Hospitalist

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I learned a new word today: "hospitalist".  The fist time I saw it, in a paper on "Determinants of Hospitalist Efficiency", I mis-read it as "hospital's", then realized it wasn't that, and thought it might be a really spectacular typographical error. But in fact it's a real word, coined in 1996 by Robert Wachter and Lee Goldman, which now gets nearly 34,000 hits on Google Scholar (where hit counts seem to be more or less believable).

What does it mean? Well, Dr. Wachter ("An introduction to the hospitalist model", Annals of Internal Medicine, 1999) explains:

Motivated by a search for improved quality and efficiency, increasing numbers of hospitals and physicians are moving from systems in which all primary care providers manage their own hospitalized patients or rotate this responsibility among themselves at infrequent intervals to voluntary or mandatory systems in which patients are "handed off" to the care of an inpatient physician, the "hospitalist." All hospitalists manage medical patients in the hospital. Other potential roles for these physicians include triage in the emergency department, transfer of "out-of-network" patients, management of patients in the intensive care unit, preoperative and postoperative management of surgical patients, and leadership in hospital quality improvement and regulatory work. Hospitalists may add value by being more available to inpatients, having more hospital experience and expertise, and having an increased commitment to hospital quality improvement compared with primary care providers. Potential disadvantages of the hospitalist model include loss of information as a result of discontinuity of care, patient dissatisfaction, loss of acute care skills by primary care physicians, and burnout among hospitalists. A variety of models of care are needed to meet the clinical, organizational, financial, and political demands of diverse health care systems. The favored model should be that which produces the best clinical outcomes and the highest patient satisfaction at the lowest cost.

The word was obviously formed by analogy with specialist, internist, gastroenteroogist, radiologist, opthamologist, urologist, psychiatrist, etc. This might suggest that hospitalists treat patients whose problem is a malfunction in the hospital — though maybe that's the point.

Hospitalist is in the OED, glossed as "Med. (chiefly U.S.). A physician specializing in the care of hospital in-patients.", and in Merriam Webster, glossed it as "a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians".

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22 Comments »

  1. Dick Margulis said,

    January 30, 2013 @ 11:47 am

    I've met more than one hospitalist. I think anyone who has had a family member admitted to a med-surg floor in the last decade or so has probably encountered the word. Consider yourself fortunate that you first ran across it in a paper rather than in a hospital room.

  2. Jenni Levy, MD, FAACH said,

    January 30, 2013 @ 12:07 pm

    Some hospitalists are nocturnalists.

  3. Jesse Sheidlower said,

    January 30, 2013 @ 12:07 pm

    Looks like it's in OED to me, with the definition "Med. (chiefly U.S.). A physician specializing in the care of hospital in-patients," and a first quote from 1971.

    [(myl) Oops -- looks like I carelessly misspelled it when I looked in haste this morning. Thanks for the correction.]

  4. Anonymous said,

    January 30, 2013 @ 12:19 pm

    I have heard medical professionals who are skeptical of hospitalists say that just as the cardiologist's job is to take care of the heart, and the pulmonologist is there to take care of the lungs, the hospitalist is there to take care of the hospital. I don't know if that's true, but I post the comment for its linguistic interest rather than its medical-ethics content.

  5. Steve said,

    January 30, 2013 @ 12:25 pm

    At the risk of stating the obvious, the thing that seems odd about "hospitalist" is that all the other medical -ists are specialists in a field of medicine, while "hospitalist" is not a speciality per se, but serve a specific a functional or adminstrative role. It seems more analogous to "primary care physician" (a role, not a specialty) or "attending physician" (which is also a role, not a speciality). It seems to be a sub-category (I'm tempted to say "sub-speciality", but that would just confuse things) of attending physician: a physician who attends a patient during a given hospitalization, whereas "attending physician" generally denotes a physician who follows a patient for a specific medical condition, often over a prolonged period of time, and who is often not, but who could be, the patient's primary care physician.

    I'm a bit surprised that the term wasn't modeled after either primary care provider or attending provider, i.e., something like "Inpatient Attending Provider", which would lend itself nicely to an acronym like IAP, just as primary care provider is often referred as PCP and the attending physician (or attending provider) is often dubbed the AP. Or simply "IP" (inpatient provider). Or they could have gone with a cutesy acronym like HAP (Hospitilization Attending Provider), TAP (temporary attending provider), STAP (short-term attending provider), and possibly even a C-CAP (chronic-care attending provider).

  6. Simon Wright said,

    January 30, 2013 @ 12:44 pm

    In the UK NHS, it would be highly unusual for your primary care physician (GP) to attend you in hospital.

  7. Ø said,

    January 30, 2013 @ 1:20 pm

    (@Steve: That's not what attending physician means.)

    These terms for specialized physicians are a hodge-podge, aren't they? Pediatricians and geriatricians are not called pediatrists or geriatrists (in analogy with psychiatrists and podiatrists). Podiatrists are not medical doctors at all. Internists (what an odd word! are they called that it in the UK?) are specialists in internal medicine, a specialty sometimes referred to (confusingly) by doctors as "medicine". Surgeons call themselves neither "-ist" nor "-ician", and the name of their specialty is also used in the UK for what is called a "doctors office" in the UK. Otolaryngologists are called ENTs, which means something else in Middle Earth.

    And then there are the plastic surgeons.

  8. Ernie in Berkeley said,

    January 30, 2013 @ 1:27 pm

    Around 1988 I was surprised to hear that a doctor "hospitalizes at Pacific Lutheran", meaning that this hospital is where he sends his patients.

    (and on a non-linguistic note, I can testify that "loss of information as a result of discontinuity of care" is a problem–during a week's stay at a hospital last year I was assigned three different hospitalists.)

  9. Rod Johnson said,

    January 30, 2013 @ 1:39 pm

    If a specialist has a specialty, the a hospitalist has a hospitality, right?

  10. Rod Johnson said,

    January 30, 2013 @ 1:43 pm

    Ø: According to Wikipedia, which is never wrong, "The term "attending physician" or "attending" also refers to the formal relationship of a hospitalized patient and their primary doctor during the hospitalization, as opposed to ancillary physicians assisting the primary doctor." Is that not what Steve is referring to?

  11. Graham Strong said,

    January 30, 2013 @ 2:14 pm

    In Thunder Bay, Ontario (Canada), the Hospitalist Program is designed to be a substitute for a primary care physician (i.e. family doctor or GP) for inpatients who do not have a primary care physician.

    This is important for a number of reasons. Say a patient is recovering from a heart attack. The cardiologist is obviously closely monitoring that patient while in hospital, but only from an acute care perspective. A hospitalist would take a more general approach, perhaps addressing reasons for the heart attack in the first place, like obesity, smoking, etc. He or she could refer the patient to community programs, connect with a clinic for primary care, and provide other services that normally would be taken care of by a family doctor.

    The program is designed to increase continuity of care, and perhaps more importantly decrease re-admissions.

    The top story here has more info:

    http://www.healthsciencesfoundation.ca/upload/documents/cj-april-28-2011.pdf

    ~Graham

  12. Ted said,

    January 30, 2013 @ 3:42 pm

    Ø:

    Surgeons call themselves neither "-ist" nor "-ician

    Unless they're opthalmologists, or gynecologists, or obstetricians, or urologists, or orthopedists, or otolaryngologists — all of which are surgical specialties.

  13. G said,

    January 30, 2013 @ 4:25 pm

    Wow. I'm surprised that some commenters know very little about medical hierarchies. As a doctor this has implications for how I introduce myself!

    Primary care refers to the first level of care in the community. Family physicians in the US, general practitioners in the UK (who work in a surgery).

    Attending refers to the highest level of doctor, who is in charge of all the other doctors on his/her team and takes ultimate responsibility for his/her patients. In the UK this is known as a consultant.

    By definition one cannot be a primary care physician and an attending/consultant. In the UK at least, those are equivalent in terms of seniority and after a period of post-graduate training (5 or 8 years) is the final destination for medical graduates.

    And it's orthopods.

  14. Keith M Ellis said,

    January 30, 2013 @ 5:58 pm

    By definition one cannot be a primary care physician and an attending/consultant.

    Not precisely by the definition of primary care you provide, nor by some inherent necessity, as you imply. Your idea of a primary care physician sounds suspiciously equivalent to the lowest-status, lowest-authority practictioner, not unlike a field medic or nurse practitioner or a physician's assistant — someone who provides the most common, well-understood care and triage as first-point-of-contact and refers everything more difficult to more, er, competent caregivers.

    An alternative view of a primary care physician is one that is exactly equivalent to your definition of an attending — the physician with ultimate responsibility for the patient, coordinating care among specialists.

    Of import in this is that your model provides someone acting in that "attending" role only within the context of intense, acute care, such as during surgery or hospitalization. Outside that context, there is only your low-status antiobiotics-prescriber and no one playing the coordinating, authoritative role. In my model, there's always someone in that coordinating, authoritative role which, not coincidentally, is also an impetus for PCP's to delegate the routine antiobiotics-prescribing and such to … empowered nurses and physician's assistants and similar.

    There is a clear need for a provider to play that coordinating, authoritative role in contemporary systems like the US's where patients are seeing, on a regular out-patient basis, numerous specialists. And I think it it also clear that it is counter-productive for the physician with regular interaction with the patient and the greatest awareness of the patient's medical history to become increasingly lower-status relative to other physicians. That this is the case is an accident of history of the increase in prevalence and status of specialists that simply marginalized PCPs without redefining that role.

    I don't really object to your explanation of the nuances of these terms in actual practice; I just don't much like what I think is the implication that this is some platonic ideal. Put another way, you have it backwards: in practice the two terms are usually exclusive. But there's no reason why by definition a PCP could not play that attending physician role. Looking at Merriam-Webster's online entry for primary, for example, I see that two of the four definitions emphasize the "first in a series" sense, while the other two emphasize the "first in importance" sense.

  15. Jenni Levy, MD, FAACH said,

    January 31, 2013 @ 9:15 am

    "Attending physician" has two meanings. *An* attending is a fully qualified doc (as distinct from a resident or fellow, still in training). *The* attending is the physician who is ultimately responsible for the patient's care in any setting, or is the most senior physician of a team.

    I have been *an* attending physician since I finished residency in 1989. When I see patients in the hospital in my current role (palliative medicine consultant) I am not *the* attending for that patient, but I am *the* attending for the palliative care team. In my outpatient role as a hospice medical director, I am *the* attending for about 30% of our patients; the other patients are followed by their own doctors.

  16. Mark said,

    January 31, 2013 @ 9:16 am

    My mother is hospitalized. The doctor that is ultimately responsible for her care and to whom the specialists defer on treatment is her primary care physician.

  17. John said,

    January 31, 2013 @ 8:51 pm

    During a hospitalization a few years ago, I dealt with a hospitalist at my highly rated local hospital. I showed up in poor condition and it took a while before the vast array of doctors could figure out what was going on. I was seen by doctors specializing in heart, liver, kidney, gall bladder, diabetes, and, I'm sure, a few others. The hospitalist's role was to have been the central mediator of these specializations, coordinating their functions and relaying that to me, the patient.

    In the end, it turned out to be an E. coli infection that simply wreaked havoc across many systems. This was announced to me, by an infectious disease specialist, 30 minutes before a scheduled gall bladder operation and 60 minutes before being discharged from the hospital.

    As this was my sole experience with a hospitalist, I can't speak in general. This one provided no added value. He did, however, try hitting up my wife. And yes, he billed separately, outside the hospital's insurance coverage.

  18. David said,

    January 31, 2013 @ 9:19 pm

    It's on the always-fascinating O-net (dictionary of occupational titles):
    http://www.onetonline.org/link/summary/29-1069.03

    One of the faster-growing occupations, 691,000 U.S. employees in 2010 and 300,000 projected openings in 2010-2020.

  19. John Swindle said,

    January 31, 2013 @ 10:50 pm

    @Ernie in Berkeley: You had three different hospitalists; what I found as a patient was that they worked in shifts (as Jenni Levy, MD, FAACH, noted). Their specialty, if I'm not mistaken, was "hospital medicine," like emergency medicine.

    @G: We're agreed that "orthopod" is informal and in-groupish?

  20. Milan N. said,

    February 1, 2013 @ 9:35 am

    To me it would have been certain that a hospitalist is one who suffers of hospitalism. (cf. http://en.wikipedia.org/wiki/Hospitalism)
    Probably that's because "Hospitalismus" is used quite often in my native (German) language to colloquially denote a state of restlessness one is overcome with after being in a closed room for several hours and doing only unsatisfying work.

  21. Alex said,

    February 3, 2013 @ 3:41 pm

    The first time I encountered the word "hospitalist," it took me a few seconds to realize it probably did not refer to a member of the famous order of crusader knights, the Hospitalers. Who were apparently founded to provide hospitality to sick and poor pilgrims in the Holy Land. It was a funny image, though. I suppose a lot of hospitalized patients would like a crusader on their side.

  22. Maneki Nekko said,

    February 11, 2013 @ 3:22 am

    Similarly, physicians who specialize in intensive care like to be called intensivists.

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