'd often turn these questions overto consultants, and in many cases that led to high-cost diagnostic procedures.The fact is, we primary care physicians often know the answer already; we'veseen such symptoms hundreds of times in other patients.

Brushing up on these skills was a bit frightening at first. But now Ifind that if I can steer a patient through an illness without relying ona high-tech hospital environment, it brings personal and professional satisfaction.

I've also come to realize that hospitalists have developed a level ofknowledge and skills I don't possess. Recently, a 72-year-old patient withcongestive heart failure came to see me. In my opinion he had end-stageheart disease that I believed--based on my training and 30-plus years ofexperience--was incurable.

I treated the patient with digoxin, an ACE inhibitor, and a diuretic--standardprotocol for CHF. The patient didn't improve; in fact, he became so illthat his wife called the paramedics to take him to the emergency room. TheER physician contacted me, and I coordinated his move to the hospital.

If I'd cared for this patient in the hospital, I would have continuedto follow accepted protocols and maintained his medications. Upon admission,however, he was immediately placed under the care of a hospitalist. Aftera thorough workup, that physician decided there was another option: He recommendedradical surgery to replace the aortic valve, as well as bypass surgery onthree or four vessels.

My initial reaction was that this was far too drastic a procedure forsuch an elderly and sick patient. But the hospitalist's opinion was persuasive,and the operation was performed. Before surgery, the patient had an ejectionfraction of 25 percent. Several months post-op, his heart was pumping withinthe normal range. In addition, he no longer had any swelling in his legsor shortness of breath. The hospitalist had known there were other options,and thanks to the aggressive treatment, my patient is doing well, his prognosisis excellent, and his family is delighted.

Meanwhile, I've gained a better understanding of our ability to correctstructural abnormalities and clogged arteries in the elderly. It will helpme to give optimal care--and hope--to my patients.

Another reason I'm pleased by my experience with hospitalists is thatI know and respect the people behind the program our IPA uses. Good Samcontracts with a company that specializes in providing hospitalist programsand services. The people who started the company are physicians, and manyof them are also practicing hospitalists. They're bright, young, and fullof knowledge, and they give great care to my patients.

I get to see how the hospitalists practice firsthand because I'm on theutilization review committee for my group. We meet once a week, and thehospitalists come in to summarize who's been admitted, what treatments they'rereceiving, and so on. I can get information on the types of care provided,therapies offered, and more. It's like a teaching session for me as wellas a way to keep in touch with my patients' care.

Incorporating a hospitalist program into our IPA has had tremendous clinicaland financial impact. We've reduced the number of hospital days and trimmedour readmission rates. That has put us on solid ground economically, sincemost of our contracts are structured so that we share risk for inpatientcare.

As for my own income, I'd thought it would suffer, but it hasn't. Infact, my bottom line has improved by about 10 percent since we began usinghospitalists. A key reason, I believe, is productivity: I can spend moretime seeing patients in the office and being reimbursed for that time.

Is it a perfect system? Of course not. I do miss some things aboutthe old system. For one, I don't recognize the nurses in the hospital anymore. A hospital is a dynamic and exciting environment filled with wonderfulpeople, and I don't know those folks like I once did. For another, as aphysician who's used to running the show for his patients, it's been hardto lose control over things like diagnostic tests.

If your group is considering incorporation of a hospitalist program,you need to proceed carefully. Starting a program is expensive. I stronglyrecommend looking for an outside organization, one that has developed systemsand procedures that will enhance patient care. Especially crucial are systemsto promote communication between the primary care physician and the hospitalist,especially at the points of admission and discharge.

Be sure, too, that your program makes the use of hospitalists voluntaryrather than mandatory. No one knows better than I how difficult such a movecan be for many doctors. Allowing physicians to see the benefits for themselves--notforcing the change on them--will help everyone involved.

For me personally, the change has been well worth making. I have moretime with my family, no more weekend rounds, no calls from the hospitalat 3 am. My workload and stress level have been reduced. My knowledge ofmedicine and ability to deliver care are better than ever. What's not tolike?

By Fred Lieberman, MD, Internist / Los Angeles



Fred Lieberman. Hospitalists: They've made me a believer.

Medical Economics

1999;18:120.

x