Q&A 004 Who is the Hospitalist?

⏱ 9 min read

Dr. Hayes Q&A · No. 004

By Eleanor Hayes, M.D. · Hospitalist

The Question

“I was in the hospital four days with pneumonia. The doctor I have seen for twenty years never came. He never called either. The doctor in charge of me was someone I had never met, and on the third day he was replaced by a different one. I had to explain everything from the beginning each time. Is this normal? Can I ask for my own doctor to come?”

— Name withheld

The Short Answer

Who is the hospitalist? It is the doctor who works only inside the hospital, and in your case it was the stranger at the foot of your bed. What happened to you is normal. Roughly three quarters of American hospitals run this way. Asking for your own doctor to come will almost certainly not work, because most primary care physicians no longer hold admitting privileges at the hospital. But there are things you can ask for that change your care, and they are worth more than the request you were trying to make.

Who Is the Hospitalist, and Where Did This Job Come From?

The name for this job is not old. It was coined in 1996. Thirty years later more than 50,000 physicians in the United States work as hospitalists, which makes it one of the largest groups in internal medicine. The most recent count from the Society of Hospital Medicine puts the number near 52,000. We do not keep an office. We do not see anyone in clinic. We work inside the building.

It is worth explaining why that changed, because it did not change to inconvenience you.

The old arrangement was that your own doctor stopped by the hospital in the morning, saw the one or two patients of his who happened to be admitted, and drove to his office. That worked when a hospital stay was long and slow. It stopped working as stays got shorter and patients got sicker. What used to unfold over three days now happens in one. A single morning visit cannot carry that. Somebody had to be in the building all day.

There is also a handoff you probably did not see. Most admissions begin in the emergency department. The emergency physician runs the tests, starts treatment, and at some point decides you cannot safely go home. That is when a hospitalist gets called. I wrote about what that sequence actually looks like from the inside in what happens in the first hour in an emergency room. So the unfamiliar doctor you met upstairs was already the second team on your case.

What This Trade Actually Costs

I do not want to be vague about this part, because the system did give something up.

A study of more than half a million Medicare admissions looked at exactly your question. It compared patients cared for in the hospital by their own primary care doctor against patients cared for by hospitalists. Patients whose own doctor took care of them had stays about 12 percent longer, used slightly more specialist consultations, were more likely to be discharged home rather than to a facility, and were less likely to die within 30 days.

Read that honestly and it says two things at once. Hospitalists are faster and lean on fewer consultants. Knowing a patient for twenty years is worth something that speed does not replace.

In that same data, only about 14 percent of patients were cared for by their own primary care doctor. Everyone else was seen by a hospitalist or another covering generalist. So what happened to you is not an exception. It is the default.

Why the Doctor Changed Again on Day Three

Most hospitalists work in blocks. Seven days on and seven days off is the most common schedule in the country. When a block ends, the patients move to the next physician. That transfer is called a handoff, and it has been flagged for a long time as one of the points in medicine where things go wrong.

The evidence points in a consistent direction. In one single-center study, the odds of death rose with each additional hospitalist involved in a patient’s care. In a Texas cohort, patients looked after by physicians with the most continuous schedules had lower mortality after discharge, fewer readmissions, lower costs, and were more often sent home. The concern goes back to the earliest studies of this model, which noted that the arrangement introduces breaks at admission and at discharge, the moments when errors are most likely.

You cannot change the schedule. You can change how much falls through it. For that you need to know what actually falls.

What Actually Leaks in a Handoff

Start by throwing out the obvious guess. The diagnosis and the lab values do not get lost. Those live in the chart. What gets lost is the part that was attached to a person rather than a record, and it comes in three kinds.

The reason behind a decision. The chart holds outcomes. It says a medication was stopped. It often does not say why. Whether it was stopped because of a kidney number, or because you told someone you felt dizzy, is the sort of thing that lives in the head of the doctor who made the call. The next doctor, not knowing, restarts it. Then the same problem happens again.

Whatever is still pending. Cultures growing, imaging waiting to be read, a consultant who has not called back. None of these are written anywhere as a conclusion until the result exists. If that list does not transfer cleanly on the day the doctor changes, a result can come back with nobody assigned to look at it. A good share of the problems that surface after discharge start right here.

How you actually live. Whether the prescription list matches what you really swallow. Whether you live alone. Whether there are stairs. Whether anyone can drive you. This is life information rather than clinical information, so it rarely makes it into a record, and the entire discharge plan depends on it.

All three are gaps a patient or a family member can fill in about thirty seconds. Which is why the cheapest useful thing you can do on a changeover day is ask the new doctor to walk you through the plan and tell you what results are still outstanding. I have watched that one question catch a missed result more than once.

What I See in the Hospital

People read their own doctor’s absence as indifference. Usually it is not. Seeing patients in a hospital requires privileges at that hospital, and most office-based physicians no longer keep them, because there is no longer a reason to. Your doctor may be unable to come rather than unwilling.

What he can still do is pick up a phone. Three minutes from someone who has known you for twenty years delivers what a hundred pages of chart cannot: what your baseline actually is, which medication caused trouble two years ago, what you tend to worry about. That call does not happen on its own. Somebody has to ask for it, and the person who asks is most often the patient or the family.

The other thing I see constantly happens before the ward, not on it. Patients arrive upstairs after many hours downstairs, worn out, having already told their story twice, and by then they have stopped expecting anyone to know who they are. That long stretch in the emergency department has its own logic, which I laid out in why the emergency room makes you wait. It is worth understanding, because the tiredest version of you is the one that gets asked the most important questions.

And the thinnest stretch of all is the week after you leave. The medication list changed, a result landed after discharge, and the follow-up appointment is three weeks out. That gap is where readmissions live.

Plain-Language Reference

What to Actually Do

· Ask once every morning: “Who is my doctor today, and how long are you on service?” Many hospitals write it on the whiteboard in the room.
· On day one, give the hospital your regular doctor’s name and fax number, and let that office know you are admitted. That is also the moment to ask for a phone call between them.
· Bring a written list of what you actually take, not what was last prescribed. The two are often different.
· On a changeover day, ask the new physician to summarize the plan and name anything still pending.
· Before you leave, confirm two things: what results are still outstanding, and who is responsible for reading them.
· Book a follow-up with your own doctor within seven days of discharge.
· Expect two bills. Hospital facility charges and physician charges are billed separately, and the hospitalist’s fee arrives on its own.

This article is for general information only and does not constitute medical advice. Reading it creates no provider-patient relationship. Hospital staffing arrangements, privileges, and billing practices vary by institution, state, and insurance plan, so the details of your own stay may differ from what is described here. Questions about your specific care belong with the physician treating you or with the hospital’s case management team.

Take care of yourself. Nobody else will do it for you.
— Eleanor Hayes, M.D.