Intensivist or Hospitalist: What Is the Difference?

A reader asked the question:  What is the difference between a hospitalist and an intensivist?  What is a hospitalist? Well reader, quite simply, a hospitalist is usually an internist (but can be a pediatrician or a family medicine doctor) that only works in the hospital and an intensivist is usually a pulmonologist with critical care training that works in the ICU (and usually the pulmonary office as well).  Hospitalists generally do not follow the patient outside the hospital.  They do not have clinics.  Many programs use the shift model of care.  That is, the hospitalist works defined daily shifts and checks out at the end of the shift to their partner who would then address any patient care issues that may arise while their partner is off service.

This is the model of choice in big hospitalist programs  that can support the funding of overnight, in-house physicians.  Hospitalists who just work overnight shifts are called nocturnists.  They generally command a higher rate of payment than doctors who work the day shift.  And hospitalists who don't work any nights should expect to be paid less than those who do.

Shift hospitalist programs can be expensive to fund, mainly because many hospitals  do not have the patient  volumes  to support dollar for dollar nocturnal care.    Most programs shoot for 40 hour work weeks as the standard  shift model.  You can view the latest hospitalist salary  data here

Many smaller hospitalist programs use home call as their scheduling of choice.  In otherwords, the doctors take their pager home with them.  This is the way medicine has been practiced for decades.  This model allows fewer physicians to run a program while still having enough bodies to fill the needs of the program.  Unfortunately, I think some of the benefits  of in-house hospitalist medicine are lost with the home call model, specifically, the immediate bedside evaluation in patients with acute changes. Unfortunately, smaller programs just can't afford the cost of 24 hour a day in house physicians.

Some hospitals at larger referring centers will close their ICU.  What does this mean?  It means only critical care doctors and other subspecialists are allowed to practice medicine in the ICU.  I just filled out my recredential paperwork that gives me privileges at Happy's hospital. Intensive care  unit privileges are something that must be granted by the hospital credentialing committee.  If the hospital closes their ICU, they are basically granting  practicing privileges to some doctors and not to others.

Usually a closed ICU denies privileges to the primary care fields of internal medicine, pediatrics and family medicine.  This is why I hate the designation of internal medicine as primary care.  So much of what we internists are trained to do is complex, intense and critical. It's not primary care and it's not something that can be done, in full scope, by those without a medical degree. 

This is how my University medical center functioned  when I was a resident.  If a patient of mine required transfer to the ICU, I gave up care to the ICU team.  When they came back from the ICU, I would pick them up again onto my medicine service.  Why do hospitals close their ICU?  Perhaps there are concerns about the quality of care being offered by the pediatricians, internists and family medicine doctors.  I know a study a few years ago suggested better outcomes (I can't remember what was being measured) when hospitalists rounded in the ICU when compared with the intensivists.  If Happy's ICU ever turned into a closed system and denied my ability to care for ICU patients, I would quit.  Providing ICU care is part of the great satisfaction I have as a hospitalist.

How about the  intensivist?  Intensivists are usually internists who have gone on to specialize in a two year (or three year) pulmonary critical care fellowship.  The word intensivist is used to defined these doctors as their role in the ICU.  Usually, an intensivist is available for immediate consulation during a defined period of time.  Most hospitals, even large hospitals, cannot afford to have an in-house 24 hour a day  intensivist. As a result, most intensivists may have a set period of time, perhaps 7 am to 5 pm, as agreed on with the hospital, where they are in-house, doing multidisciplinary rounds with the nurses and respiratory therapists and pharmacists along with doing procedures and taking care of patients.

Happy's hospital has both a hospitalist program and an intensivist program.  In fact, we have two intensivist programs.  Both groups have privileges at both hospitals.  Happy's hospital system is awash in intensivists.  We have an excellent working relationship with our intensivists.  Happy's hospitalists will often admit the patient to the intensive care unit and  obtain a consultation with the intensivists if we think it is necessary.

I have heard over and over again that Happy's hospitalists have given back the lives of the pulmonary critical care doctors, doctors who used to come in at 3 am to admit simple pneumonias because the family medicine doctor didn't want to take the time to make an evaluation.  We offer a great service to the patients and the intensivists, and they reciprocate by helping us manage patients that need a higher level of expertise or procedures and other interventions we aren't trained to provide.

I am thrilled with the relationship I have with the intensivists at Happy's hospital.  They are always available, 24 hours a day to assist in the evaluation and management of critically ill patients.  Rarely will I ever  call them  in for  a middle of the night consult. However, I know if I need them they are available.

Often times both the intensivist and the hospitalist will round on ICU patients.  The intensivist will often  limit their evaluation and management to the pulmonary issues at hand.  Frequently, there are multiple subspecialists on the case in the ICU (renal, surgery, GI, pulmonary, cardiology, ID).  Sometimes, too many subspecailists are involved.  In these cases, the role of the hospitalist can be limited.

I try and avoid this scenario, as I know, and my experience tells me, that more doctors and more care will often have no good effect, and perhaps even a detrimental effect on the care patients are receiving. 

So there you have it. A hospitalist can do a lot of what an intensivist does in the ICU, but not all.  An intensivist generally does not do hospitalist work, because they have limited most of their practice to pulmonary and critical care issues.  While they could do some hospitalist work, I wouldn't want them evaluating an 89 year old with weakness  anymore than I would want me doing a bronchoscopy.


Facebook humor:

I once heard a doctor say, "I wish all my patients were on a ventilator". People in healthcare will appreciate the sentiments of this physicians for saying out loud what many people's filters prevent. People not in healthcare are probably asking, "What' is a ventilator" and have no idea why that doctor's statement is such a downer on them.


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