Micaela La Regina, MD

 

In the United States, family physicians (general practitioners) used to manage their patients in the hospital, either as the primary care doctor or in consultation with specialists. Only since the 1990s has a new kind of physician gained widespread acceptance: the hospitalist (“specialist of inpatient care”).¹

In Italy the process has not been the same. In our health care system, primary care physicians have always transferred the responsibility of hospital care to an inpatient team. Actually, our hospital-based doctors dedicate their whole working time to inpatient care, and general practitioners are not expected to go to the hospital. The patients were (and are) admitted to one ward or another according to their main clinical problem.

Little by little, a huge number of organ specialty and subspecialty wards have filled Italian hospitals. In this context, the internal medicine specialty was unable to occupy its characteristic role, so that, a few years ago, the medical community wondered if the specialty should have continued to exist.

Anyway, as a result of hyperspecialization, we have many different specialists in inpatient care who are not specialists in global inpatient care.

Nowadays, in our country we are faced with a dramatic epidemiologic change. The Italian population is aging and the majority of patients have not only one clinical problem but multiple comorbidities. When these patients reach the emergency department, it is not easy to identify the main clinical problem and assign him/her to an organ specialty unit. And when he or she eventually arrives there, a considerable number of consultants is frequently required. The vision of organ specialists is not holistic, and they are more prone to maximizing their tools than rationalizing them. So, at present, our traditional hospital model has been generating care fragmentation, overproduction of diagnoses, overprescription of drugs, and increasing costs.

It is obvious that a new model is necessary for the future, and we look with great interest at the American hospitalist model.

We need a new hospital-based clinician who has wide-ranging competencies, and is able to define priorities and appropriateness of care when a patient requires multiple specialists’ interventions; one who is autonomous in performing basic procedures and expert in perioperative medicine; prompt to communicate with primary care doctors at the time of admission and discharge; and prepared to work in managed-care organizations.

 

We wonder: Are Italian hospital-based internists – the only specialists in global inpatient care – suited to this role?

We think so. However, current Italian training in internal medicine is focused mainly on scientific bases of diseases, pathophysiological, and clinical aspects. Concepts such as complexity or the management of patients with comorbidities are quite difficult to teach to medical school students and therefore often neglected. As a result, internal medicine physicians require a prolonged practical training.

Inspired by the Core Competencies in Hospital Medicine published by the Society of Hospital Medicine, this year in Genoa (the birthplace of Christopher Columbus) we started a 2-year second-level University Master course, called “Hospitalist: Managing complexity in Internal Medicine inpatients” for 35 internal medicine specialists. It is the fruit of collaboration between the main association of Italian hospital-based internists (Federation of Associations of Hospital Doctors on Internal Medicine, or FADOI) and the University of Genoa’s Department of Internal Medicine, Academy of Health Management, and the Center of Simulation and Advanced Training.

In Italy, this is the first concrete initiative to train, and better define, this new type of physician expert in the management of inpatients.

 

According to SHM’s definition of a hospitalist, we think that the activities of this new physician should also include teaching and research related to hospital medicine. And as Dr. Steven Pantilat wrote, “patient safety, leadership, palliative care and quality improvement are the issues that pertain to all hospitalists.”²

Theoretically, the development of the hospitalist model should be easier in Italy when compared to the United States. Dr. Robert Wachter and Dr. Lee Goldman wrote in 1996 about the objections to the hospitalist model of American primary care physicians (“to preserve continuity”) and specialists (“fewer consultations, lower income”), but in Italy family doctors do not usually follow their patients in the hospital, and specialists have no incentive for in-hospital consultations.³ Moreover, patients with comorbidities, or pathologies on the border between medicine and surgery (e.g. cholecystitis, bowel obstruction, polytrauma, etc.), are already often assigned to internal medicine, and in the smallest hospitals, the internist is most of the time the only specialist doctor continually present.

Nevertheless, the Italian hospitalist model will be a challenge. We know we have to deal with organ specialists, but we strongly believe that this is the most appropriate and the most sustainable model for the future of the Italian hospitals. Our wish is not to become the “bosses” of the hospital, but to ensure global, coordinated, and respectful care to present and future patients.

Published outcomes studies demonstrate that the U.S. hospitalist model has led to consistent and pronounced cost saving with no loss in quality.⁴ In the United States, the hospitalist field has grown from a few hundred physicians to more than 50,000,⁵ making it the fastest growing physician specialty in medical history.

Why should the same not occur in Italy?
 

 

References

1. Baudendistel TE, Watcher RM. The evolution of the hospitalist movement in USA. Clin Med JRCPL. 2002;2:327-30.

2. Pantilat S. What is a Hospitalist? The Hospitalist 2006 February;2006(2).

3. Wachter RM, Goldman Lee. The emerging role of “Hospitalists” in the American Health Care System. N Engl J Med. 1996;335:514-7.

4. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Medicine. 2011;9:58:1-22. http://www.biomedcentral.com/1741-7015/9/58.

5. Wachter RM, Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016;375:1009-11.
 

Valerio Verdiani, MD, director of internal medicine, Grosseto, Italy. Francesco Orlandini, MD, internal medicine, health administrator, ASL4 Liguria, Chiavari (GE), Italy. Micaela La Regina, MD, internal medicine, risk management and clinical governance, ASL5 Liguria, La Spezia, Italy. Giovanni Murialdo, MD, department of internal medicine and medical specialty, University of Genoa (Italy). Andrea Fontanella, MD, director of medicine department, president of the Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), Naples, Italy. Mauro Silingardi, MD, director of internal medicine, director of training and refresher of FADOI, Bologna, Italy.

 

In the United States, family physicians (general practitioners) used to manage their patients in the hospital, either as the primary care doctor or in consultation with specialists. Only since the 1990s has a new kind of physician gained widespread acceptance: the hospitalist (“specialist of inpatient care”).¹

In Italy the process has not been the same. In our health care system, primary care physicians have always transferred the responsibility of hospital care to an inpatient team. Actually, our hospital-based doctors dedicate their whole working time to inpatient care, and general practitioners are not expected to go to the hospital. The patients were (and are) admitted to one ward or another according to their main clinical problem.

Little by little, a huge number of organ specialty and subspecialty wards have filled Italian hospitals. In this context, the internal medicine specialty was unable to occupy its characteristic role, so that, a few years ago, the medical community wondered if the specialty should have continued to exist.

Anyway, as a result of hyperspecialization, we have many different specialists in inpatient care who are not specialists in global inpatient care.

Nowadays, in our country we are faced with a dramatic epidemiologic change. The Italian population is aging and the majority of patients have not only one clinical problem but multiple comorbidities. When these patients reach the emergency department, it is not easy to identify the main clinical problem and assign him/her to an organ specialty unit. And when he or she eventually arrives there, a considerable number of consultants is frequently required. The vision of organ specialists is not holistic, and they are more prone to maximizing their tools than rationalizing them. So, at present, our traditional hospital model has been generating care fragmentation, overproduction of diagnoses, overprescription of drugs, and increasing costs.

It is obvious that a new model is necessary for the future, and we look with great interest at the American hospitalist model.

We need a new hospital-based clinician who has wide-ranging competencies, and is able to define priorities and appropriateness of care when a patient requires multiple specialists’ interventions; one who is autonomous in performing basic procedures and expert in perioperative medicine; prompt to communicate with primary care doctors at the time of admission and discharge; and prepared to work in managed-care organizations.

 

We wonder: Are Italian hospital-based internists – the only specialists in global inpatient care – suited to this role?

We think so. However, current Italian training in internal medicine is focused mainly on scientific bases of diseases, pathophysiological, and clinical aspects. Concepts such as complexity or the management of patients with comorbidities are quite difficult to teach to medical school students and therefore often neglected. As a result, internal medicine physicians require a prolonged practical training.

Inspired by the Core Competencies in Hospital Medicine published by the Society of Hospital Medicine, this year in Genoa (the birthplace of Christopher Columbus) we started a 2-year second-level University Master course, called “Hospitalist: Managing complexity in Internal Medicine inpatients” for 35 internal medicine specialists. It is the fruit of collaboration between the main association of Italian hospital-based internists (Federation of Associations of Hospital Doctors on Internal Medicine, or FADOI) and the University of Genoa’s Department of Internal Medicine, Academy of Health Management, and the Center of Simulation and Advanced Training.

In Italy, this is the first concrete initiative to train, and better define, this new type of physician expert in the management of inpatients.

 

According to SHM’s definition of a hospitalist, we think that the activities of this new physician should also include teaching and research related to hospital medicine. And as Dr. Steven Pantilat wrote, “patient safety, leadership, palliative care and quality improvement are the issues that pertain to all hospitalists.”²

Theoretically, the development of the hospitalist model should be easier in Italy when compared to the United States. Dr. Robert Wachter and Dr. Lee Goldman wrote in 1996 about the objections to the hospitalist model of American primary care physicians (“to preserve continuity”) and specialists (“fewer consultations, lower income”), but in Italy family doctors do not usually follow their patients in the hospital, and specialists have no incentive for in-hospital consultations.³ Moreover, patients with comorbidities, or pathologies on the border between medicine and surgery (e.g. cholecystitis, bowel obstruction, polytrauma, etc.), are already often assigned to internal medicine, and in the smallest hospitals, the internist is most of the time the only specialist doctor continually present.

Nevertheless, the Italian hospitalist model will be a challenge. We know we have to deal with organ specialists, but we strongly believe that this is the most appropriate and the most sustainable model for the future of the Italian hospitals. Our wish is not to become the “bosses” of the hospital, but to ensure global, coordinated, and respectful care to present and future patients.

Published outcomes studies demonstrate that the U.S. hospitalist model has led to consistent and pronounced cost saving with no loss in quality.⁴ In the United States, the hospitalist field has grown from a few hundred physicians to more than 50,000,⁵ making it the fastest growing physician specialty in medical history.

Why should the same not occur in Italy?
 

 

References

1. Baudendistel TE, Watcher RM. The evolution of the hospitalist movement in USA. Clin Med JRCPL. 2002;2:327-30.

2. Pantilat S. What is a Hospitalist? The Hospitalist 2006 February;2006(2).

3. Wachter RM, Goldman Lee. The emerging role of “Hospitalists” in the American Health Care System. N Engl J Med. 1996;335:514-7.

4. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Medicine. 2011;9:58:1-22. http://www.biomedcentral.com/1741-7015/9/58.

5. Wachter RM, Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016;375:1009-11.
 

Valerio Verdiani, MD, director of internal medicine, Grosseto, Italy. Francesco Orlandini, MD, internal medicine, health administrator, ASL4 Liguria, Chiavari (GE), Italy. Micaela La Regina, MD, internal medicine, risk management and clinical governance, ASL5 Liguria, La Spezia, Italy. Giovanni Murialdo, MD, department of internal medicine and medical specialty, University of Genoa (Italy). Andrea Fontanella, MD, director of medicine department, president of the Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), Naples, Italy. Mauro Silingardi, MD, director of internal medicine, director of training and refresher of FADOI, Bologna, Italy.

 

In the United States, family physicians (general practitioners) used to manage their patients in the hospital, either as the primary care doctor or in consultation with specialists. Only since the 1990s has a new kind of physician gained widespread acceptance: the hospitalist (“specialist of inpatient care”).¹

In Italy the process has not been the same. In our health care system, primary care physicians have always transferred the responsibility of hospital care to an inpatient team. Actually, our hospital-based doctors dedicate their whole working time to inpatient care, and general practitioners are not expected to go to the hospital. The patients were (and are) admitted to one ward or another according to their main clinical problem.

Little by little, a huge number of organ specialty and subspecialty wards have filled Italian hospitals. In this context, the internal medicine specialty was unable to occupy its characteristic role, so that, a few years ago, the medical community wondered if the specialty should have continued to exist.

Anyway, as a result of hyperspecialization, we have many different specialists in inpatient care who are not specialists in global inpatient care.

Nowadays, in our country we are faced with a dramatic epidemiologic change. The Italian population is aging and the majority of patients have not only one clinical problem but multiple comorbidities. When these patients reach the emergency department, it is not easy to identify the main clinical problem and assign him/her to an organ specialty unit. And when he or she eventually arrives there, a considerable number of consultants is frequently required. The vision of organ specialists is not holistic, and they are more prone to maximizing their tools than rationalizing them. So, at present, our traditional hospital model has been generating care fragmentation, overproduction of diagnoses, overprescription of drugs, and increasing costs.

It is obvious that a new model is necessary for the future, and we look with great interest at the American hospitalist model.

We need a new hospital-based clinician who has wide-ranging competencies, and is able to define priorities and appropriateness of care when a patient requires multiple specialists’ interventions; one who is autonomous in performing basic procedures and expert in perioperative medicine; prompt to communicate with primary care doctors at the time of admission and discharge; and prepared to work in managed-care organizations.

 

We wonder: Are Italian hospital-based internists – the only specialists in global inpatient care – suited to this role?

We think so. However, current Italian training in internal medicine is focused mainly on scientific bases of diseases, pathophysiological, and clinical aspects. Concepts such as complexity or the management of patients with comorbidities are quite difficult to teach to medical school students and therefore often neglected. As a result, internal medicine physicians require a prolonged practical training.

Inspired by the Core Competencies in Hospital Medicine published by the Society of Hospital Medicine, this year in Genoa (the birthplace of Christopher Columbus) we started a 2-year second-level University Master course, called “Hospitalist: Managing complexity in Internal Medicine inpatients” for 35 internal medicine specialists. It is the fruit of collaboration between the main association of Italian hospital-based internists (Federation of Associations of Hospital Doctors on Internal Medicine, or FADOI) and the University of Genoa’s Department of Internal Medicine, Academy of Health Management, and the Center of Simulation and Advanced Training.

In Italy, this is the first concrete initiative to train, and better define, this new type of physician expert in the management of inpatients.

 

According to SHM’s definition of a hospitalist, we think that the activities of this new physician should also include teaching and research related to hospital medicine. And as Dr. Steven Pantilat wrote, “patient safety, leadership, palliative care and quality improvement are the issues that pertain to all hospitalists.”²

Theoretically, the development of the hospitalist model should be easier in Italy when compared to the United States. Dr. Robert Wachter and Dr. Lee Goldman wrote in 1996 about the objections to the hospitalist model of American primary care physicians (“to preserve continuity”) and specialists (“fewer consultations, lower income”), but in Italy family doctors do not usually follow their patients in the hospital, and specialists have no incentive for in-hospital consultations.³ Moreover, patients with comorbidities, or pathologies on the border between medicine and surgery (e.g. cholecystitis, bowel obstruction, polytrauma, etc.), are already often assigned to internal medicine, and in the smallest hospitals, the internist is most of the time the only specialist doctor continually present.

Nevertheless, the Italian hospitalist model will be a challenge. We know we have to deal with organ specialists, but we strongly believe that this is the most appropriate and the most sustainable model for the future of the Italian hospitals. Our wish is not to become the “bosses” of the hospital, but to ensure global, coordinated, and respectful care to present and future patients.

Published outcomes studies demonstrate that the U.S. hospitalist model has led to consistent and pronounced cost saving with no loss in quality.⁴ In the United States, the hospitalist field has grown from a few hundred physicians to more than 50,000,⁵ making it the fastest growing physician specialty in medical history.

Why should the same not occur in Italy?
 

 

References

1. Baudendistel TE, Watcher RM. The evolution of the hospitalist movement in USA. Clin Med JRCPL. 2002;2:327-30.

2. Pantilat S. What is a Hospitalist? The Hospitalist 2006 February;2006(2).

3. Wachter RM, Goldman Lee. The emerging role of “Hospitalists” in the American Health Care System. N Engl J Med. 1996;335:514-7.

4. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Medicine. 2011;9:58:1-22. http://www.biomedcentral.com/1741-7015/9/58.

5. Wachter RM, Goldman L. Zero to 50,000 – The 20th Anniversary of the Hospitalist. N Engl J Med. 2016;375:1009-11.
 

Valerio Verdiani, MD, director of internal medicine, Grosseto, Italy. Francesco Orlandini, MD, internal medicine, health administrator, ASL4 Liguria, Chiavari (GE), Italy. Micaela La Regina, MD, internal medicine, risk management and clinical governance, ASL5 Liguria, La Spezia, Italy. Giovanni Murialdo, MD, department of internal medicine and medical specialty, University of Genoa (Italy). Andrea Fontanella, MD, director of medicine department, president of the Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), Naples, Italy. Mauro Silingardi, MD, director of internal medicine, director of training and refresher of FADOI, Bologna, Italy.