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.

Some would argue that it’s an issue of care as much as cost-cutting. “Taking care of hospitalized patients is substantially more complicated than it was five years ago,” says Larry Wellikson, an internist and executive director of the Philadelphia-based Society of Hospital Medicine (SHM). The patients are sicker, he says, and “with new technology, tests and medications are changing all the time, and it’s hard to keep up with the changes.”

Doctors who choose this line of medical work are young, usually under 40, attracted to the low overhead, the salary—at $150,000 to $180,000, it is 10 to 15 percent higher than that of a general internist—and the lifestyle: a fairly predictable schedule and finite contact with patients and family.

Hospitalists present a Chinese menu of services. Some primary-care doctors ask them to handle every aspect of a patient’s care; others may want help only with a specific medical problem. “It’s strictly voluntary,” says David Cohen, vice-chairman of the department of medicine at Maimonides, where there are more than a dozen hospitalists.

Not all doctors are convinced of the value of hospitalists. “They see the disruption in their relationship with a patient,” says Beth Israel’s Robert Schiller. “Doctors as a group don’t collaborate well, and this is an area that requires a high degree of collaboration and communication to be successful.”

But even some doctors who are good at sharing are resistant; they have no interest in bucking the med-school training that taught them they were responsible for the care of their patients in sickness and in health, in the hospital and out. “I want to see my own patients. I don’t feel I’m doing my job if I hand them over to someone else,” says Vicki LoPachin, an Upper East Side internist. “It’s not that a hospitalist couldn’t handle it, but I think I bring a certain amount of knowledge of the patient and previous medical problems, and I know the family.”

“A good doctor knows when he needs help and gets it,” says internist-oncologist Bernard Kruger. “I wouldn’t have any trouble using hospitalists, but I think it’s more how my patient would feel about my using them.”

Exactly. “They tried a hospitalist program here, but there was no interest,” says a neurologist affiliated with Mount Sinai. “Think about it. If you say, ‘Now, Mr. Jones, I’m putting you in the hospital, and Dr. Smith, who you’ve never met, is going to take care of you,’ just how do you think the average New Yorker is going to react?”

Not surprisingly, SHM head Larry Wellikson sees hospitalists as part of the natural evolution of health care. Schiller, for all his support of the Beth Israel program, is uncertain.

“The phenomenon reflects a flaw in the current health-care system,” Schiller says. “My concern is that until our society is willing to address some of the larger issues related to the flaws—the lack of universal health insurance and inequities in access—hospitalists are a Band-Aid. They’re the best we can do.”

Doctors in the House