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. . . in some countries [there has been] the emergence of a "hospitalist" who has a wide range of expertise, but concentrating more on acute hospital medicine -- more like a general physician, but specialising in acute and serious illness rather than chronic and mainly ambulant medicine. The hospitalist also has advanced resuscitation and procedural skills. They are familiar with the medical comorbidities increasingly associated with surgical patients and understand how different organs fail and interact in acute illness. They are a move back to the generalist physician. The equivalent in Australia is probably the intensive care or emergency physician. The hospitalist also understands about continuity and coordination of patient care, managing the patient's inpatient course and arranging a seamless transition to a community setting. . . . A hospitalist could enable community-based specialists to devote more time to what they do best, rather than being continuously confronted by the dilemma of maintaining a busy professional practice with tight appointment schedules and having seriously ill in-hospital patients who might require their attention day or night in an unpredictable way. Having skilled clinical cover 24 hours a day would also help guarantee patient safety. . . . Australia could explore other ways of achieving the same standards. (Hillman K. MJA 1999; 170: 325-328)

. . . patients are more likely to be assured of continuous, integrated and efficient care for a multiplicity of concurrent problems if attended to by general physicians from the time of admission via emergency departments right through to the time of discharge and beyond into ambulatory care. Adequate resourcing of general medical units, greater involvement of general physicians in emergency and intensive care settings, ready access to specialised medical, nursing and allied health expertise as needed . . . (Scott IA, Phillips PA. MJA 1999; 171: 312-314)

We argue here that this role is already evolving and currently functioning in a variety of clinical situations in the Australian healthcare system.¹⁰ The doctor delivering those aspects of seniority, experience and permanence relevant to a hospital generalist is a Career Medical Officer (CMO) (see Box).

There are two interrelated parts to this debate:

• What problems are there with current medical staffing of acute care hospitals?

• What solutions are available?

There is increasing evidence of major inadequacies in the functioning of our hospitals.¹¹ This may reflect the way we educate and organise our medical staff. An analysis of the causes of adverse events reported in the Quality in Australian Health Care Study¹² showed that human error was involved in 82% of adverse events and that the most common causes were failure in technical performance and cognitive failure: failure to act on available information, failure to consult or investigate, and failure to attend or provide adequate attention.

A recent study of critical events (ie, cardiac arrest or unplanned admission to ICU) in an Australian metropolitan teaching hospital¹³ found that these episodes are frequently preceded by documented clinical instability of the patient and multiple medical review before admission to ICU or cardiac arrest ensued. The authors commented that the patients in their study (generally those with complex medical and surgical conditions) were usually managed initially by the most junior member on the ward (intern or resident). We do not suggest that junior medical officers should not be involved in direct care of the very sick, but there appear to be problems with current hospital practice: the major deficiencies appear to us to be the understandable lack of experience of the junior medical staff and their rapid turnover. This outdated way of organising medical staffing has long caused problems with our nursing colleagues^14-16 and others, who assist the overworked and inexperienced medical officers organise their time and energies to most effectively care for and investigate sick patients -- and then repeat this education once again with the next rotation.

Is it right to give increasing responsibility to our junior doctors, but leave them at times relatively unsupervised, unsupported and responsible for major medical decisions when their level of training may be inadequate for the task? The Postgraduate Medical Councils in the various states provide increasingly good-quality support for first- and second-year graduates, but this is in a logistical and educational role rather than a directly supportive clinical role.

Hillman¹ and Scott and Phillips² appear to be attempting to address the problems by placing another specialist physician into the increasingly fragmented world of hospital medicine. There are examples of this in the United States,^17-19 where the hospitalist is usually (but not always²⁰) a specialist in internal medicine who works predominantly in the hospital setting. Physicians who work outside of the hospital relinquish their responsibility for the patient at the hospital entrance and take it up again on discharge.

The unstated but underlying expectation is that the hospitalist would usurp the primary role and responsibility of the attending doctor. We believe this vision of a hospitalist to be fundamentally flawed. On the one hand, it sidelines doctors who should be intimately involved in the inpatient care of patients (including specialist physicians, general practitioners and paediatricians) whose main area of practice remains office based; on the other, it may miss out on providing a "new deal" of care for many patients who are in hospital and whose particular problems might not necessarily fall within the expertise of the intensivist/physician (eg, falls in hospital, paediatric problems, or dementia).

Our contention is that this role demands not the narrow focus of the specialist but the broad-based knowledge of the generalist -- someone who can be a "jack of all trades". The preceding contributions to this debate^1,2 appear to have as their central vision a hospital filled with medical patients or seriously ill surgical patients who would be better managed by a physician. Most hospitals have, and will continue to have, a much wider range of patients and conditions, including all the major and minor acute problems that one finds in paediatric, gynaecological, obstetric and psychiatric wards.

We believe the role calls for a "middle management" doctor who has a breadth of knowledge and experience gained from working in hospitals and who is proficient in as many branches of hospital medicine as possible. The optimal solution is to have someone who is conversant with and experienced in treating seriously ill patients expeditiously, who is quite at home in managing the multiple minor problems that beset hospital patients, and who is used to consulting with a wide range of medical and surgical specialties as needed.

The role of hospitalist should be complementary to, not in confrontation with, the established Australian model of inpatient care. That is, it seems to us better to have an experienced doctor "on site" to organise -- not take over -- the management of the hospital inpatient. There is some evidence that hospitalists who have complete control of inpatient care increase, rather than decrease, the length of stay in hospital.²¹

In the model we propose, the consultant physician, surgeon, paediatrician, gynaecologist, or, increasingly, general practitioner would retain primary responsibility for the patient's management, but would be actively supported by someone who had worked in the hospital system for many years and could competently manage most problems that may arise, at least in the short term. This doctor should also have the trust of, and rapid access to, the consultant staff, and good working relationships with the nursing and paramedical staff (mutual respect of each other's role and abilities) as well as a good understanding of the "mechanics" (eg, layout, routine, and regular practices) of the hospital.  

Many of the problems outlined above have in the past been handled by registrars, RMOs and interns. Senior registrars are usually quite able to manage patients without the direct supervision of the VMO; however, this is not necessarily the case with more junior registrars and RMOs. Again, frequent rotation takes well-performing doctors out of the loop just as they attain a level of familiarity and experience with a particular group of patients.

Although doctors who performed similar roles had been in the health systems throughout Australia for many years, CMOs were initially brought into service in New South Wales in the early 1980s to maintain experienced medical practitioners in the public hospital system. These doctors were working in posts as unaccredited medical registrars or emergency medical officers, particularly in suburban and rural hospitals. The New South Wales Department of Health¹⁰ noted in 1989 that there had been a positive response to the introduction of CMOs: it had increased retention rates of hospital doctors, improved middle grade medical staffing in peripheral hospitals, and addressed the service needs of these hospitals, and the individuals were able to undertake more clinical responsibilities and required less supervision. Many CMOs have now been working in these positions for well over 12 years, and have developed considerable expertise in their area of practice.

A recent study in Queensland,²² addressing the training needs and career paths of this cohort of doctors, noted their wide range of practice -- predominantly in emergency medicine ("they make up the majority of the senior emergency work force in Queensland"²²), but also in orthopaedics, sexual health, community health, and other areas. The report also pointed out the experience of those who worked in emergency medicine: 73% had worked for more than three years full-time since their third postgraduate year, and 25% had worked for 10 or more years in this capacity. Furthermore, a large proportion (69%) of CMOs had postgraduate qualifications. The study also commented on a major flaw in the Australian Medical Workforce Advisory Committee report The Emergency Medicine Workforce in Australia,²³ which totally ignored the role played by CMOs in the staffing of emergency departments. This omission seems to be symptomatic of a "blind spot" by some in the profession to the valuable service provided by these doctors.

Many modern private hospitals are turning to CMOs to fill a demand in the medical care of hospitalised patients. In the Sydney area the Hills, Kareena and the Sydney Adventist private hospitals have significant CMO staffing (Dr Stephen Delprado, Deputy Director, Emergency Department, Hills Private Hospital, personal communication), and seven private hospitals in Queensland have CMO cover.²²

Most CMOs report that they are quite happy to continue to work in these roles (J M E and M R D K, unpublished survey of 32 rural CMOs in NSW, presented to Directors of Clinical Training meeting, Postgraduate Medical Council, Sydney, May 1996). Recently, some have formed themselves into organised subgroups of the medical workforce. The largest of these (the Career Medical Officers Association) is now taking responsibility for initiating educational and industrial policies for CMOs. Examples of these are the provision of continuing medical education (in association with the Royal College of Pathologists of Australasia); discussions with universities and others about more formal training, qualifications and accreditation; and representations on various committees, including the Hospital Medical Officer Subcommittee of the Medical Training Review Panel.

We believe that this broad-based experience and commitment is what makes the CMO the ideal person to take on the role of the hospitalist. Furthermore, the changes necessary to do this are relatively minor and merely a continuation of recent trends in medical workforce utilisation in the modern Australian hospital. In our opinion, CMOs are well able to fulfil such future requirements and do it in the most efficient and cost-effective way.

We note the invitation by Scott and Phillips to put the respective views of hospitalist practice to the test in a randomised trial comparing the intensivist or internal medicine models of hospitalist.² Although we have some misgivings about the applicability of this methodology, we firmly believe that any rigorous evaluation of the various hospitalist models on offer would be incomplete without the inclusion of CMOs.

1. Hillman K. The changing role of acute-care hospitals. Med J Aust 1999; 170: 325-328.
2. Scott IA, Phillips PA. Hospitals and hospitalists: an alternative view. Med J Aust 1999; 171: 312-314.
3. Denaro CP, Bennett CJ. The changing role of acute-care hospitals [letter]. Med J Aust 1999; 171: 224.
4. Hillman K. Hospitals and hospitalists: an alternative view [letter]. Med J Aust 2000; 172: 299.
5. Sartain JB. Hospitals and hospitalists: an alternative view [letter]. Med J Aust 2000; 172: 299.
6. Phillips PA, Scott IA. Hospitals and hospitalists: an alternative view [letter]. Med J Aust 2000; 172: 299.
7. Komesaroff PA, Clunie GJA, Duckett SJ. What is the future of the hospital system? Med J Aust 1997; 166: 17-22.
8. Braithwaite J. The 21st-century hospital [editorial]. Med J Aust 1997; 166: 6.
9. Braithwaite J, Hindle D. Research and the acute-care hospital of the future. Med J Aust 1999; 170: 292-293.
10. Career Medical Officers (CMOs). Circular no. 89/156. Sydney: NSW Health, 1989.
11. Wilson RMcL, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471.
12. Wilson RMcL, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 1999; 170: 411-415.
13. Buist MD, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust 1999; 171: 22-25.
14. Lublin J, Gething L. RNs as teachers of junior doctors. Aust J Advanced Nursing 1992; 10(2): 3-9.
15. Agnew T. Just rewards on the wards. Nursing Times. 1995; 91(34): 19.
16. Junior doctors turn to nurses for help. Nursing Standard 1999; 13(47): 8.
17. Wachter RM. An introduction to the hospitalist model. Ann Intern Med 1999; 130: 338-342.
18. Sox HC. The hospitalist model: perspectives of the patient, the internist, and internal medicine. Ann Intern Med 1999; 130: 368-372.
19. Schroeder SA, Schapiro R. The hospitalist: new boon for internal medicine or retreat from primary care? Ann Intern Med 1999; 130: 382-387.
20. NAIP affiliates with the American College of Physicians. <http://www.naipon line.org/hist.htm>. Accessed 2 March 2000.
21. Jackson JL. The international experience with hospitalists. The Hospitalist 1997; Summer. Available at <http://www.naiponline.org/archives/guest.htm>. Accessed 2 March 2000.
22. Bricknall B, Daly M, Catchpole M. The career paths, training needs and future role of non-specialist senior medical officers in the Queensland public health care system. An exploratory study. Brisbane: Health Advisory Unit, Queensland Health, 1999.
23. Australian Medical Workforce Advisory Committee. The Emergency Medicine Workforce in Australia. Sydney: AMWAC, 1997. Summary available at <http://amwac.health.nsw.gov.au/corporate-services/amwac/emerg.htm>. Accessed 2 March 2000.

Kareen Private Hospital, Sydney, NSW.
Mary G T Webber, MB BS, Career Medical Officer, Emergency Department, and President Career Medical Officers Association.

Coffs Harbour Base Hospital, Coffs Harbour, NSW.
Michael R D King, FRACGP, FACRRM, Director of Emergency Services.

Camden Hospital, Sydney, NSW.
Michael Boyd, MB BS, Co-ordinator of Emergency Department.

Prince Charles Hospital, Brisbane, QLD.
Gabrielle du Preez-Wilkinson, FRACMA, AFCHSE, Medical Officer, Emergency Department.

Tweed Heads Hospital, Tweed Heads, NSW.
David Brock, MB BS, Career Medical Officer, Emergency Department.

Reprints: Dr J M Egan, PO Box 131, Goulburn, NSW 2580.
eganjATinteract.net.au

©MJA 2000
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