August 2004

Grant Results

National Program

Strengthening the Patient-Provider Relationship in a Changing Health Care Environment

SUMMARY

In 1999, the University of California, San Francisco, School of Medicine held a conference examining how a new group of hospital-based physicians, called "hospitalists," are affecting the patient-provider relationship.

The project was part of the Robert Wood Johnson Foundation (RWJF) Strengthening the Patient-Provider Relationship in a Changing Health Care Environment national program.

Key Results

  • The conference, entitled "The Patient-Provider Relationship and the Hospitalist Movement," took place on September 22–23, 1999, in San Francisco. It examined the challenges raised by the hospitalist model, particularly with regard to the discontinuity of care between the inpatient and outpatient setting, and offered potential solutions.

    More than 150 individuals — including researchers, policy leaders and patient advocates — attended the conference.

Funding
RWJF supported this project through a grant of $176,368.

 See Grant Detail & Contact Information
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THE PROBLEM

A very competitive health care marketplace in the United States has placed an unprecedented premium on increasing the value of medical services. In this environment, the traditional American model for hospital care, in which primary care providers manage their own patients in the hospital, is quickly being replaced by a new model in which inpatients are cared for by hospital-based physicians, also known as "hospitalists."

The hospitalist model has a number of potential advantages over the traditional primary care provider-based model for hospital care:

  1. Hospitalists can become expert in both clinical and logistical aspects of increasingly complex hospital care.
  2. They can be available to patients and their families throughout the day.
  3. They are more likely to participate in inpatient quality improvement efforts.
  4. They free up primary care physicians so they are more available to their patients in the office setting.

On the other hand, the hospitalist movement has raised a number of concerns. One of the most important is the extent to which the discontinuity between office and hospital may adversely affect the patient-provider relationship. If information crucial to the patient's care is not seamlessly transmitted from office to hospital and vice versa, clinical outcomes may be compromised. In addition, critically or terminally ill patients may dislike being cared for by a physician with whom they have not established a trusting relationship.

In December 1997, Robert W. Wachter, M.D., and his colleagues at the University of California, San Francisco, (UCSF) School of Medicine hosted a national conference, funded by the Agency for Healthcare Research and Quality, entitled "The Emerging Role of Hospitalists in American Health Care." The conference, which focused on major policy, educational and manpower issues, attracted more than 500 registrants received significant publicity and the results were widely disseminated, including published proceedings in the Annals of Internal Medicine. Wachter, a leading researcher and analyst of the hospitalist movement, coined the term "hospitalist" in a seminal article published in 1996 in the New England Journal of Medicine.

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THE PROJECT

With support from RWJF, Wachter and his colleague Steven Pantilat, M.D., conference co-director, designed and hosted the conference, "The Patient-Provider Relationship and the Hospitalist Movement," held on September 22–23, 1999, in San Francisco. The conference examined the challenges raised by the hospitalist model, particularly with regard to the discontinuity of care between the inpatient and outpatient setting, and offered potential solutions.

More than 150 individuals — including researchers, policy leaders, and patient advocates — attended the conference, which featured 17 presentations and one panel discussion (see the Bibliography for a complete list of conference speakers and their topics).

The conference was held immediately after the third annual "Management of the Hospitalized Patient," a two-day continuing medical education course that was produced by the UCSF Department of Medicine and co-sponsored by the Society for Hospital Medicine. The back-to-back timing of the course and conference provided maximum exposure for the RWJF-funded conference and an opportunity for interested individuals to attend both.

The conference was partly supported by the UCSF Office of Continuing Medical Education and through conference registration fees. In addition, some of the corporate support for the CME conference held immediately before the patient-provider conference defrayed expenses for the latter.

With the approval of RWJF and the National Program Office, the project team used some of its funding to produce a series of four videotaped vignettes — using professional actors — that captured key elements of the patient-provider relationship. These tapes generated significant discussion at the conference and were subsequently used in CME programs for hospitalist physicians and medical students and residents.

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CONCLUSIONS

The conference proceedings were published as a supplement to the American Journal of Medicine (Vol. 111, No. 9. Supplement 2, December 2001). The conference presentations and discussions helped frame a number of issues of critical importance to the hospitalist movement, according to Wachter. They include the following:

  • Although malpractice law for hospitalist systems is still evolving, both the primary care physician and the hospitalist have a duty to provide follow-up care after discharge. Clear and comprehensive information should be provided to the patient, and the hospitalist and primary care physician should communicate with one another about on-going care. (Alpers)
  • Hospitalists face the challenge of establishing rapport with very sick patients during a limited period of time. Good communication skills and other techniques that build rapport can be learned, but require training and practice. (Barnett)
  • In hospitalist systems, it is not uncommon for a patient to be "passed from one physician to another." To ensure healthy outcomes and patient satisfaction and prevent the loss of information during these transitions, it is vital to communicate and consult effectively and in a timely manner with the primary care physician and to partner with the patient and clearly act as an advocate. (Goldman, Pantilat and Whitcomb)
  • Hospitalist systems raise ethical concerns because "they create discontinuity of care when patients are sickest and least able to look after their own interests." Hospitalist systems may diminish patient autonomy because patients are not free to choose their own inpatient physician. They may also hinder informed decision-making because hospitalist physicians have not typically had a prior relationship with the patient and therefore do not have a good understanding of the "patient's values, attitudes toward risk and preferred level of involvement in decision-making." For particular groups of patients, such as the terminally ill, the discontinuity of care imposed by the hospitalist system may be a significant burden. (Lo)

Communications

The conference proceedings were published as a supplement to the American Journal of Medicine in December 2001. The proceedings included papers by conference speakers and additional invited papers on hospitalist care.

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LESSONS LEARNED

The project director offers the following lesson for the field:

  1. If a project director knows in advance that conference proceedings will be developed for publication in a peer-reviewed journal, it will save time and effort in the long run to "forcefully insist" that all speakers submit papers on their presentations. Several of the participants in this conference chose not to deliver manuscripts and instead asked the conference sponsor to tape the event and work with an edited transcript. This process added time and complexity to the development of the proceedings. (Project Director)

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AFTER THE GRANT

The project director and his colleagues at UCSF recently submitted a proposal to the National Institute on Aging to examine how to improve palliative care for patients cared for by hospitalists and how to use the hospital-based pharmacist to facilitate discharge planning.

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GRANT DETAILS & CONTACT INFORMATION

Project

Conference on the Hospitalist and Provider-Patient Relationships

Grantee

University of California, San Francisco, School of Medicine (San Francisco,  CA)

  • Amount: $ 176,368
    Dates: January 1999 to May 2001
    ID#:  035842

Contact

Robert M. Wachter, M.D.
(415) 476-5632
bobw@medicine.ucsf.edu

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Pantilat S and Wachter R (eds.). "The Patient-Provider Relationship and the Hospitalist Movement: Conference Proceedings." American Journal of Medicine, 111(9 Suppl. 2): 1–52, 2001.

Sponsored Conferences

"The Patient-Provider Relationship and the Hospitalist Movement," September 22–23, 1999, San Francisco. Attended by 150 individuals. Seventeen presentations and one panel discussion.

Presentations

  • Ann Alpers, J.D., UCSF, "Key Legal Issues of Handoffs and Liability Issues."
  • Robert Arnold, M.D., University of Pittsburgh, "Ethical Issues for Hospitalists."
  • John Benson, M.D., Oregon Health Sciences University, "On Being a Physician in the Hospitalist Era."
  • Tom Delbanco, M.D., Harvard Medical School, "The Patient-Provider Relationship: Hospital Care."
  • Tom Dickson, M.D., Peer Memorial Hospital, Ontario, "Insights from Other Countries."
  • Lee Goldman, M.D., UCSF, "Key Clinical Principles for Handoffs."
  • Vaughan Keller, Ed.D., Bayer Institute, "Establishing Rapport with a New Patient."
  • Bernard Lo, M.D.,UCSF, "Key Ethical and Policy Issues for the Future."
  • Peter Lovett, M.D.,UCSF, "Insights from Other Countries."
  • Blackford Middleton, M.D., MedicaLogic, Inc., "Information Links Between Inpatient and Outpatient Settings."
  • John Nelson, M.D., Society for Hospital Medicine, "New Strategies for Hospitalists to Improve the Patient-Provider Relationship."
  • Steven Pantilat, M.D.,UCSF, "What do Primary Care Physicians and Patients Want? Innovative Models for the Handoff."
  • Harry Synder, J.D., Consumers Union, "The Patients' Perspective."
  • Robert Wachter, M.D., UCSF, "Hospitalists 1999: A New Name and View of the Social Visit."
  • Winthrop Whitcomb, Society for Hospital Medicine, "Skilled Nursing Facility/Homecare Handoffs."
  • Walter Zelman, Ph.D., California Association of Health Plans, The Managed Care Perspective."
  • Abigail Zuger, M.D., Albert Einstein College of Medicine, "Hospitalists in the Care of the Chronically Ill."

Panel Discussion

  • "Other Specialists," John Luce, M.D., UCSF, Nancy Milliken, M.D., UCSF and Ellen Weber, M.D., UCSF.

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Report prepared by: Karin Gillespie
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Judith Whang

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