Annals of internal medicine
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Motivated by a search for improved quality and efficiency, increasing numbers of hospitals and physicians are moving from systems in which all primary care providers manage their own hospitalized patients or rotate this responsibility among themselves at infrequent intervals to voluntary or mandatory systems in which patients are "handed off" to the care of an inpatient physician, the "hospitalist." All hospitalists manage medical patients in the hospital. Other potential roles for these physicians include triage in the emergency department, transfer of "out-of-network" patients, management of patients in the intensive care unit, preoperative and postoperative management of surgical patients, and leadership in hospital quality improvement and regulatory work. ⋯ A variety of models of care are needed to meet the clinical, organizational, financial, and political demands of diverse health care systems. The favored model should be that which produces the best clinical outcomes and the highest patient satisfaction at the lowest cost.
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The number of hospital-based physicians, or hospitalists, in the United States has grown rapidly, yet no published data have characterized hospitalists or their practices. A self-administered questionnaire was used to describe 1) the features of hospitalists, 2) the hospitals in which they practice, and 3) the practice of inpatient medicine. The questionnaire contained 48 questions that covered four domains: demographic information about the respondent, the clinical and nonclinical workload and responsibilities of the respondent, organizational and financial aspects of the respondent's practice, and the respondent's satisfaction and his or her perception of the reaction of other physicians and nurses to the hospitalist system. ⋯ Small group practices (31%) and staff-model health maintenance organizations (25%) were the most common practice settings, and 78% of participants were reimbursed through salary. Financial incentives were common (43%) but modest. Accurate information about hospitalists and their practices will be important to clinicians, educators, researchers, and policymakers as the hospitalist movement continues to grow.
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The use of hospitalists has implications for patients, for internists, and for the specialty of internal medicine. For patients, the greatest concern is interrupting the continuity of a supportive relationship with their regular physican. For many internists, the hospitalist model is attractive, but they are concerned that health plans will compel physicians to transfer their patients to a hospitalist at the time of admission to the hospital (mandatory hand-off). ⋯ The specialty of internal medicine is very concerned about the mandatory hand-off because it threatens the internist's identity as the physician who can care for the sickest patients in any venue, making it harder for patients and health plans to distinguish the internist from family physicians and nurse practitioners. The hospitalist movement has much to offer internal medicine. To enjoy the benefits and avoid the harms associated with the hospitalist model, internal medicine must resist the imposition of the mandatory hand-off and use the hospitalist's focus on excellent inpatient care to improve the practice of medicine by all internists.
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The relation between endogenous steroid hormones and risk for breast cancer is uncertain. Measurement of sex hormone levels may identify women at high risk for breast cancer who should consider preventive therapies. ⋯ Estradiol and testosterone levels may play important roles in the development of breast cancer in older women. A single measurement of bioavailable estradiol and free testosterone may be used to estimate a woman's risk for breast cancer. Women identified as being at high risk for breast cancer as determined by these hormone levels may benefit from antiestrogen treatment for primary prevention.
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The growing reliance on hospitalists in the United States has implications for several areas of internal medicine, including patient care, administration, clinical practice, and medical education. This paper discusses some of the potential advantages and disadvantages of the use of hospitalists in each of these areas. ⋯ Clearly, hospitalism meets a clinical need and expands opportunities for internists, but it is important that it not overreach, forfeiting primary care turf and distorting medical education. This new field warrants close monitoring because of its potential effects and because-unlike related fields, such as emergency medicine and intensive care--its birth was strongly influenced by system-wide financial considerations.