Doctors in the House

Family physician Steven Wilks got to Beth Israel Medical Center at his usual time last Monday morning: 7 a.m. He headed first for the ICU to check on a 60-year-old woman with pneumonia and respiratory failure. Then he visited the telemetry unit to check on a patient who’d been admitted with chest pains the night before. Then it was on to the orthopedic unit to evaluate two patients with hip fractures. Over the next few hours, Wilks had three admissions, four discharges, and countless phone calls. Oh, and here’s a page from the ER: He’s got to run down and admit yet another new patient.

Wilks is, as the very awkward term has it, a hospitalist. He’s part of a new breed of M.D.’s whose numbers are popping (7,000 compared with 2,000 in 1998, compared with a few hundred in the mid-nineties) and whose raison d’être is handling in-patient care in place of your primary-care physician. And where is your primary-care doctor, the one who diagnosed you and is responsible for your being in the hospital in the first place? In the office seeing patients, phoning in prescriptions, dealing with paperwork, and arguing with insurance companies. But I’m getting a little ahead of the story.

Fifteen to twenty years ago, a primary-care physician may have had half a dozen patients or more in the hospital at the same time. It would have taken a good part of the morning to look in on them, order or review tests, and tinker with medications, according to Robert Schiller, chairman of family medicine at Beth Israel, where there are hospitalists in pediatrics, medicine, family medicine, neurology, cardiology, and pulmonary care. “The doctors would interact with the house staff”—i.e., the residents—“and have the day’s plans arranged for the patients,” he says. “In the leisurely past, if something didn’t get done or if a patient’s course changed, it was acceptable to come back the next day and address it.”

Now, with ever-growing pressure on the health-care system to be more efficient and to get patients out of the hospital pronto, that whole idea of the doc coming back the next day—or perhaps later the same day—no longer cuts it. The hospital is eager to turn over the bed, the patient is ready to leave, but the transportation hasn’t been planned and the doc isn’t there. Because hospitalists work almost exclusively in hospitals, they become wise in the ways of wards, experts in management and efficiency. They know that the MRI machine was just moved from the second floor to the fourth, and that you need to fill out the blue form, not the pink one. As a result, according to the Journal of the American Medical Association, hospitalists decrease the length of a patient’s stay by an average of almost 17 percent and lower a hospital’s costs by more than 13 percent.

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Doctors in the House