Introduction A fast-growing specialty in medicine, the hospitalist is a physician who works solely in the hospital to administer general medical care of a patient, coordinate all care from specialists and ancillary staff, and return the care of the patient to the primary care physician upon discharge.     In the last few years, the number of physicians going into this specialty has skyrocketed – from 1,000 physicians in the mid-1990s to 28,000 today and growing, according to President & CEO of Beth Israel Deaconess Medical Center in Boston Paul Levy. At the April 9 seminar of the Society of Hospital Medicine, held in Washington, D.C., Levy said that hospitalists are now the largest specialty group in the U.S.    A study published in the August 2009 issue of Archives of Internal Medicine found that institutions using hospitalists provider higher quality care to patients with acute myocardial infarctions, heart failure and pneumonia. Additionally, other earlier studies indicate that hospitalists increase hospital efficiency by decreasing length of stay, reducing hospital costs and readmission rates, and result in higher patient satisfaction. These outcomes are thought to be attributed to better coordination of services in the hospital because of the familiarity of hospitalists with organizational structure and daily routines within various hospital departments. This model also appealed to primary care physicians who value the additional time it gives them to attend to the demands of a busy office practice. Specifically, the primary care physician saves a few hours a day traveling to the facilities where patients may be admitted, which could be a significant time savings if the physician has privileges in more than one hospital.   Shorter lengths of stay meant that the few patients remaining in the hospital were extremely ill, and there was palpable pressure to expedite their discharge. This resulted in changes to the pace of hospital care. It became faster, and at the same time, the patients who were discharged required more attention from their primary care physician for continued care. Time pressure, increasing patient acuity and complexity of inpatient care, as well as pressure to reduce cost, convinced many hospital leaders (and the clinicians that the hospitalist can serve) that hospitalists could, indeed, play a valuable role. The net effect is increased productivity and revenue. Today, hospitalists work in many areas of the hospital; they are in the ICU and CCU, the ED and the medical and surgical units. They oversee many aspects of a patient’s hospital care and communicate with other physicians, case managers, patients and family members. The availability of this dedicated hospital-based physician has made a positive impact on inpatient care. There is better coordination of care, which improves quality and efficiency that could translate into better outcomes. However, for this coordinated approach to the care of the patient to be successful, it requires the hospitalist to have effective communication skills. Hospital Risks Recognizing the benefits of this growing specialty, there is a need to acknowledge the risks associated with it as well.  The risk to the hospital that utilizes hospitalists is similar to the risk typically associated with having independent contractors such as the physicians in the ED, radiology, anesthesiology and others who are contracted by the hospital to provide patient care. The hospital may be held liable for the negligent acts of these physicians under an “ostensible agency” theory. Knowing this potential, the hospital can mitigate these risks by clearly identifying the hospitalists as independent contractors in patient consent forms (if that is, indeed, the case) and by implementing proper credentialing and privileging, as well as having a good peer review system in place.   Primary Care Physician Risks Is there a risk to the primary care physician? It is surprising to think that there is risk to the primary care physician when in fact they don’t provide the care to the patient when the patient is in the hospital.  The risk does exist, however, when there is a perception by the patient of abandonment, or when the patient is lost to follow-up. If the patient does not understand that the care in the hospital is being provided by a hospitalist during the inpatient hospitalization, the patient may assume that he or she has been abandoned by their primary care physician. It is important that this is explained to the patient and family prior to admission, if at all possible.  It is likewise important that the responsibility for the follow-up be clearly determined so that there is continuity of care and the patient is not lost in the process. Generally, the patient is returned to the care of the primary physician on discharge; therefore, follow-up care becomes the responsibility of the primary care physician. It becomes very important then that key information regarding the patient’s follow-up care needs is provided by the hospitalist. This information can be communicated by providing a discharge summary or, at the very least, a provisional summary along with key information about the patient’s hospital course and plan for continued care. This includes the main diagnosis, results of procedures and laboratory tests, discharge medications and changes to the previous medication regimen, if applicable, with reasons for the change. It is equally important that follow-up arrangements and any instructions given to the patient and family are communicated to the primary care physician.   Hospitalist Risks As the previous paragraph discusses what needs to transpire at discharge, one can only appreciate the need for an effective handoff. Ineffective patient handoffs can lead to inappropriate or lack of treatment.  This is particularly important when a test result is not available at the time of discharge and intervention may be required, pending the result. The failure of the hospitalist to communicate this information to the primary physician can lead to a delay in diagnosis and therefore increases everybody’s potential exposure to liability.  Poor communication between the primary care physician and the hospitalist is sometimes referred to as the “Achilles heel of the hospitalist movement.”   To facilitate better communication, some hospitals and hospitalists have developed a systematic approach to handoffs to reduce their liability exposure and prevent disastrous outcomes.  The primary purpose is to provide a framework for the accurate communication of information about the patient’s care, treatment, current condition and any recent or anticipated changes. An effective approach involves:   ·         Use of standardized communication tools. ·         Use of an interactive form of communication to allow for questions/discussion and require repeat-back of the exchanged information. ·         At a minimum, the following information should be provided: diagnoses, current condition, recent changes in condition or treatment, anticipated changes, and warning signs of changes in the patient’s condition. ·         Limited interruptions. ·         Communication that is clear, sincere and open. Establishing Trust Finally, both primary physician and hospitalist need to develop a trusting and supportive relationship. There will always be challenges, but open communication is important for all healthcare providers in any setting.  Use of the following questions for guiding what information is communicated during the handoff can be quite helpful.    ·         What is important to communicate? ·         Who needs to know what information? ·         When should communication occur? ·         How should the information be transmitted? ·         How can I validate the communication was successful?