Pediatric Hospitalist Medicine: An Overview and a Perspective From Toronto, Canada

Abstract

spent on inpatient wards, the emergency department, intensive care settings, and primary care clinics; physicians may work at community or academic centers; and models included those with regular daytime hours versus shift work, as well as incorporating house staff versus staff-only models. Communication between hospitalists and referring pediatricians was identified as a priority. A teaching and an educational component were important parts of most models and required support in terms of both faculty development and compensation. Similarly, leadership in administration and research was beginning to emerge as hospitalist fellowships and research priorities began to evolve. Evidence in support of the hospitalist model has been published, most notably by Landrigan et al, who systematically reviewed and reported 20 primary-data studies of pediatric hospitalist systems. Although limited data were available on the quality of patient care provided, length of stay and inpatient hospital costs—factors closely related to one another—were consistently decreased when hospitalist systems were compared with traditional models. Ratings of parental experience and those of house staff ’s educational experiences were also positive. Less clear is the financial impact as hospitalist programs subject to economic analyses have been found overall to lose money. Pilot data, however, indicate adjustable factors that may serve to increase hospitalist program’s profits, namely increasing the daily census and professional and consultative services. Few centers have measured clinical outcomes associated with pediatric hospitalist care, which need to be addressed in future research. The term hospitalist was introduced by Wachter and Goldman in 1996 and was more recently defined by the Society of Hospital Medicine as “physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital care.” Although hospitalists were originally described in the context of adult internal medicine, their prominence in the care of general pediatric inpatients has rapidly emerged. By 1999, 50% of academic pediatric departments in North America had incorporated a hospitalist model, and estimates suggest that 1000 pediatric hospitalists are currently in practice. Growth of the pediatric hospitalist movement is attributed to multiple factors, namely the demand for expertise specific to inpatient medicine; limitations on resident work hours, and financial pressures to decrease both admission rates and length of stay, leading to an increase in patient complexity. Recent literature describing the state of pediatric hospitalists emphasizes the diverse nature of the field. At a 2003 meeting of academic pediatric hospitalists, Lye et al found that the hospitalist role varied widely: inpatient clinical work made up 75% ± 32% of their time, which may be