Pediatrics: Benefits of Hospitalizing Mother with Child

The use of hospitalists—physicians who limit their practice largely or exclusively to hospital inpatient care—has been a growing trend in the United States. The authors examine some pressures affecting an academic medical center and present the results of a hospitalist pilot project there. Based on the criteria of reduced patient length of hospital stay, hospital financial savings, physician satisfaction, and payer interest, the pilot hospitalist program was successful within 6 months.     

What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?

OBJECTIVE: Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, “Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?” DESIGN/PARTICIPANTS: The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association’s Masterfile were surveyed (adjusted response rate=52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N=339). MEASUREMENTS AND MAIN RESULTS: We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout. CONCLUSIONS: Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.     

Economic effects of community versus hospital-based faculty pneumonia care

To compare the length of stay and charges for patients with pneumonia admitted in 1995 to the teaching and nonteaching services of a Northeastern teaching hospital, we reviewed the charts of 237 patients. Patients cared for by hospital-based generalists working with housestaff (teaching service) were discharged more quickly and with lower or equivalent charges than patients cared for by community-based attending physicians working either with housestaff (private teaching service) or alone (nonteaching service). Academic teaching services staffed by general medicine faculty may provide efficient inpatient pneumonia care.     

Principles to consider in defining new directions in internal medicine training and certification

SGIM endorses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.     

Development and Implementation of a Proactive Geriatrics Consultation Model in Collaboration with Hospitalists

Acutely ill hospitalized older adults often experience a decline in function that may be preventable using a proactive, interdisciplinary, patient-centered approach. Hospitalists are treating an increasing number of these patients. A collaborative geriatrics consultation model to prevent functional decline and improve care for older patients with geriatrics syndromes was developed and implemented in partnership with a large hospitalist group in a community teaching hospital. A team of a geriatrician and a geriatrics nurse practitioner led the new consultation service. The team assisted with identifying cases, provided consultation early in the hospital stay, focused its evaluation on functional and psychosocial issues, and assisted in clinical management to optimize implementation of recommendations. In the first 4 years, the consultation service conducted 1,538 consultations in patients with a mean age of 81 (range 56–103). The most frequent geriatrics diagnoses were gait instability, delirium, and depression; recommendations usually included consulting physical therapy, increasing activity, and changing medications. The number of referrals and referring physicians grew steadily each year. Twenty-eight of 34 (82%) of the referring hospitalists completed a Web-based satisfaction questionnaire. All responding hospitalists agreed that proactive geriatrics consultation helped them provide better care; 96% rated the service as excellent. Analysis of hospital administrative data revealed a lower length of stay index and lower hospital costs in patients receiving a geriatrics consultation. The Proactive Geriatrics Consultation Service represents a promising model of collaboration between hospitalists and geriatricians for improving care of hospitalized older adults.     

Tropical Diseases in a Temperate Climate

A growing problem in this era of international mobility, these parasitic infections are less difficult to treat than they are to diagnose. Dr. Cahill discusses the appropriate diagnostic maneuvers when such an infection is suspected, describing in detail four of the most important entities currently prevalent in the U. S.     

Health care market trends and the evolution of hospitalist use and roles

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.