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The impact of hospitalists: one system experiences major problems after hospitalists arrive. (The Hospitalist Movement).


While adding hospitalists certainly can help an organization, it must be well planned to win acceptance by primary care physicians. A recent study illustrates haw assigning equal value and power to bath primary care physicians and hospitalists can help reduce friction in a health care system.

PRIMARY CARE physicians traditionally played an important role as both outpatient and inpatient care providers. They secured their place as key stakeholders in a variety of organizational models.

Recently, a new type of provider emerged as an important player in health care organizations: the hospitalist, a full time admitting physician.

Primary care physicians perceive hospitalists as undermining their own value and power. A study of the attitudes and opinions concerning the hospitalist movement seems to bear this out.

The qualitative study, known as a stakeholder analysis, was based on semi-structured questionnaires with a sample of 28 physicians (23 primary care physicians and five hospitalists) and 189 patients interviewed during October through December 2000.

Physicians were asked about issues in nine areas:

1. Organizational issues

2. Job security and satisfaction

3. Quality of care provided

4. Leadership and management style within the organization

5. Incorporation of hospitalists to the inpatient care network

6. Referral system

7. Workload before and after hospitalists joined the system

8. Communication between all physicians and administration

9. Overall satisfaction with the health care network

A stakeholder analysis is a great tool to generate knowledge about the value and power of relevant stakeholders. It allows for an objective understanding of the dynamics of relationships, interactions, agendas, behavioral traits and the overall impact of elements each stakeholder has contributed, or could potentially recruit, to the organization. (1)

The study was conducted at a health care system in the Southeast that had recently completed a merger. Leaders of the newly merged system promised to reduce operating costs, consolidate duplicated services and negotiate better reimbursement rates.

While successful at first, the system eventually ran into economic troubles the marketplace changed and the system began to crumble. A plan to save the system focused on numerous changes, including the integration of hospitalists, distribution of inpatient care workload and a redesigned payment plan for physicians.

Numerous concerns and conditions came to light through the stakeholder analysis, including many that illuminated the friction that existed between primary care physicians and hospitalists.

The physician viewpoint

All the physicians who participated--primary care providers and hospitalists--perceived the institutional culture to be both market-driven and hierarchical. They also indicated a significantly reduced perception of job security and satisfaction. This was due to several factors including work redesign, changes in unit configuration and leadership.

Both primary care physicians and hospitalists saw the system's decision-making process turning more bureaucratic and complex. They also saw deterioration in communication between the administration and both physician groups.

Within the two physician groups, referrals were one area of disagreement. Hospitalists preferred a referral system designed and dictated by the health care system, while primary care physicians struggled to keep referral patterns shaped by years of practice experience in their community.

Distress and disenchantment between primary care physicians and hospitalists in how the inpatient service should be operated were found, as well. The administration appeared to please hospitalists when resolving call schedule disputes and coverage conflicts.

Key issues that emerged relating to the cultures of primary care physicians and hospitalists included communication and workload. Barriers to change were identified including less accommodating attitudes of hospitalists and the sometimes-individualistic culture of primary care physicians.

A substantial change in physician's fringe benefit package--including base salary--created discontent among all providers, who then saw their tenure and seniority ignored or jeopardized.

The compensation paid to primary care physicians for weekend rounds dropped an average of 45 percent of traditional average earnings per weekend call, A non-compensated evening call from 5 p.m. to 11 p.m. was imposed upon the primary care physicians to accommodate time-off requests made by hospitalists.

Personal time off for physicians in the system (including vacation time, continuing medical education time and holidays) was reduced an average of 25 percent, despite contractual agreements that stipulated differently.

The workload during weekend call increased significantly, with an average increase of 50 percent in the number of admissions done by physicians on weekend call, while the average weekend patient census per physician increased by 30 percent.

The frequency of scheduled weekend calls increased for primary care physicians. Prior to integrating hospitalists, the frequency of weekend calls was every sixth weekend. After integrating hospitalists into the system, the frequency increased to every fourth weekend.

In the end, primary care physicians and hospitalists began a continuous exodus from the primary health care network, diminishing the pool of available physicians for the call schedule rotation and for the overall patient care responsibilities.

The health system discontinued the hospitalist program as an integral part of the health care network and began contractual agreements with a privately run hospitalist program.

The patient viewpoint

Patients participating in the study were asked about issues in four major areas:

1. Accessibility to care

2. Quality of care

3. Shared care by hospitalists and primary care physicians

4. Overall satisfaction with the health care network before and after hospitalists joined the system

Patients expressed dissatisfaction with the merger and downsizing of offices; they viewed these changes as promoting a less pleasant office environment and over-crowded facility.

They experienced difficulty when attempting to contact the offices. The telephone system failed to accommodate the call volume and the average return calls to pharmacies or patients exceeded 24 hours.

About 80 percent of the patients also perceived a decline in the quality of care that they received at both the office site and the hospital. Overcrowded facilities and poor access to care were mentioned as key problems.

And nearly 85 percent expressed discontent that their care was usually provided by one or more unknown physicians (hospitalists), who later had no opportunity to participate in the continuity of their medical care.

Management implications

Newly structured incentives and uncontrollable losses are prompting health care organizations to rethink how care is planned and delivered. Low reimbursement rates from both managed care plans and government plans are determining the need to implement survival strategies as the only viable response to a more competitive marketplace. (2)

The integration of hospitalists as key stakeholders in full time inpatient care has an impact on both the quality and cost of care, as well as the value and power of primary care physicians as key stakeholders. (3)

Evaluation of the multifunctional role of primary care physicians, when compared with the role of the newly created hospitalists, is essential to objectively measure the outcome of work redesign initiatives.

The size and complexity of the combined pool of physicians within large health care organizations may not foster the ideal flexibility needed to maintain the primary care physician stakeholder value and power.

Examining this particular not-profit health care system, the analysis identified the lack of managerial strategies that may have led to a better integration of a hospitalist service into the traditional system.

The instability of the resulting primary care system and in-hospital care team may have been lessened significantly if particular attention was given to the proper identification and management of key stakeholders, in particular those that provided direct patient care.

In this situation, the integration of hospitalists into the health care system took place in a rushed fashion. This fast-paced change created an unbalanced climate for both primary care physicians and hospitalists.

The viability of the system continued to erode during two subsequent years. Early this year, the primary care network management announced their decision to close all operations related to the primary care services. All network-operated outpatient clinics will be closed or transitioned to private, independent operation by the end of 2002.

The network administration justified this change in the organization's mission, arguing that the primary care network had average yearly losses of one to two million dollars. Local health care administrators with no relation to the system viewed this move as a general directive given by a higher entity, the hospital and system owner, and not as a reflection of the sustainability of the system and its financial outlook within the particular local market.

Integrating hospitalists into the system, and the impact this newly added service had on family physicians, may have played a significant role in the disintegration of the primary care network. However, this argument needs further analysis.

The results of the qualitative analysis do show dissatisfaction in those surveyed. Data from other studies suggest that the influence and autonomy of health care professionals are declining, with health care decision making shifting from independent practitioners to hospital, government, insurance industry, research and pharmaceutical organizations. (4)

This analysis of inequalities in the value approach of two key stakeholders within a system corroborates these managerial trends and reinforces the need to develop clear strategies to strengthen the organization's position.

The implications of not assigning equal value to primary care physicians and hospitalists in their internal stake within the organization's inpatient care structure may be a catalyst for the system's failure.

Research has shown that when organizations value key stakeholders as the core of their structure and function, they consistently outperform their counterparts. Redesigning services can only be successfully implemented if the needs of all stakeholders involved are taken into consideration. (5)

Physicians practicing in various settings generally have favorable perceptions of the hospitalists' effect on patients, and on their own practice satisfaction, especially in voluntary hospitalist systems that decrease the workload of primary care physicians and do not threaten their income potential. (6)

This qualitative analysis does corroborate the disagreement and opposite effect generated when the hospitalist system is integrated into a health care system, and when this integration represents a threat to the earning potential of primary care physicians.


Sincere thanks to Fern Jureidini Webb, PhD and Donna M. Malvey, PhD for their critical review of this article and overall instructive guidance.


(1.) R, Brugha and Z, Varvasovsky. "Stakeholder Analysis: A Review." Health Policy and Planning. Sep 2000, 15(3):239-46.

(2.) KR, Jones and others. "Evaluation of the Multifunctional Worker Role: A Stakeholder Analysis." Outcomes Manag Nurs Pract. Jul-Sep 1999, 3(3):128-35.

(3.) AP, Halpert and others. "The Impact of an Inpatient Physician Program on Quality, Utilization, and Satisfaction." American Journal of Managed Care. May 2000, 6(5):549-55.

(4.) MD, Ermann, "The Social control of Organizations in the Health care Area." Milbank Mem Fund Q Health Soc. Spring 1976, 54(2):167-83.

(5.) V, Carignani. "Management of change in Health care Organizations and Human Resource Role." European Journal of Radiology. Jan 2000, 33(1):8-13.

(6.) A, Fernandez and others. "Friend or Foe? How Primary care Physicians Perceive Hospitalists." Archives of Internal Medicine. Oct 2000, 160(19):2902-8.

Pablo J. Calzada, DO, MPH, is clinical assistant professor, department of community health and family medicine at Shands Jacksonville, University of Florida. He can be reached by phone at 904/244-5801 or by e-mail at
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Article Details
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Author:Calzada, Pablo J.
Publication:Physician Executive
Geographic Code:1USA
Date:Nov 1, 2002
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