I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful. We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalised patients. These were heady times.
I experienced déjà vu last week in a nondescript conference room at a San Francisco airport hotel, where the Society of Hospital Medicine and the American Hospital Association gathered a dozen folks to discuss specialty hospitalists. Representing the ‘traditional’ hospitalist field (I never thought I’d say that) were SHM CEO Larry Wellikson, SHM co-founder John Nelson, SHM president-elect Joe Li, pediatric hospitalist Erin Stucky, and me. We were joined by AHA Senior Vice President John Combes. But the real stars were six leading physicians in new subspecialty hospitalist fields: a neurohospitalist (Dave Likosky), two surgical hospitalists (John Maa and Leon Owens), two ob-gyn hospitalists (Rob Olson and Ken Jacobs), and even an ENT hospitalist, Matt Russell. Here’s what I learned:
The Neurohospitalist: “Neurologists have left the building”
At my yearly hospital medicine CME course, I ask the 600 attendees what topics they believe they need to learn more about. The top answer is always neurology. Why? Because most neurologists are perfectly content to remain in their offices seeing headaches and neuropathy; few want the pressure and hassle of managing acute strokes or status epilepticus. When the neurologist ‘has left the building’, which is most of the time, medical hospitalists are left to pick up the pieces.
While a well trained internist-hospitalist can handle large swaths of hospital neurology, as the cases get more complex, patients benefit from the expertise of a real-live neurologist. Because of the time sensitivity of stroke management (brain attack), many hospitals have had to establish elaborate emergency call rotations, or even outsourced their ED stroke assessment to teleneurologists. But some forward thinking organisations - particularly those seeking to be ’stroke centers’ - have seen the wisdom of hiring hospital-based neurologists.
I’m familiar with neurohospitalists since my University of California, San Francisco (UCSF) colleague Andy Josephson did much of the field’s pioneering work. While some neurohospitalists have received formal training in neuro-intensive care, many neurohospitalists have not. At UCSF, in fact, a troika of new ‘ists’ now cover different segments of neurological care: neurointensivists manage ICU patients; neurohospitalists handle neurology inpatients and much of the ED consultative work; and medical hospitalists co-manage neurosurgical patients. While our neurohospitalists serve as physicians-of-record for their own inpatients, at Likosky’s hospital the neurohospitalists serve as consultants; the neuro patients’ primary service is the medical hospitalist service. As in virtually all hospitalist arrangements, the hospital either hires the neurohospitalist or provides financial support for the role.
There are now neurohospitalist fellowships, and a textbook and journal (The Neurohospitalist) are on the horizon.
The Surgical Hospitalist: One solution to the ED crisis
Surgical hospitalists (or acute care surgeons - most surgeons apparently hate the ‘H Word’) emerged as a solution to the ED coverage crisis. As with neurohospitalists, hospitals found that they were paying more and more for ED surgical coverage, particularly on nights and weekends. Eventually, many decided that they might as well use their dollars to support a dedicated cadre of acute care surgeons, who were always available to see patients promptly and operate rapidly.
In a program’s early years, the surgical hospitalist often works up patients for community-based colleagues and then hands them off for the actual operation. Over time, the hospitalists frequently evolve from a “can you cover me this weekend” relationship to one in which they perform most surgeries themselves, as community surgeons become less enthusiastic about coming into the hospital for acute cases, preferring to focus on their office practice and elective cases.
Scheduling is interesting. In most programs, I’m told, surgical hospitalists work 24-hour shifts, never two days in a row. (A typical job description might be 8 to 10 such shifts per month). This makes for an attractive job for the surgeons (“we wouldn’t be able to recruit without it,” one participant said) but no day-to-day physician continuity for the patients. Dr Owens’ practice softens this blow by having a dedicated daytime nurse practitioner, present at the start and end of each day and responsible for information transfer from one day’s physician to the next. His perception is that patients don’t seem to mind the physician discontinuity because of the NP’s continuity. I’ll return to this point later.
The Ob-Gyn Hospitalist: “If you hear the baby cry, go away; if you hear me cry, come in”
One of the obstetric hospitalists at the meeting heard this quote from a family physician he works with. Family physicians are trained in obstetrics and are generally comfortable with routine deliveries. But the presence of the ob-gyn hospitalist has made deliveries by family practitioners much safer: the hospitalist hovers outside the room, immediately available should the family doc perceive early signs of trouble.
The ob-gyn hospitalist trend is growing rapidly and has received a fair amount of press (such as here), usually under the shorthand ‘laborist’. The two physicians at this week’s meeting don’t like that term - believing that it implies that they handle only the labor and a ‘real doctor’ comes in to do the delivery, or that they no longer do any gynecology. Their preferred term: ob-gyn hospitalist.
Like surgery, the typical ob-gyn hospitalist works 24-hour shifts (which makes more sense in ob than surgery because of the relatively brief labor and delivery cycle). The average ob-gyn hospitalist works about 7-9 shifts a month, which means that 4.5 hospitalists can cover a 24-365 call schedule.
These physicians are certain that they are improving safety for women and children, and the growth of the field to approximately 1000-2000 practitioners supports their claim. Hospitals and malpractice carriers have come to embrace the subspecialty as well. The reasons are the usual ones: constant availability (no more handwringing for the nurses, hoping that the obstetrician arrives before the baby does), increased expertise in handling complex cases, and standardization of processes. The result is better, safer care and, importantly, significantly lower malpractice risk, as demonstrated in this study.
The ob-gyn hospitalists claim not to be bothered by attending to a woman’s labor for 14 hours, then stepping aside when the patient’s obstetrician comes in to catch the baby (along with the professional fees for a delivery). I imagine that will change over time, but for now, these hospital-funded obstetricians - whose salaries don’t depend on their delivery volumes - see themselves as being there to serve, not only women but also the obstetricians and family physicians in their community.
In addition to improving safety and lowering malpractice risk, hospitals - and many pregnant women - are interested in decreasing the rate of unnecessary c-sections. Because the ob hospitalists can be there constantly and have more experience managing tough deliveries, they are less likely to pull the trigger for a c-section. And for women with prior c-sections who opt to try for a vaginal delivery the second time around (the so-called vaginal birth after cesarean, or VBAC), the ob hospitalists are more likely to give it a go. Converting even a small number of cases from c-sections to vaginal deliveries saves boatloads of money and increases the satisfaction of many mothers.
ENT Hospitalists: “The average age is 41: I’m 32 and the other guy is 50”
This is obviously a small niche - Matt Russell, recently hired by UCSF to be our first ENT hospitalist, believes he is only one of two such specialists in the country. I mention it to demonstrate how the hospitalist concept may be applicable even to smaller specialties. The forces are the same: sick patients, highly specialised providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement. Matt’s job is really to be an acute-care generalist ENT physician, expert in and available for complex airway management, as well as a variety of acute inpatient problems. Matt even does unsexy but vital stuff like cleaning out a hospitalised patient’s ear wax to test his hearing before an ototoxic medication is initiated.
What does all this mean
When I coined the term ‘hospitalist’ 15 years ago, I had in mind a medical hospitalist: a generalist physician who would take over inpatient medical care from the primary care physician or from the one-month-a-year academic ward attending. The field has become the fastest growing specialty in medical history because of the evidence that this model improves efficiency, quality, and education. While hospitalists began by doing tasks that others didn’t want to do (caring for uninsured patients, night coverage), their scope quickly expanded into other activities. In this way, the field followed the classic start-up model best described in the case of Southwest Airlines: begin by taking on tasks that others don’t want to do, perform them extremely well, and then expand into everything.
The specialty hospitalist represents the next stage of the evolution of the hospitalist idea. If dichotomizing inpatient and outpatient care is sensible for generalists (and it is), then the same might be true for some types of specialty care. But which ones? After hearing this week’s discussion, this is my checklist:
1. Is the number of inpatients who require the services of that specialty (either for consults or principal care) large enough to justify having at least one doctor in the house during daytime? As a rough guess, I’d peg this number at a minimum of 10-15 patients/day.
2. Is there a premium on urgent availability? When this specialist is needed, is it via a stat page, as opposed to “anytime this afternoon would be fine”?
3. Are most of the specialists stuck in the office or the OR for many hours at a time, making it difficult to get away when called acutely (see #2)?
4. Has the field become sub-sub specialised, such that many covering physicians are now uncomfortable managing common acute inpatient problems (i.e. the headache neurologist asked to handle an acute stroke; the ENT doc who spends her days seeing otitis and swollen tonsils now being asked to manage an airway emergency).
For specialties in which the answer to these questions is “yes”, I predict that we’ll see the emergence of specialty hospitalists, perhaps beginning with only a few physicians but growing to dominate inpatient care in the specialty over time.
What was particularly wonderful about last week’s meeting was hearing the common issues and the creative ways these new hospitalists are solving them. Of course, many of these issues and solutions have analogs to the ones we faced in the early days of the ‘medical’ hospitalist movement. Here are my thoughts on some of the emerging issues for specialty hospitalists:
1. What do we call ourselves? Whether people like it or not, the term ‘hospitalist’ is now generally accepted (now I really feel stupid for not trademarking it - Doh!), referring to a physician with broad skills whose practice centres on the hospital setting - and who focuses not just on the care of individual patients but on making the system work better. So I’d vote to extend this terminology to these new domains, thus:
• Internist (and FP) hospitalists are hospitalists.
• When internist-hospitalists co-manage patients on orthopedics, neurosurgery, or other specialty services, they are still hospitalists.
• Pediatric hospitalists are, er, pediatric hospitalists.
• And neuro, ENT, surgery, cardiology, ob-gyn, and psychiatry hospitalists are just that: “[name of specialty]-hospitalist.”
By my lights, ‘SNF-ists’ aren’t hospitalists, nor are rotating primary care doctors or surgeons who spend a little time in the hospital while managing their outpatient practice. You can’t be a ‘hospitalist for the day’ or the week if you aren’t a hospitalist generally, and you’re only a hospitalist (or a hyphenated hospitalist) if hospital care is your main professional focus.
2. Where do we live in our hospitals and healthcare organisations? I imagine the specialists will live within their specialties, and yet a matrix management structure will be needed, one in which all of a hospital’s hospitalists get together periodically to share ideas and concerns. I finished this week’s meeting committed to hosting a quarterly meeting of all UCSF hospitalists.
3. Which professional society represents us? I think this will mirror #2. I’m confident that all these specialty hospitalists will be welcomed with open arms by the Society of Hospital Medicine – and SHM will be a place to share information regarding practice organization, dealing with their hospital, and improving quality, IT, and other system-type issues. But it is inconceivable that SHM’s annual meeting will ever have enough content in acute care surgery, neurology or obstetrics to satisfy these specialists’ CME needs.
So specialty hospitalists need to continue to push their national societies (American College of Surgery, American Academy of Neurology, and so on) to launch and support vigorous hospitalist sections. Many specialty hospitalists are already seeing the predictable pattern: their specialty society initially rejects them as outsiders or weirdos (just as happened to us with ACP and SGIM 15 years ago), but ultimately does the math and realizes that by shunning their hospitalists, they risk losing the fastest growing, and youngest, segment of their specialty (“let’s see, 1200 hospitalists times $350 per year in dues - damn it, we need a hospitalist section!”). Trust me - they won’t love you on day one, but ultimately they will try to win you back.
4. Who signs my paycheck? The poor hospital CEO, who only paid a few dollars to physicians for coverage or medical directorship 20 years ago, now spends millions of dollars each year to guarantee physician coverage and engagement. That’s life. It is up to hospitalist groups of all flavors to ensure that the hospital is getting its money’s worth. Most smart hospital management teams quickly realize that, if they’re going to be paying for physician coverage anyway, they might as well give these dollars to a small cadre of docs who have committed themselves to hospital care and to aligned goals with the hospital. It’s a win-win.
5. How should programs be organised? This will have to be determined by trial and error. I wasn’t terribly excited about a program in which the patient sees a different surgical hospitalist every day. Even in medical hospitalist programs that have short spin-cycles (i.e. where the hospitalists rotate every few days), I commonly hear patient complaints about seeing “a different doctor every day.” This is tricky and there are tradeoffs - the program that emphasises daytime continuity (the same hospitalist works 5-10 days consecutively) pays the price with a separate system of night coverage. There are arguments on both sides of this one but the coverage schedule should be selected based more on the needs of the patients than of the doctors.
6. The role of evidence. One of the critical decisions we made in the early days of the hospitalist field was to be evidence-based: to describe why this model might be better, but then to wait until it was proven before we claimed that it actually was better. With few health policy/outcomes researchers in their midst, these smaller specialties may have a tough time developing this evidence, but the larger hospitalist field - and SHM - should help. This needs to be a priority.
7. The importance of systems improvement. Our other crucial move in the early days of the hospitalist field was to immediately embrace the safety and quality revolutions when they emerged in 1999-2001. The new hyphenated hospitalists should do the same - focusing on the unique safety/quality issues in their fields, but paying particular attention to the matter of discontinuity. The patient in the hospital now has a new doctor, for good reason. But it is up to us to ensure that nothing is lost in translation as the patient moves from outpatient to inpatient and back out again. Luckily, much of the heavy lifting on improving handoffs has already been done by traditional hospitalists, and many of the solutions are completely applicable to subspecialty hospitalist transitions.
With all of these specialty hospitalists joining forces with the existing generalist (medical and pediatric) hospitalists, the hospital’s ‘home team’ - a group of physicians committed to transforming hospital care - is now established. And, as a bonus, hospitals that manage to create and support high functioning hospitalist programs and develop a culture of physician-hospital collaboration focused on improving value have formed the nucleus of an Accountable Care Organisation. Because of this, I see the extension of the hospitalist model into this broad group of specialties as the most exciting thing that has happened to our field in the past 5 years.
Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.
This article appears in Hospital Dr by agreement with The Health Care Blog. THCB is one of the most respected independent voices in the healthcare industry in the US.