Enter the hospitalist: new type of patient creating a new type of specialist

Patrick Sullivan

CMAJ 2000;162:1345-6

These new specialists, usually internists but sometimes family physicians, take over responsibility for the care for "orphan patients" who arrive in hospital without an FP or someone else to assume the role of most responsible physician (MRP) during the patient's hospital stay. In many cases, patients become orphaned when family doctors resign their hospital privileges because of the increasing demands associated with hospital-based care.

Dr. Tom Dickson, chief of staff at the William Osler Health Centre in Brampton, Ont., said the FP shortage is so severe in the ring of suburbs surrounding Toronto — the "905 belt" — that dozens of orphan patients are arriving at local community hospitals every day.

He told 120 physician managers attending the recent annual meeting of the Canadian Society of Physician Executives (CSPE) that the hospitals are then forced to find a doctor willing to assume the MRP role.

Enter the hospitalist. Dickson, who noted that the word didn't exist before 1996, said there are now more than 10 000 hospitalists in the US, primarily because of the advent of managed care. Now the movement has come to Canada. Dickson's 350-bed community hospital has just hired its first 2 hospitalists, a geriatrician and a general internist. In Canada, the term defines doctors who spend almost all of their practice time managing the care of hospital inpatients. The hospitalist issue is primarily confined to community hospitals because training staff and medical specialists fill the MRP role at large teaching centres.

In community hospitals, surgeons still assume the role for surgical patients, but for internal medicine patients the role was presumed to belong to family doctors. No longer. "At many large community hospitals in my area, the FPs have threatened or actually withdrawn from the role of MRP for patients who are admitted and do not have a family physicians on staff," Dickson explained. "And now they are extending this withdrawal to their own patients."

Dr. Les Pattison, chief of medical staff at the Royal Victoria Hospital in Barrie, Ont., says staff managers throughout southern Ontario are becoming familiar with the problem. "It really started to be noticeable in the past 2 years," said Pattison. He said the orphan-patient problem first became serious in Windsor, Ont., which has a well-documented shortage of FPs.

Although family doctors working a hospital rotation have traditionally taken over MRP responsibilities for orphan patients, Pattison said the low fee paid for providing this service — $13 in Ontario — combined with the growing number of orphans and added responsibilities, meant that many FPs refused to accept them. "Physicians have a healthy dose of altruism, but after a while the goodwill starts wearing thin," he said.

Dickson, a past president of the Ontario Medical Association, said that both financial and social issues are driving family physicians from hospital work. "At our hospital," he said, "we charge more for parking than physicians can make caring for orphan patients."

He also thinks physicians are being driven away from hospitals because today's patients tend to be sicker and to be released earlier, "sicker and quicker" in today's doctors' lounge jargon. This means that the FP might become responsible for an orphan patient released from hospital following an acute illness.

"Family doctors have found this situation increasingly stretching their comfort zone, particularly when covering each other's practices after hours," said Dickson. "And they're dealing with a payment system that reflects fee relativity based on acuity levels from the 1970s."

As a result, "serious cracks" have started to appear in what, until 18 months ago, had been a "very stable system of care."

At Dickson's hospital, the newly hired geriatrician and general internist work 8 am to 5 pm shifts and deal with all orphan patients; each hospitalist handles 12 to 15 patients a day, with a 5-physician call group providing after-hours coverage. "Our experience to date is that it is working," he said. "And the family physicians seem to be happy."

Dickson said hospitals are in a difficult position because family doctors no longer need them to remain busy. "The demand [for physician services] today is such that you can survive quite well from your office."

He has 4 suggestions for dealing with the current problems:

• fix the payment system, which is "a mess";
• provide target funding to allow hospitals to hire hospitalists;
• produce more hospitalists, either general internists or FPs with enhanced training; and
• develop a welcoming environment for FPs in community hospitals.

Dickson admits that the introduction of the hospitalist carries risks. "We pride ourselves in Canada on our system of family physicians who quarterback their patients through the complete process of care. With the advent of the hospitalist, we are at risk of marginalizing the valued role of the primary care physician in the community."

Pattison agrees that the hiring of hospitalists is a potential solution, although it does raise budgetary issues because the dollars involved are "not insignificant."

Meanwhile, he remains concerned about what the future holds for his hospital, whether or not it hires hospitalists. "Barrie is 20 FPs short right now, we're not producing enough new graduates and the number retiring is growing. Things are just getting tighter and tighter all the time."

During the meeting, one doctor may have summed up the situation best with a question: "Where do I get some hospitalists? We want 3 right now."

There was no ready answer available at the CSPE meeting, but it was clear that more doctors in more hospitals are going to be asking the same question shortly.

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Membership in the 2-year-old Canadian Society of Physician Executives has passed the 250 mark and attendance at the second annual meeting more than doubled, organizers report. The fledgling society, designed as a networking and information-sharing organization, has proved particularly popular with physicians such as chiefs of staff.

"We were quite pleased with the attendance, which amounted to half of our membership, and feedback from the meeting has been very positive," said Dr. Chris Carruthers, the president. Carruthers, chief of staff at the Civic Campus of the Ottawa Hospital, said the organization hopes to hold some regional workshops in conjunction with other medical organizations in the next year.

Membership costs $75 a year. Doctors can join online (www.cma.ca/cspe) or by sending a cheque payable to the CSPE to Dr. Chris Carruthers, 3540 Paul Anka Dr., Ottawa ON K1V 9K8; ccmd@home.com.

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