Renaissance of hospital generalists

Factors driving the growth of the hospitalist and acute medicine

The American hospitalist is a generalist physician who is responsible for patients throughout their hospital stay—not only in medicine units but often in intensive care units, “step-down” units (high dependency units in the UK), and surgical units (where the US model is known as co-management).3 6 Many studies have found that hospitalists significantly decrease lengths of stay and costs without harming quality and patient satisfaction.6 7 8 9

In addition to the generally favourable outcome data, several other developments in the US promoted hospitalist growth. When hospitals came under pressure to improve their quality and safety, hospitalists embraced these tasks and became recognised leaders in them.3 10 And after regulators capped the working hours of residents (known as specialty registrars in the UK) in 2003, hospitalists filled the gaps. As hospitalists became established, many primary care doctors withdrew from hospital care, judging their skill set or availability to be insufficient or that the economics of attending hospital were unfavourable. Finally, because most US hospital stays are reimbursed with a fixed payment (based on diagnosis) per admission, hospitals benefited from savings in cost and length of stay generated by hospitalists and were therefore willing to provide financial support for hospitalist programmes.

The care model in the UK has led acute medicine to assume a different shape. Patients are referred to hospitals by general practitioners to see subspecialists (for elective or urgent consultations) or as an emergency.11 Patients admitted to hospital from an emergency department or referred by a general practitioner would in theory be placed on the ward best able to manage their primary problem. Given the prevalence of multisystem diseases and the fact that wards are often full, misallocation was a problem. For example, a patient with asthma or heart failure might be assigned to a gastrointestinal unit, where care would be overseen by the doctors on that ward (with or without specialist input) or by the correct specialist team visiting the ward. In either case, such mismatches are likely to compromise the quality and efficiency of care.12 Even when patients were on the “right” ward, many had comorbidities that required other medical or nursing expertise.

Acute medicine emerged in an effort to improve the early management of acutely unwell medical patients.2 13 14 15 In the US, most hospitalists (80%) are general internists, who need not obtain additional training or certification to practise as hospitalists. However, because general internal medicine had been declining as a specialty in Britain for a generation, acute physicians were initially drawn from a variety of specialties, most commonly chest medicine, nephrology, and intensive care medicine.11 16 A four year training programme in acute medicine was introduced in 2003.

Acute physicians focus on the first few days of hospital care, usually managing patients within an acute medicine unit, obtaining specialty input as needed. Unlike the US, where the hospitalist remains the responsible physician until discharge (table 1⇓), UK patients not discharged home within 48-72 hours (in practice, about 50% of patients) are routinely transferred to the most suitable specialty ward.17

Just as in the US, where the hospitalist growth was promoted by national policies, acute medicine has been buoyed by two national policy initiatives. Firstly, the introduction of a maximum four hour stay in emergency departments in 2002 promoted the appointment of acute physicians to improve the running of acute medical units.18 Secondly, the European Working Time Directive required UK training programmes to reduce the duty hours of registrars to 58 hours/week in 2004 and then 48 in 2009.19 As in the US, these restrictions created a vacuum that was partly filled by acute physicians working in acute medical units, particularly in routine hours.5

Theoretical and empirical rationale

In both the US and UK, economic pressures, combined with the increasing availability of sophisticated diagnostic testing (such as computed tomography) and therapeutics (such as intravenous antibiotics administered at home), have driven more complex care into the outpatient setting. The result is that the average patient in hospital is now older, has more comorbidities, and takes more medications than before. Moreover, healthcare leaders now appreciate the need to re-engineer systems of care to achieve the highest quality, safety, and efficiency. Hospitalists and acute physicians are well placed to deal with both of these challenges through their expertise in managing complex patients, focus on the hospital setting, comfort in leading multidisciplinary improvement teams, and adoption of performance improvement skills as core competencies.1 3 10

Although some growth has been driven by these organisational imperatives, research evidence has also been critical. Hospitalist care has been shown to reduce hospital lengths of stay and costs, for both medical and surgical patients (although some costs may shift to outpatients).6 7 8 20 Other evidence shows that medical education improves, patient satisfaction is neutral, and the effects on quality are mixed.6 7 8 9

Acute medical units in the UK have been associated with lower inpatient mortality, improved patient and staff satisfaction, reduced hospital stays, and increased throughput.14 15 21 Although there are no controlled studies comparing generalist care with subspecialty care, there is good evidence that generalist care is less expensive.22 Specialist care for patients with certain acute problems (such as stroke or myocardial infarction) has advantages over generalist care,23 but a US study showed that when mismatches occurred (such as a gastroenterologist caring for a patient with heart failure) both costs and mortality rose substantially.24 Providing guideline concordant care for every disease in patients with multiple illnesses is difficult and can lead to polypharmacy, a further argument in support of a generalist coordinator for patients with multiple conditions.25

Influence of healthcare systems

Hospital medicine and acute medicine both emerged in response to the desire to re-establish the role of a generalist coordinator for acutely unwell patients in hospital. Both specialties have positioned themselves as leaders in direct clinical care and systems improvement, both have thriving specialty societies, and both have experienced extremely rapid growth.

Nevertheless, the two specialties have some important differences. Hospitalist programmes in the US average about 10 physicians; some large hospitals have over 40 hospitalists.3 This is far larger than in the UK, where the number of acute physicians in a hospital averages three, up to a maximum of 7-8.2 14 This difference is partly explained by the broader scope of hospitalists, who care for patients throughout their hospital stay and provide 24 hour cover (table⇑). Most US hospitalists also co-manage surgical patients, in some cases assuming the role of responsible physician postoperatively (with the surgeon acting as consultant).6 By contrast, most acute physicians in the UK provide comprehensive care for only the initial phase of hospital treatment, occasionally including surgical patients with medical problems, and do not provide resident cover at night.

Another reason for the smaller numbers and more restricted scope in the UK is the requirement for specialty training in acute medicine and the limited number of training and certification programmes, although these have increased in recent years.

While their overall scope is narrower, acute physicians carry out several activities uncommon among US hospitalists. For example, few hospitalist programmes have the equivalent of the admission avoidance or complex care ambulatory clinics that acute physicians staff. Moreover, acute physicians are required to obtain at least one specialty skill (such as endoscopy, echocardiography, or an educational diploma) to obtain their specialty qualification.16 No such requirement exists in the US.3

The relative absence of centralised planning and the dominance of market forces in determining the US workforce has also contributed to the differences between the two countries. Hospitalists’ unprecedented growth was not accompanied by, nor did it depend on, changes in federal regulations, payment policies, or early endorsements from key professional associations or certifying boards.3 However, the UK’s tight control over its physician workforce—exercised through training programmes and NHS consultant positions—meant that acute medicine required early endorsement by key national bodies, the development of training slots, and major changes in payment policies and hospital unit structures.5 11 13 16 Any expansion of the role of acute physicians beyond the acute medicine unit would need to take account of the displacement of other hospital specialists, since consultants hold lifelong NHS employment contracts. Few such contracts exist in the US, permitting more rapid change, with all of its benefits and challenges.

Cross learning

Hospital generalists in both the UK and US have cause to look wishfully at their colleagues across the Atlantic. For a US hospitalist looking at acute medicine, the localisation of the acute medicine unit is enviable (hospitalists often care for patients scattered around the hospital), and the requirement for an additional skill and participation in specialised ambulatory clinics may add value and prevent burnout. For a British acute physician, the greater size and scope of the hospitalist’s domain seem attractive, as does the avoidance of a mandatory handover to a subspecialty ward after an arbitrary period.

It seems inevitable that hospital medicine and acute medicine will continue to grow and evolve. While recognising that they will always be shaped by local forces, we also believe that they should learn from each other’s experience. Cross-Atlantic dialogue will increase the chances that each system meets its goals.