by Gretchen Decker

A former guidance counselor from Niagara Falls, Janowski takes pride in his knowledge of jobs and career paths. This trip to the hospital, he was introduced to a new kind of specialist: the hospitalist. Simply put, this internist works only in the hospital, providing care and services to hospital patients for the duration of their stay -- care traditionally delivered by a patient's primary care physician (PCP).

The hospitalist team at Emory Dunwoody Medical Center was the first to suspect there was nothing simple about Janowski's hip fracture. After many tests, Janowski was diagnosed with a rare bone cancer that had weakened his hip and made it prone to fracture. During a prolonged stay in the hospital and several surgical procedures, the hospitalist team stuck with Janowski, managing his diabetes, hypertension, and heart disease.

The hospitalist was born in response to increasing demands on physicians' time. Members of physician groups began taking turns seeing patients in the hospital, freeing their colleagues to attend to outpatients in the office. Today, hospitalists are paid by physician groups that contract with the hospital, by insurers, by managed care organizations (MCOs), or are often subsidized by the hospital itself. In systems such as those in place at Emory Hospitals, the choice to use a hospitalist's services is left in the hands of the community doctor.

Often misrepresented as a tool of MCOs, hospitalists employed by these organizations make up only 14% of hospitalists in the United States. In effect, some hospitalist programs evolved in reaction to MCO market dominance. PCPs, under increasing pressure from insurance companies to keep costs down, admit fewer patients to the hospital. Meanwhile, the PCP is under pressure to see more patients at the office, often due to capitated fee structures. It makes economic sense for PCPs to free themselves to see more patients in the outpatient setting.

"The growth of hospital-based medicine is a natural fit," says Williams. "Take Mrs. Smith who's taken to the ER in the middle of the day with pulmonary edema. Her PCP is called to admit her to the hospital, and he has to go across town to do that. Meanwhile he has a waiting room full of 25 patients, who are getting more impatient by the minute."

Instead of fighting traffic, under the EHCA program, the PCP can "hand off" the patient to a hospitalist, who will admit the patient to the hospital and care for the patient during his or her stay, consulting with specialists and the PCP as necessary. The PCP, in turn, is able to focus on the patients in his office practice. The hospitalized patient returns to the PCP's care upon discharge.

Inpatient physicians have been an integral part of European and Canadian health care systems for years. But in the United States, hospitalists were not seen until the late 1980s and early 1990s. These new doctors were known as "inpatient specialists," "inpatient physicians," "hospital managers," or "inpatient consultants," and their job duties were as varied as their titles.

Because of the grass roots nature of the hospitalist movement, no one knows how many hospitalists there are. Some at the National Association of Inpatient Physicians (NAIP) estimate between 4,000 and 5,000; others think the number may be two or three times that. The Universe Project, led by NAIP, is attempting to solve the riddle by tracking the explosive growth of hospitalists since 1994.

About the same time that Grady was starting the UCC, Bob Wachter, associate professor at the University of California San Francisco (UCSF) and chief of medical services at Moffitt-Long Hospitals, published "The Emerging Role of Hospitalists in the American Health Care System" in the New England Journal of Medicine. In the article, Wachter coined the term "hospitalist" and detailed the benefits of rethinking the traditional role of the internist as the sole provider of patient care in both the inpatient and outpatient setting.

The emerging hospitalist system described by Wachter dovetailed with the philosophy of Grady's UCC. Creating resources within the hospital to deal with the internal medicine needs of inpatients would benefit the entire system immensely, Williams believed. Why not develop a similar program at Grady?

Williams felt that patient quality of care would improve because inpatient physicians based at Grady would be more available to analyze tests, diagnose, prescribe, and respond quickly to clinical changes in patients. Grady would save money by decreasing patient length of stay. A hospitalist's ability to respond quickly to patients' needs would speed patients through the complex medical system.

The administration at Grady was enthusiastic over the prospect of having physicians focus on inpatient care, and in July 1998, Grady initiated the first US hospitalist program in a public hospital. Grady currently has 11 hospitalists and two hospital medicine fellows on staff.

A hospitalist program in the Emory system, though, was not without precedent. Even before Grady established its program, Emory's Crawford Long Hospital (CLH) recognized the benefits of having in-house physicians but took a different approach in providing those services. Hospital Admissions Services, the CLH hospitalist program, contracts with a private physician group, directed by community physician Jacinto Del Mazo.

At the time of the announcement, HCA (formerly Columbia/HCA) was trying to implement a hospitalist system of its own to compete with well-established programs at DeKalb Medical Center and Piedmont Hospital as well as newer programs at CLH, Southern Regional, Northside, and Wellstar hospitals. Clearly hospitalist programs were becoming the standard in the Atlanta area.

Just as HCA was about to sign a contract with another group, Williams submitted a proposal that became the basis for one of the first joint initiatives of the EHCA alliance. The EHCA hospitalist program started in July 1999 at Emory Dunwoody and Emory Northlake medical centers. Currently, 13 hospitalists cover five EHCA hospitals: Emory Dunwoody, Emory Northlake, Emory Parkway, Emory Cartersville, and Emory Eastside medical centers.

Ko soon discovered that her experiences with acute care and the care delivered by hospitalists was a perfect fit. "I wanted to treat complex medical problems in critically ill patients," she says. "I thrive on treating an acutely ill patient and then seeing that patient walk out the door. A hospitalist focuses more on critical care as opposed to the management of existing problems that can be treated in an outpatient setting. Of course, we see a lot of high blood pressure and diabetes, which contribute to other problems."

Unchecked chronic conditions often land patients in the hospital. Recently, a patient was brought to the Emory Northlake emergency room because her family was concerned about her lethargy and general drowsiness, a symptom of diabetes gone out of control. The ER doctor immediately referred the patient to the hospitalist team. "Her blood sugar was about 10 times the normal limit," says Ko. Noting other blood chemistries that were severely out of balance and a skin boil on the patient's foot, Ko ordered x-rays. They revealed what Ko had suspected: the patient had gas gangrene, a potentially life-threatening skin condition common among diabetics. "We quickly placed a call to the surgeon, who agreed that prompt surgical intervention was necessary. After the patient was stabilized, she was taken to the OR where her foot was amputated. Afterward, we continued to monitor and treat her diabetes and other medical problems."

Ko is one of a team of four hospitalists who cover Emory Dunwoody and Emory Northlake around the clock. Each physician works a 12-hour block for four days in a row and then has four days off. Physician assistant (PA) Denise LeDoux assists five days a week.

Like an interpreter at the United Nations, the hospitalist must keep the channels of communication open. On a typical day, the key to a successful hospitalist program begins at 7 am when Ko and LeDoux meet with the night-shift hospitalist in a small office tucked away at the end of the first-floor Emory Dunwoody patient ward.

After comparing notes and sharing any changes that occurred during the night, the night-shift doc goes home, Ko starts rounds in the intensive care unit (ICU), and LeDoux makes her rounds on the patient ward. Ko follows up on any of LeDoux's pertinent findings, conducting her own physical examination of the patient if necessary. Meanwhile, LeDoux drives to Emory Northlake to check on patients there, and Ko soon follows. At Emory Northlake, the entire process begins again.

On light days, the hospitalists care for 12 to 15 patients between the two hospitals. During cold and flu season, they are responsible for sometimes as many as 40 patients. Most are discharged within 24 to 72 hours.

At Emory Dunwoody, the ICU's six beds are often full, with at least five patients under hospitalist care. If nearly all the patients there could use the services of a hospitalist on any given day, it's more than likely that patients elsewhere could use hospitalist services as well.

"For example, a patient with a hip fracture is often elderly and will have multiple medical problems. The hospitalist cares for all of these conditions -- diabetes, heart medication, high blood pressure -- while the surgeon takes care of the hip," Williams says.

The Mayo Clinic has developed a hospitalist unit known as HOT -- the Hospitalist Orthopedics Team -- to specifically address this common scenario. Other hospitalist specialties are emerging as well in areas such as pediatrics, cardiology, and end-of-life care.

Hospitalists carry a much higher critical care patient load than most community-based physicians. And hospitalists may have better outcomes treating inpatients than community-based physicians. Published research demonstrates a decrease in the readmission rate of patients discharged from hospitalist services, and preliminary data from UCSF researchers indicate a reduction in mortality among hospitalized patients cared for by hospitalists compared with PCPs.

"These findings are consistent with other studies showing that when AIDS patients are under the care of a physician specializing in AIDS, you have a reduction in mortality," says Williams. "It's simple: the more experience you have with certain conditions, the more you build up your knowledge base, and you become better at treating these conditions."

Internists like Williams and Ko see severe pneumonia, complications of diabetes, strokes, heart attacks, respiratory failure, and gastrointestinal bleeding -- all diseases that Williams calls, "the heart of medicine" -- on almost a daily basis. And Williams posits that eventually hospitalized patients will insist on the care of an inpatient physician when they are admitted to the hospital, much in the same way that folks who have suffered a heart attack demand the services of a cardiologist.

Although Janowski was rushed to the ER with little preparation for his new team of doctors, he noticed almost immediately that his experience at Emory Dunwoody was different from other hospital stays. "There was always somebody available when I had a question," says Janowski. "The doctors and staff at Dunwoody took a real personal interest in me and my family."

In general, hospitalist programs contribute to greater patient safety simply because a hospitalist is on site around the clock and entirely focused on inpatient care. At the same time, two new handoffs -- one at the time of admission and one at discharge -- have the potential to introduce medical errors due to loss of information.

The most vulnerable area in this chain of events is communication. To protect against loss of information, hospitalists must contact the PCP to determine a patient's previous procedures and medications as well as the PCP's preferences.

Partly because hospitalist programs were created as a service to PCPs, "accountability falls on the shoulders of the hospitalists," says Bill Bornstein, associate administrator and chief quality officer at Emory Hospitals. "A hospitalist must find out and respect the PCP's preferences and rationales."

Williams agrees, "If necessary, we are in daily contact with the community physician if the patient's condition is changing rapidly, and we always talk to the community physician on the day of discharge to relate instructions, medications, and diagnoses. The collaboration between the two groups, the inpatient and outpatient physicians, is crucial."

Bornstein speculates that access to hospitalists improves patient safety because staff can easily follow up with a physician with questions about a doctor's orders. "Overall, the net effect of greater patient safety rationalizes these two new handoffs introduced by hospitalist programs," he says.

For LeDoux, a former PA on a cardiology floor at Emory University Hospital (EUH), working with a hospitalist team has changed the nature of her job. "The best part of my job now is not having to go back and forth between offices," says LeDoux. "Before, I would make rounds in the morning and then rush back to the office to see outpatients all day. Then I would have to go back to the hospital and do follow-ups and make phone calls. Here I'm able to really concentrate, spend more time with patients, do any necessary follow-up right away, move them through the hospital a little faster, and I never feel like I have to rush things."

Ava Cabal, a longtime bedside nurse at Emory Parkway, echoes a similar sentiment. The hospitalists' around-the-clock availability has made her job easier. "They're very approachable and easily available. And they remember our names. Now, in the morning when I come in and read lab results, if I see that a patient's hemoglobin is low, I can contact the hospitalist right away and get orders on the patient. They always answer their pages right away."

Maria Kulma, the chief nursing officer at Emory Parkway, says hospitalists challenge nurses and vice versa. "Nurses may make rounds with the hospitalist, making it more like a partnership in which both sides learn," says Kulma. "It also provides an added sense of security for the nursing staff. There is continuity of care in real time."

Mark Harris, a neurologist with Georgia Neurology Associates, is an avid supporter and client of the EHCA hospitalist program. "The doctor is always in," says Harris. "As a specialist, it's a relief knowing that the hospitalist can admit a patient who presents in the emergency room with both medical and neurological problems. Patients are seen and evaluated immediately, enabling me to participate in a consultative role. This makes me more efficient and effective in caring for all my patients."

Not all community doctors feel that way. Some are leery of the EHCA program, especially those who depend on revenue from patient hospitalizations.

"Some of my internist colleagues are reluctant to work with hospitalists," says Harris. Their reluctance stems from misperceptions about how the voluntary EHCA hospitalist system works. Many are concerned that they won't be able to maintain control of patient care and that over time they may lose their skills for managing the kinds of problems they see in the hospital. Others worry that their patients will not be referred back to them after discharge and will be sent instead to other Emory system doctors.

Harris says better education and communication will encourage physicians to participate in hospitalist programs. EHCA plans to follow up its earlier group meetings with physicians at each of the hospitals and provide community practitioners with ongoing information about the benefits of the hospitalist programs.

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Williams, a tall man with an almost boyish eagerness, is convinced that hospitalist programs are the greatest innovation since sliced bread. But the jury is still out. It seems likely, though, that whether you view the system as boon or bane, the hospitalist movement is an innovation of the American health care system that's here to stay.

Gretchen Decker is editorial associate and production manager of Momentum magazine.