"The Hospitalist: a third alternative"

There has been some discussion in the pages of this Journal recently ^1,2 on the changing role of the acute care hospital and in particular the possibility of a new type of doctor, the "hospitalist". It is envisaged that in the hospital of the near future there will be fewer patients who will, generally, be more seriously ill than at present ³. Many other services, such as palliative care, day care surgery, surgical and medical convalescence and rehabilitation will be managed in the home or in other facilities. Leaving aside the likelihood of this scenario ⁴ it has been apparent to many that there needs to be a change in the role and experience of doctors who are employed in the hospital setting. This realisation is similar to that which saw emergency departments needing senior, not junior, medical cover and general practice/family medicine becoming a specialty in its own right. The proposed role of the hospitalist is one suggestion for this change.

We would like to bring to your attention the fact that this role is already in evolution and, indeed, currently functioning in a variety of clinical situations in the Australian Health System. The doctor delivering those aspects of seniority, experience and permanence relevant to a hospital generalist is a Career Medical Officer (CMO - NSW & SA). Other terms are in current use for doctors who also carry out this function include: Multi-Skilled Medical Officer (MMO - Illawarra region of NSW), Hospital Senior Medical Officer (Victoria) and Senior Medical Officer (SMO - Qld, W.A., NT) .

 

There are three interrelated parts to this discussion.

1. Is there a real need for such a doctor?
2. What would be the expected role of this doctor?
3. Who could best perform this role?


1. The need for the "hospitalist"


The present system of Visiting Medical Officer (VMO) who has overall responsibility for the patient and who delegates this responsibility to more junior medical staff in a hierarchical manner - registrars, RMOs etc - while out of the hospital, has a long history in medicine and is similar to the apprenticeship system in widespread use in society in the recent past. This model, while having some good features, has outlived its usefulness at the beginning of the 21st century.


There is increasing evidence of major inadequacies in the running of our hospitals⁵ and some part of the blame for this must lie with the way we organise our medical staffing. The major deficiencies are the (understandable) lack of experience of the junior medical staff and their rapid turnover. Most doctors would be horrified if the standard medical or surgical ward was run during the busiest parts of the day by junior nurses who were rotated to new positions on a regular basis. This is exactly what happens with the medical staffing of most wards in the modern Australian hospital. This outdated way of doing things has long caused problems with our nursing colleagues and others, who assist the overworked and inexperienced medical officer organise their time and energies to most effectively care for and investigate the sick patient - and then repeat this education at the next rotation.

Is it right to give increasing responsibility to junior doctors, but leave them effectively unsupervised, unsupported and responsible for major medical decisions when their level of training may be inadequate for the task⁶? The hospital wards would run more smoothly, there would be greater satisfaction by patients, nursing staff, consultant medical staff and, importantly, junior medical staff if there was rapid access to an experienced medical officer at all times. If this person was conversant with the dynamics of the ward - had good relationships with and an appreciation of the role of ancillary staff and had a relatively long-term commitment to the hospital it would address most problems before they became major problems.

2. The role of the hospitalist

It seems apparent from the articles by Hillman, and Scott and Phillips that their expectations are of placing another specialist physician into the increasingly fragmented world of hospital medicine. There are examples of this in the USA ^7,8,9 where the hospitalist is usually a specialist in internal medicine who works exclusively, or almost so, in the hospital setting. Physicians who work outside of the hospital hand over their responsibility at the hospital entrance and take it up again on discharge.

The unstated but underlying expectation is that the hospitalist would usurp the primary role and responsibility of the attending doctor. We believe this vision to be fundamentally flawed. On the one hand it sidelines doctors who should be involved intimately in the inpatient care of patients - including specialist physicians whose main area of practice is office based - on the other hand it misses out on providing a "new deal" of care for all the other (non-internal medical) patients who are in the hospital.

What this role demands is a not the narrow focus of the specialist but the broad-based knowledge of the generalist. Someone who can be a "jack of all trades". Both of the above articles appear to have as their central vision a hospital filled with medical patients (perhaps just about to have a cardiac arrest) or seriously ill surgical patients who would be better managed by a physician. Most hospitals have, and will continue to have a much wider range of patients and conditions - including all the major and minor problems that one finds in paediatric, gynaecological, obstetric and psychiatric wards.

We believe the role calls for a "middle management" doctor who has a breadth of knowledge and experience gained from working in hospitals - and who is as proficient in as many branches of hospital medicine as possible. Someone who is used to treating seriously ill patients expeditiously but also someone who is quite at home in managing the multiple minor problems that beset hospital patients. Someone used to consulting with a wide range of medical and surgical specialties as needed.

We believe the role should be complimentary to, not in confrontation with, the established Australian model of inpatient care. That is, it seems to us better to have an experienced doctor "on site" to organize - not take over - the management of the hospital inpatient. There is some evidence that hospitalists who have complete control of inpatient care increase, rather than decrease, the length of stay in hospital¹⁰.


In the model proposed, the consultant physician, surgeon, gynaecologist and perhaps increasingly, general practitioner would still have primary responsibility for the management of the patient, but would be actively supported by someone who had worked in the hospital system for a number of years and could competently manage most problems that may arise, at least for the short term. This doctor should also have the trust of and rapid access to the consultant staff as well as good working relationships with the nursing and paramedical staff - mutual respect of each others' roles and abilities - and have a good understanding of the "mechanics" (layout, routine, regular practices etc.) of the hospital.


3. Who best fills this role?

There are two views already described ^1,2 as to who best could manage this role - the intensivist or the general physician. On this point, it is interesting to note that, while the American literature generally refers to hospitalists as internists1¹ this is not necessarily the case¹². We would like to comment on the above two proposals and suggest a third alternative.

We believe that Scott and Phillips are right in having major reservations about intensivists being responsible for general ward patients. The prevention of a slow deterioration of a general medical or surgical patient to serious illness does not require the considerable skills of an intensivist - most doctors with experience and education, alerted by protocols that highlight dangerous trends can quite adequately look after these cases and refer to ICU or CCU if appropriate. The opposite and far more common scenario, that of a relatively minor (for an intensivist) problem may well lead to over investigation and treatment for conditions that are managed very well by broadly experienced medical officers such as Career Medical Officers. Although the general physician may have a better claim to this role, (and this is especially so with country physicians who really are, by necessity, well - rounded generalists) there is still the problem of a doctor who may be over-educated for some aspects of the work, and un der-educated for others. Further, if the general physician has private rooms (as most have) they will be often be unable or unwilling to leave these to attend a ward based problem.

Many of the problems outlined above have in the past been handled by registrars or RMOs. Although senior registrars are usually quite able to manage patients without the direct supervision of the VMO, this is not necessarily the case with more junior registrars and RMOs. Again, the problem of frequent rotation of terms takes out of the loop well performing doctors just as they attain a level of familiarity and experience with a particular group of patients. There is something wrong when seriously ill patients are primarily being cared for by relatively junior doctors.

Many modern private hospitals are turning to Career Medical Officers(CMO) to fill this gap in the care of hospitalised patients.¹³ Although doctors who performed similar roles had been in the health systems throughout Australia for many years, CMOs were initially brought into service in New South Wales in the early eighties to maintain experienced medical practitioners in the public hospital system, . These doctors were working in posts as unaccredited medical registrars or emergency medical officers, particularly in suburban and rural hospitals. Many CMOs have now been working in these positions for well over ten years and have developed considerable expertise in their area of practice.

Many are quite happy to continue to work in these roles and recently some have formed themselves into organised subgroups of the medical workforce. The largest of these (The Career Medical Officers Association - CMOA) is now taking responsibility for educational and industrial policies for CMOs¹⁴. While not confined to hospital work - some of these doctors work in community settings in areas such as developmental disability, psychiatry and
community care - many have years of experience in hospital work either in emergency departments or general ward work, and some also bring the broad experience gained from time spent in general practice¹⁵.

We believe that this broad-based experience is what makes the CMO the ideal person to take on the role of the hospitalist, and furthermore, the changes necessary to do this are relatively minor and merely a continuation of recent trends in medical manpower utilisation in the modern Australian hospital.

We note the invitation by Scott and Phillips to put the respective views of hospitalist practice to the test (in their case comparing the intensivist and general physician models via a randomised trial). Although we have some misgivings about the applicability of this methodology, we firmly believe that any rigorous evaluation of the various hospitalist models on offer would be incomplete without the inclusion of career/senior medical officers.

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REFERENCES

1 Hillman K. The changing role of acute-care hospitals. Med J Aust 1999; 170: 325-328

2 Scott I A, Phillips P A, Hospitals and hospitalists: an alternative view Med J Aust 1999; 171: 312-314

3 Braithwaite J. The 21st-century hospital. Med J Aust 1997; 166.6

4 Braithwaite J. Hindle D. Research and the acute-care hospital of the future Med J Aust 1999; 170: 292 - 293

5 Wilson RMcL, Runciman WB, Gibbert RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458 - 471

6 The Post Graduate Medical Councils (PMCs) in the various states provide increasingly good quality support for first and second year (PGY1 & 2) graduates - however this is in a logistical and educational rather than a directly supportive clinical role.

7 Wachter RM. An introduction to the hospitalist model. Ann Intern Med 130:4 Pt2 338-42

8 Sox HC. The hospitalist model: perspectives of the patient, the Internist, and internal medicine. Ann Intern Med 1999; 130:4 Pt2 368-72

9 Schroeder, SA Schapiro R. The hospitalist: new boon for internal medicine or retreat from primary care? Ann Intern Med 1999 130:4 Pt 2 382-7 medicine. Ann Intern Med 1999 130:4 Pt2 368-72

10 Jackson JL. The international experience with hospitalists; The Hospitalist Summer 1997 published on the National Association of Inpatient Physicians web page guest site (http://www.naiponline.org/) Accessed 6/12/99

11 Kelley MA. The hospitalist: a new medical specialty?; Ann Intern Med 1999 Feb 16 130:4 Pt 2 373-375

12 NAIP Affiliates with the American College of Physicians; http://www.naiponline.org/ Accessed 10th Nov 1999

13 Dr Stephen Delprado, Deputy Director ,Emergency Department, Hills Private Hospital. Personal communication

14 The Career Medical Officers Association website has many details of current interest for CMOs and others.
http://www.cmo.asn.au/ Accessed 14^th Dec 1999

15 Egan JM, King M: Presentation on career medical officers to the Directors of Clinical Training Conference,
Postgraduate Medical Council, Oct 1996, Sydney