When Dr. Joseph Li pinned his young career to a controversial new medical concept — doctors who treat patients only while they are hospitalized — he had a hard time explaining his job to patients.
"I'll be your hospitalist," he would tell them as they checked into Beth Israel Deaconess Medical Center. And they would look at him strangely, thinking he was talking about hospice care: "You mean you help people die?"
Patients still don't know the name of Li's field — these days he just tells them he is "a hospital doctor" — but five years after doctors like him were dubbed "hospitalists" by an article in a leading medical journal, the new breed of physicians represents one of the fastest-growing trends in medicine.
Now, a movement that some initially viewed as a cost-cutting scheme driven by insurance companies has five years of data to show that it doesn't harm patients, that it may help them — and that it saves hospitals $2.4 billion a year.
Hospitalists shorten the average patient's hospital stay by 16.6 percent and trim its cost by 13.4 percent, without sacrificing quality of care or patient satisfaction, according to a review of 19 studies, published in Wednesday's Journal of the American Medical Association.
And several of the reviewed studies found that hospitalists' patients were less likely to die in the hospital or to be re-admitted soon after going home, though the reviewers cautioned that the data are inconsistent. They said they believe hospitalists' focus on the hazards and complexities of inpatient care, such as the risk of infection, do benefit patients' health, but that broader study is needed.
"We haven't proven yet that we do better" at patient outcomes, said Dr. Sylvia McKean, director of the 15-physician hospitalist program at Brigham & Women's and Faulkner Hospitals. "But I think we've become highly respected."
For author Dr. Robert M. Wachter, associate chairman of medicine at the University of California San Francisco, the report is a triumph. In 1996, Wachter was first to embrace the hospitalist concept — a trend that was then creeping unnoticed across the country — in the New England Journal of Medicine. With hospital patients becoming sicker and their primary care doctors becoming more and more pressed for time, he argued, each hospital inpatient should be assigned to a doctor who spent all day every day in the hospital and was on call overnight.
The idea didn't evoke universal enthusiasm.
"You should be ashamed," one told Wachter. "My father would be turning over in his grave," said another.
They feared that switching a patient to a hospitalist would disrupt the doctor-patient relationship. Traditionally, patients checking into a hospital remain under the care of their own physicians, who visit the hospital briefly each day. In academic medical centers, they may also be under the care of attending physicians, specialists with their own practices who spend a month per year inside the hospital supervising the care provided by residents.
Hospitalists see patients only in a hospital setting. They have no off-site office.
There have always been a few hospital-based doctors, but they used to be seen as "second-rate doctors, who didn't have the professional skills or the social skills to build their own practice," said Li, the hospitalist at Beth Israel Deaconess.
Now Li, 34, hopes to build his career on the notion that hospitalists can lead the way in such hot areas as preventing medical errors and hospital-acquired infections, managing the complex hospital environment, finding the right transition to home care or rehabilitation, and providing palliative and end-of-life care.
After the initial objections, Wachter found that allies came out of the woodwork. As medicine changed, he said, it had become more difficult for outpatient doctors to find the time to visit the hospital, or to keep abreast of the proliferating tests and procedures their patient would need. And without calling themslves hospitalists, other doctors had stepped in to fill the void, some launching their own private hospital-based practices, others taking new staff positions hospitals were offering to "inpatient physicians."
At first, insurance companies tried to mandate the use of hospitalists, but the hospitalists themselves did not want that kind of support. The first official act of their three-year old professional society, the National Association of Inpatient Physicians, was to declare that primary care physicians should be able to choose freely whether to turn over their patients to hospitalists when they are admitted.
The association is now the fastest-growing professional group in medicine, with 2,500 members. There are now 5,000 hospitalists in the United States, and one study projected that by 2010, there will be 19,000, making them as numerous as today's cardiologists.
Ten of US News & World Report's 15 best hospitals now have hospitalist programs. Harvard's three largest teaching hospitals, Brigham & Women's, Beth Israel Deaconess and Massachusetts General, have them.
And hospitalists are beginning to gain the trappings of a medical specialty, following the path most recently treaded by emergency physicians, who now have their own residency programs, and board certification, Li noted.
Hospitalists probably won't be a recognized subspecialty for a while — they have yet to define their exact qualifications and work out their turf disputes with intensive-care physicians. But UCSF already offers a hospitalist research fellowship. Beth Israel Deaconess envisions a residency program someday. Wachter recently edited the field's first textbook, "Hospital Medicine."
And while patients may never have heard of the profession, they seem to like having their doctor a few steps away down the hall, ready to look at test results as soon as they are ready, rather than cooped up in an office miles away with a long list of appointments and paperwork. It also doesn't hurt to have a doctor who knows everyone else in the hospital and has access to what Wachter calls "the favor bank."
McKean, who has had specialty training in nephrology but chose to work as a hospitalist before the field had a name, said she is as busy as an overbooked primary care doctor but has more flexibility, because she has no predetermined appointment slots.
"If I want to spend an hour and a half with a patient, I can," she said.
Wachter said he was reluctant to ascribe his field's appeal purely to the decline of old-fashioned doctoring.
"Even Marcus Welby, (the television character) who had 30-year relationships with patients, who had gone to their weddings and bar mitzvahs, might have said today, 'I can only be here from 7:30 to 8:30 a.m."