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Hospital Checkup

Doctor Knows Best--but Which Doctor?

Health care: For many hospitalized patients, in-house physicians are displacing regular doctors. Experts are divided on the benefits of the trend.


Anurita Mendhiratta leaned close to the bedside of stroke patient Richard Bryan and asked him whether his right side still felt numb. Then Mendhiratta, an internist with Kaiser Permanente, told the 72-year-old Rockville, Md., resident that he would need to spend several more days in the hospital, so that doctors could carefully monitor the levels of a blood-thinning drug he was taking.

"I'll be here every day for the rest of your hospital stay," she said, handing a business card bearing her beeper number to Bryan, whom she had just met, and telling him she would stop by later to see him.

Bryan has a regular Kaiser internist, but she did not take care of him when he was admitted. Once the retired federal worker was hospitalized, his care became the responsibility of Mendhiratta and her colleagues--members of a new medical specialty known as hospitalists.

Like Mendhiratta, most hospitalists are internists who treat and manage the care of other doctors' patients only while they are in the hospital. When patients are discharged, the hospitalist transfers their care back to their regular physician.

Generations of internists and family practitioners have shuttled between their offices and hospitals to care for patients in both settings. For years doctors have been taught that this duty is sacrosanct and that their patients are their responsibility.

"The idea of having a [hospital] physician principally responsible to inpatients who don't have a physician is not a new idea," said John M. Eisenberg, an internist and director of the federal Agency for Health Care Policy and Research.

Patients who show up in an emergency room without a doctor long have been assigned one by the hospital. "What's new is transferring the care of patients who do have a primary-care physician to another doctor while they're in the hospital. Most internists have been taught that once a patient comes to see you, you are that person's shepherd, guide, whatever, and that this is a very special relationship which may last a lifetime."


That notion, like much else in health care, is changing rapidly as managed-care companies, hospitals and growing numbers of primary-care doctors embrace the hospitalist concept, long employed in Great Britain and Canada.

Armed with data showing that hospitalist programs can reduce the length of hospital stays without triggering an increase in readmissions, some of the nation's largest managed-care companies are instituting such programs as a way to improve efficiency and cut costs. Hospitalist programs also enable doctors who choose office-based primary care to see more patients because they no longer have to divide their time between their offices and one or more hospitals.

There can be advantages for patients and their families as well.

"When I give patients my card with my pager number, they say, 'You mean you're here all day?' " said Paul Aronowitz, a hospitalist at California Pacific Medical Center in San Francisco. "The advantage is that they have a doctor readily available." Most physicians with an office practice make rounds once a day, often at dawn, then head for their offices, where they are difficult to reach because they are seeing patients. Aronowitz said he sometimes meets with patients and their families three or four times a day.

A fledgling organization for hospitalists, the National Assn. of Inpatient Physicians, founded last year, now claims about 1,500 members, says co-founder John R. Nelson, a Florida hospitalist. The burgeoning demand for such doctors has prompted UC San Francisco, one of the pioneers of the hospitalist movement, to launch a training program for residents interested in hospital-based careers.

In the past few years, hospitalist programs have sprung up in a score of cities, including Washington, D.C.; San Francisco; Tampa, Fla.; Philadelphia; Baltimore; Atlanta; and Chicago. Some insurers, among them Kaiser, Humana and Aetna-U.S. Healthcare, are requiring that in certain cities primary-care doctors hand over their patients to hospitalists. Such requirements typically have met with staunch resistance from some physicians who say they fear being squeezed out of hospitals and worry that care of their patients will suffer.

"My expectation is that many, many hospitals will be doing this in the next few years," said Hernan Padilla, executive director of Kaiser's Hospital Services Management Division.

Eisenberg, whose agency is funding a study of the impact of the hospitalist system at UCSF, has mixed feelings about the concept. "I'm very concerned about what it does to communication and the continuity of care," said Eisenberg, formerly chairman of the department of medicine at Georgetown. "Losing that personal physician and that continuity is a serious risk to the quality of care provided in the hospital."

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