Health Care Vocabulary -- <i>Hospitalist</i> Explained

By John Ballard

Thanks to the health care debate I have learned several new terms not in the vocabulary of most laymen. I have already posted a few times about the medical home concept.

This morning I was reminded of hospitalist, another term that seems simple enough but which represents a historic departure in the manner that medicine was practiced in the past. This definition comes up first in a Google search but is diplomatically polite saying that the role is nothing new.

Hospitalist: A hospital-based general physician. Hospitalists assume the care of hospitalized patients in the place of patients' primary care physician.

The term "hospitalist" was first introduced in 1996 by RM Wachter and L Goldman to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

In the most prevalent American model of hospitalist care, several doctors practice together as a group and work full-time caring for inpatients.

Hospitalists are familiar figures. Doctors specializing in intensive care have long taken care of patients admitted to the ICU by primary care doctors; geriatricians working in nursing homes have often admitted patients to the care of their hospital-based colleagues; etc.

"Thus," notes HC Sox, "the hospitalist model (of care) is not new (in the U.S.), but it is growing rapidly as a result of the role of managed care organizations, the increasing complexity of inpatient care, and the pressures of busy outpatient practices."

Close enough, I suppose,but Paul Starr's classic The Social Transformation of American Medicine spells out the origins of hospitals in America in somewhat different terms. The text is not available for copy/paste but this paper with no attribution (pdf), apparently by a graduate student at UNC, makes the point.

While the power of the individual doctor over the individual patient is obvious, it is the power of the AMA, as described in Starr�s book, which is truly astonishing. From what Starr says, nearly every aspect of the current state of the health care system in America is due to the intervention of the AMA. The labor movement in the United States has done much to protect workers� rights and prohibit activities that would be morally objectionable, and it is from this model that the AMA was created. But the power that the AMA had in removing medical schools� that would not comply with its standards, in preventing non-member doctors from having hospital privileges, all the way to the current state of insurance coverage for the average American citizen is astonishing. It was shocking to read about the power of the AMA, because in many respects it formed a monopoly in the United States in the medical system, and this monopoly resulted in ballooning medical costs. The AMA worked hard to eliminate all competition; one example of this is when they prevented public health centers from being formed in communities because they feared that these centers would take business away from private physicians. Starr explains in his book that this power has diminished since the 1970s as economic issues in the country began to take center stage, however, many of the aspects of the medical system that the AMA influenced before that time have stayed in effect as it is harder to change things in administration after they are already established.

For anyone taking even the most superficial and careless look at the history of medicine in America this is low hanging fruit. Even after all the yelling and screaming of this past summer I am still amazed that no more so-called professional investigative journalists have explained our broken system any better.

A few voices like Bill Moyers have done workmanlike exposures but the popular media has allowed the public debate to remain at the tabloid level with little effort to mention some of the less pleasant realities contributing to the train wreck we have created. I can only conclude that media supported by commercial advertising are as intimidated by special interests as elected representatives are by the bribes they receive in the form of campaign contributions.

Getting back to hospitalists, notice that the word was coined by Dr. Wachter just a few years ago. Here are two previous links to Dr Wachter:
?Bob Wachter on Rationing Health Care (July 19)
?Health Care Explained (July 28)

The reader should now see a tension between the traditional fee-for-service billing model and a more institutional approach to patient care. Paul Starr explains that in the formative days of hospitals physicians were openly hostile to the idea that hospitals would be practicing medicine. As time passed it became clear that anesthesiologists and radiologists were inextricably part of hospitals, but surgeons and other specialists whose practice was conducted in separate locations we always to be recognized as the real doctors.

It was and continues to be a question of money in the guise of medical practice. Laymen make no distinction between "hospitalists" and other doctors. Whoever wrote the headline for the episode used the word doctor with no intention of slighting the professional whom the story-teller clearly identified as a "hospitalist."

Because hospitalists are staff employees they are typically paid a salary and their services may or may not follow the fee-for-service model  I simply don't know, but my guess is that there are as many vatiants in billing as their are institutions and individual practices sending out bills and filing insurance claims. 

This morning's episode of Story Corps was the inspiration for my post. I think the story illustrates the meaning of hospitalist better than anything I might write. I like to imagine that this is the future of medicine.

?000?

Afterthought:
The paper quoted above mentioned the AMA worked hard to eliminate all competition; one example of this is
when they prevented public health centers from being formed in
communities because they feared that these centers would take business
away from private physicians.  If the reader wants another health care homework assignment look up the word deinstitutionalization and see what comes up. Sometime in the late Sixties a national trend released tens of thousands of mentally ill people from "mental asylums" or "mental hospitals" in response to problems of neglect, abuse and expense. The intended followup in community mental health clinics and other smaller local settings never materialized in any meaningful way, thanks in part to professional opposition to local support of those services.

As a result we now have a large and growing population of poorly treated or totally neglected people, many of whom are either in prisons or among the homeless. This problem (like that of long-term care) is not mentioned in the national health care debate, but hopefully will become a priority at some future date.

I went to the Cherokee County Health Department last week to receive a seasonal flu shot. When I arrived at 11:15 I was told that the shots were stopped at 11:00 and would resume at 1:00 after lunch. I reported back at about 1:30 and joined a waiting room with about twenty or thirty people there for a variety of reasons. At least half a dozen toddlers, a couple of babies, six or eight other seniors and a few couples were there. It took me almost an hour and a half to get a shot. I had the feeling that they were badly understaffed and poorly organized, which made me wonder why part of the national effort to improve health care didn't focus more on local health clinics which could get Medicaid beneficiaries in and out a lot faster and a helluva lot more economically than full-service hospitals and/or private practice physicians.

But then I remembered, the House Representative from this district is a doctor, Tom Price, one of the most articulate opponents of health care reform. It all made sense to me then. The politics are not aimed at better health care but better job security for fee-for-service providers more concerned with milking taxpayers than saving them money.  A quick check of which contributors and which industries sweeten his pie the most gives us a clue to where his concerns are most focused.