FP Report -- March 1999
Physicians nudge HMO to allow full-time or part-time hospitalists
Kaiser-Permanente of Northern California gave its generalist physicians a choice almost three years ago: Be a hospitalist or a clinic physician.
Family physician James Cotter, M.D., and 19 other FPs and internists ducked the choice.
They picked a third route: rotator.
Cotter"I'm too young not to do hospital work," said Cotter, 46, of Napa. "I don't want to give up my hospital skills. I like the intensity of hospital work. I like working with specialists. I like helping sick people get better."
But Cotter didn't want to dump his clinic practice. "I like the long-term relationships with the clinic patients and working with the same staff and doctors," he said. "At the hospital, the staff tend to come and go."
The rotators practice in a clinic for four weeks and then take a seven-day shift at Kaiser's hospital in Vallejo.
Types of inpatient care management FPs use*
Types of management Percentage
(average)Primary care physicians
manage virtually all their
own inpatient care
(with consultations, referrals)59.9 Primary care physicians
organize into groups
and take turns caring for inpatients21.1 Hospitalists are in place;
using them is optional14.6 Hospitalists are in place;
using them is mandatory4.5
*Based on a June 1998 AAFP survey of 2,052 family physicians concerning the types of inpatient care management they use for adult medicine patients. Respondents could indicate more than one type of management. The four types are adapted from a model developed by internist Robert Wachter, M.D., of San Francisco.In addition, seven hospitalists work day shifts full time, and three hospitalists cover night shifts. With the rotators, they manage inpatient medical care for some 110 patients at a time. And almost 100 generalists work in Kaiser's four clinics full time.
"This hybrid system, using rotators, is not in the Kaiser design for adult primary care," said Cotter. "Regional administrators favor a pure system, with physicians in the clinic full time so they're not distracted with hospital visits. However, the administration hasn't forced the issue. Our doctors prefer this system, so that's fine. Besides, we've not seen any problems with the efficiency of rotators vs. full-time hospitalists."
Cotter, a member of the AAFP Task Force on Hospitalists (see story below), is the physician in charge of Kaiser's Napa medical offices and assistant physician-in-chief at the Vallejo hospital, responsible for utilization and outside services.
In 1997, the first year for hospitalists for Kaiser-Permanente of Northern California, the length of stay for patients with hospitalists was 15 percent lower than for other medical patients. In 1998, length of stay was about 3.5 days, a bit longer than in 1997. It's likely the patients were sicker last year, said Cotter.
A patient survey indicated high satisfaction with hospitalists, but the survey did not ask whether the patients would have preferred care from their own physician instead of a hospitalist.
Cotter finds a day in the hospital easier than a day in the clinic.
"In the hospital, you run your own schedule. You can control how much time you spend with each patient and can come back," he said. "In the clinic, you have more patients, it's always busy, there's someone you have to work in, you work late, and you deal with the phone calls and everything else. But I wouldn't want to be a hospitalist full time. I like variety."
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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