Monday, 31 October 2016

Hospitalists: functions and competencies








Don’t panic, it’s not about defending a new specialty, it’s about thinking what should be the roles and responsibilities of the physicians in charge of hospital wards if they want to improve safety, quality and continuity of admitted patients’ care.

In 1996 Dr. Robert Watcher and Dr. Lee Goldman described for the first time the term hospitalist as a doctor specialized in the practice of hospital medicine. This matter was experienced then as necessary for the organization of hospital wards in the US, due mainly to the multitasking of specialists who caused that the management of admitted patients was often disorderly. Almost twenty years later the Society of Hospital Medicine reports that there are more than 30,000 hospitalists working in 3,300 hospitals.

In the video, you can see Dr. Chris Addis explaining the main contributions of hospitalists to the admitted patients’ care, in summary: a) assume the coordination of specialists, b) know how to communicate the patient's clinical information in a simple manner, c) ensure continuity of care, and d) be the referent for family doctors both during admission and during the transfer.





In Europe the organizational model is slightly different. Every medical department is responsible for their specialty inpatients unless the patient is admitted in specific units, as short stays, critical or geriatrics. In this model, the heads of service allocate their doctors to various resources that should be addressed: emergency room, outpatient consultations, interdepartmental consultation, support for primary care and, in certain specialties, operating rooms are added, day hospitals, home hospital care or supplementary tests, in addition, of course, of the care for patients in their own specialized hospital beds.

The distribution of functions of specialists, as done nowadays, encourages formation of cliques and hinders the work of hospital wards and, what is worse, the continuity of care to admitted patients. Future Hospital Commission of the Royal College of Physicians makes a disruptive proposal that redefines the inner workings of hospitals in two distinct lines: a) patients admitted for a routine clinical process - the responsibility should lie with the specialists of the process in question; and b) patients with sufficient clinical complexity as to require multidisciplinary work and individualized acts. For this second line of patients, Future Hospital Commission believes that a new profile of full-time general practitioner is required.

Functions of generalists

Generalists (hospitalists in US) should be responsible for patients admitted with clinical complexity, so they should deploy three functions: a) lead the multidisciplinary team incorporating nurses, specialists, consultants, family doctors and social workers, b) develop therapeutic individualized plans together, c) ensure continuity of care in all shifts and weekends, and d) preparing transfers to the community or to the social medical services in the most professional manner possible.

Competencies of generalists

To develop these functions new specialists are not needed. In fact internists, geriatricians and family doctors with specific training would be the most competent specialties; but it could be any other specialist who chooses this option in order to take care of clinically complex patients in their specialty.

For all new generalists, whatever their competence profile, there is an imperative question to ensure that the four functions described above are fulfilled: dedication to in-patients must be exclusive.

(For more details you should consult the post: "Generalist Hospital vs Factory Hospital". You can also carry out a more extensive review of the subject in this blog by clicking "Hospital" in the labels’ column).


Jordi Varela
Editor

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