The role of the hospitalist continues to expand – and so do the challenges
By Bobbie Fisher
In the August 15, 1996 issue of The New England Journal of Medicine, Robert M. Wachter, MD and Lee Goldman, MD wrote an article describing the growth of managed care in the American health care system at that time as “explosive,” leading to “an increased role for general internists and other primary care physicians.” In their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Drs. Wachter and Goldman defined the role of these specialists, and coined the name by which they are known today.
These authors were almost prescient in understanding how hospitalists – physicians who practice inpatient medicine exclusively – could assume the care of hospitalized patients, relieving overburdened primary care doctors with less and less time to make hospital rounds; and – by devoting themselves solely to hospital work – how they might function to facilitate the transition to the implementation of the Affordable Care Act.
“Hospitalists were created to respond to a need,” says Lisa Huang, DO, a Board certified internal medicine physician who works with Bayview Physicians Group at Chesapeake Regional Medical Center. “The traditional internal medicine doctor had to round on patients, then go to the office to see patients, respond to any hospital-based emergency, and return to the hospital to see patients in the evenings. It put a tremendous strain on the doctor.”
Hardik Vora, MD, MPH, Medical Director of Hospital Medicine at Riverside Regional Medical Center, elaborates: “When they were working that traditional schedule, going back and forth from the hospital to the office, it was challenging, especially when they had a full clinic schedule and had to respond to ER/hospital calls in the middle of the night. Physicians were burning out.”
When Dr. Wachter and Dr. Goldman coined the term ‘hospitalist,’ they envisioned a model where doctors would work exclusively in the hospital, taking some of the burden of the primary care physician. The goal of the model, says Peter Paik, MD, Medical Director of the Hospitalist Group at Bon Secours’ Maryview Medical Center in Portsmouth, was “to provide more continuity of care, so that physicians who are in the outpatient setting could focus on that, rather than having to run back and forth to the hospital. Hospitalists can focus on the patient from the moment he or she is admitted.”
Such focused care has greatly benefited acutely ill patients, who need access to their doctors 24 hours a day, says Colin Findlay, MD, Chief of Hospital Medicine at Sentara Medical Group: “These patients are generally sicker, and as hospitals are increasingly dealing with only the most acute phase of care, it becomes more and more important to care for patients as quickly as possible.”
Thus, hospitalists have become an important aspect of any hospital’s safety improvement plan. “It’s an essential mission of every hospital to minimize the risk to its patients,” Dr. Findlay says. “Hospitalists focus on things that improve patient safety.”
Hospitalists work at a specific hospital, often affiliated with various primary care practices. Tamara Jones, MD, is a Board certified internal medicine physician, and a hospitalist who works with the EVMS Internal Medicine Group at Sentara Norfolk General Hospital. She explains the benefit of the hospitalist to the PCP: “Because we work exclusively at the hospital, we’re available at all times during our working day to meet patients and their families, to order and follow-up labs and other tests, and to respond immediately to problems that might arise, in the moment. And we can see patients as many times a day as is medically necessary.”
The role of the hospitalist is not to do everything, these physicians caution; rather, the hospitalist needs to be an effective team captain, coordinating the patient’s individual needs and calling for specialists when indicated. Because all of their cases are inpatients, these physicians have particular expertise in dealing with the myriad issues such patients face.
And because hospitalists work solely in the inpatient setting, they have enhanced knowledge of their hospital’s operating procedures, greater familiarity with hospital staff and a sense of stewardship over the facility’s resources, all of which lead to greater efficiency. Indeed, studies continue to show that when hospitalists assume inpatient care, hospital stays are shorter and health care expenditures are lowered.
There are benefits for hospitalists, as well – more flexible schedules mean more time to spend with patients, without the worries that come with managing an individual medical office practice. In an office, when patients are scheduled every 20 minutes, there is always the sense of urgency to get from one patient to the next. “In the hospital, if I need to spend 90 minutes with a patient or family, I can do it,” Dr. Jones says, but concedes that can sometimes result in 14-hour days.
Fourteen hour days and longer are often par for the course for hospitalists, because they know the relationships between them and their patients is absolutely crucial – and they know they must be established and solidified quickly. Building relationships with patients on short notice can be a challenge. Often when they’re admitted to the hospital, it’s under acute and very stressful situations, Dr. Huang notes, “so we have to create that bond so patients can trust us to take care of them while they’re there.”
It takes a certain skill to build that trust in a short period of time, and that’s something that can’t always be learned in medical school. “But the fact is, we’re there in the hospital all day, and we can take more time with each patient,” Dr. Paik says. “We can sit down and chat with them and with their families, and not necessarily always about medicine or their care. That allows us to really connect with patients.”
Equally important as building a relationship with a patient is establishing a good working relationship with the patient’s primary care physician. Each hospital has its own protocol for communicating with its patients’ PCPs, but these hospitalists emphasize that this is a vital element of successful treatment and transition. If a patient’s stay is lengthy and complex, the hospitalist will generally call the primary care physician more often, sometimes even daily, to confer. If the stay is less complicated and the patient’s course uneventful, the hospitalist will forward dictated notes regarding the hospitalization at the time of discharge.
The role of the hospitalist doesn’t end there, however. “We take responsibility for ensuring our patients transition home safely and effectively,” Dr. Findlay confirms. “All patients need intensive coordination of care between their hospital stay and their resources at home.” If patients don’t have a primary care physician, Dr. Paik says, “we find them one – even if they don’t have insurance.”
There are some hospital programs that have started post-discharge clinics, Dr. Vora notes. “These are especially appropriate for patients who don’t have a primary care physician or can’t get an appointment with their PCP right away,” he says. “In the current health environment, they can have to wait as much as two months or more. So we will often give these patients our contact information so they can call us if they have questions. We are definitely there to help them through that phase.”
The American Board of Physician Specialists (ABPS) was the first physician certification body to recognize the emerging importance of hospitalist certification. In 2009, the ABPS developed the nation’s first board certification for hospital medicine, the American Board of Hospital Medicine (ABHM). Not merely a subspecialty of internal medicine, hospitalist certification through ABHM carries all the standing and prestige of a distinct and vital medical specialty.
The American Board of Internal Medicine (ABIM), recognizing the multi-faceted value of these specialists and the growing number of physicians who were concentrating their practice on inpatient medicine, developed a certification program called “A Focused Practice in Hospital Medicine” to accompany Board-certification in internal medicine. In addition to meeting the criteria to be Board certified in Internal Medicine, a physician is required to earn additional credits in Practice Improvement Modules and then sit for a separate test in hospital medicine. EVMS’ Dr. Tamara Jones will sit for the exam in October, and will become the first hospitalist in Hampton Roads to earn the certification.
The American Board of Family Medicine (ABFM), in conjunction with the American Board of Internal Medicine, has similarly established a Recognition of Focused Practice in Hospital Medicine program, in response to the growing number of ABFM-certified family physicians who are primarily caring for patients in a hospital setting.
“About 80 percent of practicing hospitalists are internal medicine physicians,” Dr. Vora notes, “while 10 to 15 percent are family physicians and about five percent are pediatricians.” However, he notes, there are increasing numbers of surgeons, orthopaedists, OB/GYN physicians and others who are going into hospital medicine. There’s even a word for surgeons, Dr. Jones says. “They’re called surgicalists.”
