The hospitalist: a US model ripe for importing?

To the Editor: We read with interest Hillman's editorial on the hospitalist movement.1 As our group includes a couple of recent expatriates from the Canadian healthcare system,* we can give some historical perspective on the evolution of the hospitalist in Canada, some of which parallels what is happening in Australia.

Traditionally, family physicians (general practitioners) in Canada were able to manage their patients in hospital, either as the primary care doctor or in consultation with a specialist. Not infrequently, the specialist would assume primary care and consult with the family doctor. Continuity of care was assured, and both the family doctor and the specialist benefited socially and professionally from the interaction. The "corridor consultation" thrived and the doctor's lounge was a source of medical education and social interaction as GPs and specialists met over a morning coffee before rounds.

Around 10 years ago, the family doctor became increasingly unwelcome in the hospital, particularly in teaching centres. As there was never a financial incentive to be involved in hospital practice, this atmosphere persuaded most family doctors to resign their hospital privileges. However, it soon became apparent that a visiting-consultant-based service could not cope with the numbers of patients being admitted to hospitals. Patients with no apparent "teaching value" were becoming difficult to admit into teaching units. Consequently, those few GPs who had retained hospital privileges were increasingly being asked to accept patients primarily under their care. As the system became more stressed, they found that they were managing more and more acutely ill patients. These experienced GPs evolved to become hospitalists — essentially, primary care doctors who were prepared to look after acutely ill inpatients, often in consultation with a specialist.

Unfortunately, attempts to encourage GPs back into the hospital system have generally proved unsuccessful. The College of Family Physicians of Canada, recognising that there may no longer be ready access to specialist services or hospital beds, is starting to train its residents accordingly.

We agree with Hillman that the complexities of acute medicine require specialists (such as emergency physicians, intensive care specialists and general physicians) with training and skills in acute medicine, resuscitation and multisystem problems. Indeed, our experience in rural Australia suggests that hospital-based multidisciplinary critical care physicians are already undertaking some of the hospitalist roles that Hillman describes. Perhaps we are witnessing the emergence of hospitalists in Australia.