Gunderman: Beware the advance of the hospitalist

Hospitals cannot function without physicians, but physicians can function without hospitals. Those are plain facts—the latter is demonstrated daily in war-torn parts of the world—and the observation ought to give pause to those looking to quicken the rise of the hospitalist specialty in U.S. healthcare.

So contends the influential radiologist Richard Gunderman, MD, PhD, of Indiana University in an opinion piece published online Aug. 10 in the New England Journal of Medicine.

The piece has been driving a lively combox discussion ever since.

The hospitalist model may well be making good on its promise to reduce readmissions and lengths of stay while helping coordinate care across specialties, Gunderman allows, but at what cost to care quality?

For one thing, this model necessarily concentrates on inpatient care. As a result, it may have an incurable blind spot when trying to integrate what happens, or doesn’t, in outpatient settings.

“As members of a young field, many hospitalists have relatively little experience with outpatient medicine, a deficit that’s exacerbated by hospital-only practice,” Gunderman writes. “Physicians who never see outpatients are at a disadvantage in understanding patients’ lives outside the hospital. Over time, hospitalists may become progressively less accountable to nonhospitalized patients and their communities, ultimately becoming less effective advocates for comprehensive medical care.”

At the same time, many if not most hospitalists are employed by hospitals or work at only a single hospital. Gunderman cautions hospital leaders against creating purely monetary incentives—which, by definition, “are not always well aligned with the best interests of patients and communities. … [H]ospital marketing may encourage patients to suppose that their relationship with the hospital is more important than their relationship with any particular physician.”

Paradoxically, even hospitals suffer in some ways from the hospitalist model. That’s because, as community physicians relinquish their hospital privileges, the number of physicians on hospital medical staffs tends to decline, Gunderman writes.

“Fewer and fewer physicians in the community ever set foot in the hospital, let alone participate in its decision making,” he writes. “As a result, hospital leaders can become less informed and engaged with the needs of their community. In settings where community physicians have functioned as effective advocates, the loss of their voice can widen the gap between hospital policies and community needs.”

Gunderman concludes:

“To position the hospital at medicine’s center is to create an unbalanced system, one that will continually jar both patients and the health professionals who care for them. The true core of good medicine is not an institution but a relationship—a relationship between two human beings. And the better those two human beings know one another, the greater the potential that their relationship will prove effective and fulfilling for both. Models of medicine that ensconce physicians more deeply in spatial and temporal silos only make the prospects for such relationships even dimmer.”

In the comboxes, Mike DeMatteo, MD, a hospitalist at Baystate Medical Center in Springfield, Massachusetts, calls Gunderman’s opinion “bunk.”

“Hospitalists are a solution to a screwed-up national health system, not the problem itself,” DeMatteo writes. “And nurses make the hospital work, not doctors. This is the most revealing and inaccurate bias (of which there are many) in the entire piece.”

Meanwhile San Francisco-based hospitalist Deborah Chiarucci, MD, of Kaiser Permanente answers Gunderman’s salvo by listing some points of value that her profession adds for both physician peers and hospital patients.

“We attend for residents. We manage patients post cardiac and orthopedic surgery, consult with general surgery, urology, ENT, gyn,” Chiarucci writes. “I might get called for a patient having chest pain, neurological changes after a stroke, increasing shortness of breath. I am there at the bedside immediately. The quality of care for the hospitalized patient has improved markedly. Hospitalists are needed and are here to stay.”