Practice Management

A U.S. model for Italian hospitals?


 

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.

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