Recent changes in the delivery of health care in the United States include the creation in many hospitals of positions staffed by internists whose entire or principal focus is the treatment of patients admitted to hospital wards. This new function differs from the role of the primary care physician, who is responsible for the treatment of patients in all care settings, ranging from outpatient clinics to inpatient service. Those who fill hospital positions often serve the needs of an academic medical center or a managed-care system, and this new kind of practitioner has been dubbed the "hospitalist." The editors of this textbook are among the academicians who first described the emergence of this phenomenon, and as they note in the preface to this book, there is no textbook for this new niche of internal medicine that uses the hospital admission as the unit of analysis. This textbook is an excellent attempt to fill this need and provides much essential information for the hospitalist. It should be equally useful for general internists, family practitioners, and physicians in training.
Hospital Medicine is extremely well organized and user-friendly. The structure of individual chapters facilitates scanning for information; there is a statement of key points at the conclusion of each chapter. Chapters also conclude with lists of core references and recommended additional reading. The introductory chapters identify and discuss general issues and survey management problems common to many hospitalized patients. They also describe important tools of the trade of the hospitalist: practice guidelines, clinical pathways, quality improvement, and decision analysis. The themes of evidence-based, cost-effective, and protocol-based care resonate throughout the book and are woven into discussions of the management of individual disorders. Algorithms and critical pathways are reasonably embedded in the discussion of the particular clinical entity and do not suggest a cookbook approach to care.
A section on consultation medicine is clear and succinct. It contains excellent chapters on preoperative evaluation, postoperative care, and medical complications of pregnancy that have relevance for consultation by a general internist to patients whose cases are managed primarily by surgeons and obstetricians.
The core of the book consists of chapters describing 75 of the most common conditions leading to the hospitalization of adults. These topics include almost all of the problems that would confront a clinician on the wards of a community or academic hospital. Much of this information is organized according to organ system, and introductory chapters discuss relevant signs, symptoms, and laboratory abnormalities. These chapters discuss practical aspects of treating inpatients, including indications for hospitalization, triage to monitoring environments in the hospital, cost considerations, resource use, and discharge from the hospital.
Some of the topics are peripheral to the typical practice of a hospitalist -- lung, heart, liver, and bone marrow transplantation; lung-reduction surgery; and leukemia. I also wonder about the usefulness of the chapters on critical care medicine. In some hospitals, intensivists have expanded their activity to include the evaluation and management of ward patients. For these subspecialists, the information that is provided on critical care medicine would be unnecessary, and it would most likely be insufficient to enable generalists without training in critical care to treat unstable patients with respiratory failure or multisystem organ failure. Nonetheless, it is probably best to be inclusive rather than exclusive in a book such as this, since in some environments hospitalists may provide cross-coverage in these complicated cases that typically require multiple subspecialists. It is also true that, in the rapidly changing models of care and practice, the focus and boundaries of the role of the hospitalist have not yet been fully defined, and refinement of the information base that is appropriate for practice as a hospitalist will no doubt continue in subsequent editions of this book.
How does Hospital Medicine differ from a standard internal-medicine textbook? Although much of the disease-specific information overlaps with that provided in such books, the organization of Hospital Medicine enables it to describe many clinical problems as they are typically encountered and managed over the course of an entire hospitalization, with emphasis on the practice of evidence-based medicine by a hospital-based internist. The reader is led through a logical and clear sequence of diagnostic and therapeutic management steps that will be useful with any patient whose admission to the hospital is precipitated by one of the clinical entities covered here, and whose course is dominated almost entirely by that entity. A challenge for these educators as they refine the syllabus for hospitalist medicine will be to present this information in ways that make it applicable to patients with multiple chronic and acute problems, a reality that is all too common in most hospitals. In the meantime, Hospital Medicine should serve as an extremely valuable guide to the care of the hospitalized patient.
Jesse Hall, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to an alternate
Hardcover
edition.
