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Unintended Consequences: When Hospitalists Become Too Popular, Costs Rise

It’s the fastest growing “specialty” service in medicine: hospitalist medicine. These are the doctors who limit their practice to the care and management of patients admitted to the hospital. It has been wildly popular because it adds a shift-like work schedule to medical care for physicians while supposedly preserving their personal life. It also moves patients through the hospital faster, shortening length of stays. As one of our more esteemed hospitalist bloggers likes to boast: it’s a “WIN-WIN!”

At least until the hospitalist service gets too busy.

It seems now that hospitalists services are limiting the number of patients they admit per day in response to their overwhelming “popularity.” It’s something akin to capping resident medical student ward services – they stop accepting patients when their census gets too full. I learned this today when a patient I was trying to manage with heart failure was just not turning the corner and needed to be admitted for more agressive inotropic therapy.

Finding an admitting physician becomes an interesting exercise when the patient’s primary care doctor no longer admits to the hospital (or is on vacation as was the case today) and the hospitalist service is no longer accepting patients because they’re “capped” and you’re trapped in a busy clinic.

What becomes the pop-off valve? You guessed it: the Emergency Room. Even though the patient absolutely, positively does not need the Emergency Room.

So much for cost savings.

It appears hospitalist services are increasingly finding themselves overwhelmed with admissions and the promise of a reasonable lifestyle can be assured by either limiting the number of patients admitted to each hospitalist or hiring more of them. But new hires are becoming tougher to justify in this “do more with less” economic time in medicine. As a result, it appears existing hospitalists are quickly finding they’ve hit the peak speed of their clinical-care gerbil wheels.

In a 1999 National Association of Inpatient Physicians (NAIP) survey, 25% of hospitalists were at risk for burnout, and 13% were in fact burned out. While these burnout rates were significantly lower than those documented in similar surveys of intensivists and emergency medicine physicians at the time, others suggested that his rate could increase as the field matured.

News flash: At least at some hospitals, it looks like we’re there.

Robert M. Wachter, MD; Lee Goldman, MD, MPH
The Hospitalist Movement 5 Years Later. JAMA. 2002;287:487-494.

Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001 Mar 26;161(6):851-8.

*This blog post was originally published at Dr. Wes*

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