Hospitalists, PCPs, specialists, and non‐physicians: Too many cooks in the kitchen?

The tension between continuity of care and specialization is not new, but may have reached a tipping point when the hospitalist movement erupted onto the American medical scene in the late 1990s. By definition, when a hospitalist cares for an inpatient, there is some fragmentation of care, which is, at least in theory, avoidable—if the primary care provider (PCP) can serve as attending physician in the hospital. Literature has since emerged suggesting that clinical and economic outcomes of care by hospitalists are at least as good as that provided by PCPs, and that patients are not, in general, opposed to hospitalist care. However, the degree of discontinuity is not just a feature of whether a hospitalist assumes care of the hospitalized patient. Discontinuity can be exacerbated by changing attendings throughout the hospital stay. And inpatient continuity is a potential issue for both the hospitalist model and traditional model of care (in which the PCP serves as inpatient attending physician). While one might assume that the hospitalist model fosters more inpatient discontinuity because most hospitalists—whether working a 7-on–7-off schedule or another schedule—do not commit to caring for a patient throughout an entire hospitalization the way a PCP might, this question has not previously been examined. Even if the hospitalist model is a fait accompli in many hospitals, it is worth knowing how inpatient continuity differs between the 2 models. In this issue of the Journal, Fletcher and colleagues used billing data to examine trends in inpatient continuity of care over a 10-year period ending in 2006, and sought to determine: (1) whether inpatient care has become more fragmented over time (as defined by the number of generalists caring for a patient over the course of an average hospitalization), and (2) whether inpatient care provided by hospitalists tends to be more fragmented than care provided by PCPs. They found that continuity of inpatient care has indeed decreased over time. In 1996, just over 70% of patients received care from 1 generalist; this number declined to just under 60% a decade later, despite a decrease in length-of-stay during that period. However, and perhaps surprisingly, patients cared for exclusively by hospitalists saw fewer generalists in the hospital (ie, fewer different hospitalists) than those cared for exclusively by outpatient providers. The authors conclude that the doctor–patient continuity over the course of a hospital stay is not worse in the hospitalist model than in the traditional model. While reassuring, it is important to remember that the patient experience does not begin at admission or end at discharge, and a more patient-centered analysis might take into account the outpatient providers too (ie, those seeing the patient before admission and after discharge), and would probably show that the hospitalist model indeed leads to more care fragmentation. After all, there are at least 2 providers involved in every patient’s care when a hospitalist model is used, whereas a large subset of patients cared for by PCPs would have only 1 provider involved. While not the primary focus of the analysis, Fletcher and colleagues identified additional predictors of inpatient continuity of care. Higher socioeconomic class and white race were associated with lower continuity. This suggests that care fragmentation is not a feature of inferior, or at least cheap, care. In keeping with this observation, there was also enormous geographic variation in inpatient care continuity, marked by greater fragmentation of care in the New England and the mid-Atlantic regions than in other areas of the country, and more fragmentation in larger hospitals serving heavily populated metropolitan areas. This pattern is strikingly similar to the cost-of-care patterns observed by the Dartmouth Atlas researchers. Densely populated areas tend to have more specialists per capita and also tend to deliver more expensive care—without demonstrably higher quality. In parallel, it is easy to see how care fragmentation might increase length-of-stay and lead to excessive diagnostic testing and consultation. More cooks in the kitchen might make costlier stew. How hospitalists tackle the issue of inpatient continuity is not only a matter of quality of care, but also a matter of job sustainability. The simple way to maximize continuity—working many consecutive days— can lead to burnout if taken too far. But there are *Address for correspondence and reprint requests: Daniel J. Brotman, M D, FACP, FHM, Hospitalist Program, Johns Hopkins Hospital, 600 North Wolfe St/Park 307, Baltimore, MD 21287; Tel.: 443-287-3023; E-mail: brotman@jhmi.edu