The hospitalist phenomenon is a response to the increased complexity of medical care in the 21st century. Expectations have risen in both the inpatient and outpatient setting for comprehensive mastery of increasingly complex and distinct practice environments. A significant element of modern hospital practice is driven by the increasingly demanding hospital regulatory environ- ment with its resultant privileging demands upon the physician practicing within the hospital. The hospitalist does not act in competition with the primary care provider, but rather, in coordination with the primary care provider.

The physicians hired by the hospital-based health systems are not seeking to lure more patients into the hospital in an acutely ill state, but rather to provide a safety net for those patients who require hospitalization.

Given the passage of the Affordable Care Act in 2010, all aspects of medical care have undergone significant growing pains as the health care system adjusts to the requirements of the law and evolving payment models. The quality metrics that are mentioned in the article by Kristen Consillio (“Hospitals sap private practices,” Star- Advertiser, Oct. 9) are part of the federal mandate to improve the care of all patients and often involve keeping patients out of hospitals and preventing readmission for complications. The article correctly mentioned that in the private practice model, physicians are paid based on quantity of care, not necessarily quality of care.

The article is absolutely correct in recognizing that there is a shortage of primary care physicians in Hawaii, but rather than target any hospital-based health system as contributing to a threat to primary care practice, these systems should be lauded for their contributions to the education of future physicians to help overcome the current shortfall. Given Hawaii’s remote location and the clearly documented reimbursement challenges that primary care physicians here face, it is critical that Hawaii have a mechanism to increase the number of physicians who are committed to living and working in Hawaii to improve the health of the population.

As part of that process, the John A. Burns School of Medicine relies heavily on our partners in the community, both in private practice, and based in hospital systems such as The Queens Health System, Hawaii Pacific Health, Kaiser, Tripler Army Medical Center and the Veterans Administration Medical Center, just to mention a few.

We rely on them for clinical education for medical students and medical residents with the ultimate goal of retaining large numbers of those students and residents here after graduation. We respect the steps that our health care partners have taken to create the safest environment they can when patients are hospitalized and look forward to further collaborative efforts to improve care and transitions of care for patients to return to their primary care providers when they are ready for discharge home.

Future steps include the development of strong partnerships between community-based primary care practices with the hospital-based health systems. Such partnerships will have shared care goals for chronic disease management that will minimize hospital admissions and maximize healthy living for our patient populations. Teams of ambulatory health care providers (including physicians, nurse practitioners, pharmacists, and others) will coordinate care that will prevent disease, care for minor illness and injury and manage chronic illnesses before these conditions require the need of hospital-based providers.

Today’s — and tomorrow’s — health care provider is no longer a generalist who is able to manage a full clinic practice while delivering the ward-based continuity of care in the hospital system. Practitioners must choose their practice environment, and health systems must be constructed to strengthen the hand-off between the practice settings.

It is clear that the financial and regulatory factors that have driven this divided practice environment must also evolve to permit seamless transitions for patients and their families between the community and the hospitals.

Holly L. Olson, M.D., is an assistant OB/GYN professor and deputy director of graduate medical education at the University of Hawaii John A. Burns School of Medicine.