PHYSICIANS The Role of The Hospitalist By MARIE ROHDE obert M. Wachter, MD, jokes that if he had trademarked the term “hospitalist” 18 years ago when he coined it, “I’d be on my yacht today.” Hospital medicine had always been R rooted in the tradition of individual physicians visiting the hospital to treat their own patients. In 1995, Wachter, chief of the division of hospital medicine at the University of Cali- fornia, San Francisco (UCSF) Medical Center, was asked to come up with a more efficient model of inpatient care. As he did his research, Wachter came across The number of hospitalists in the U.S. is diffi- a couple of examples of physicians who worked cult to pin down, because there is no “hospitalist” full-time in hospitals to provide care for patients certification for physicians who wish to specialize during their hospital stay. in hospital medicine. “I soon found I had spotted a trend,” Wachter “Right now, to be a hospitalist is a self-pro- said, and he came up with a term to describe it: claimed thing,” said Burke T. Kealey, MD, a hospi- hospitalist. He and co-author Lee Goldman, MD, talist with HealthPartners Medical Group based who at that time chaired UCSF’s department of in Bloomington, Minn. “You could be board certi- medicine, published in the New England Journal fied in internal medicine, family medicine or pedi- of Medicine their observations about the growing atrics,” said Kealey, who works at Regions Hospi- role of hospitalists.1 tal in St. Paul. “There are even some specialists.” After medical school, most physicians who HOSPITAL MEDICINE want to specialize in hospital medicine train The hospitalist is the primary overseer of care for as residents in general internal medicine, gen- the hospitalized patient from the time of admis- eral pediatrics or family medicine, according to sion to release. The hospitalist team works around the Society of Hospital Medicine professional the clock, focusing on the patient’s condition or membership group.2 Some also gain experience acute illness and determining the best treatment. by taking a post-residency program in hospital A major part of the hospitalist’s job is to commu- medicine. nicate with the patient’s primary care physician Kealey, who is president-elect of the Society and coordinate post-hospitalization care. of Hospital Medicine, noted that the American HEALTH PROGRESS www.chausa.org MAY - JUNE 2014 27 Board of Internal Medicine and the American It is generally accepted that hospital medicine Board of Family Medicine each offers a designa- represents the fastest growing medical specialty tion that recognizes a board-certified physician’s in history. A generation ago, a specialist in hospi- “focused practice in hospital medicine,” but these tal medicine was unheard of. The Society of Hos- are not separate or subspecialty certificates under pital Medicine reports there currently are 44,000 the boards’ definitions. hospitalists working in the U.S. and that they are Though the hospitalist works full-time in the present in 72 percent of America’s hospitals. hospital, taking care of patients isn’t his or her Of the 640 Catholic hospitals in the U.S., more only role. “The other part of the job is taking care than half say they have hospitalists. About half of of the system,” Kealey said. “We all know that our the hospitalists employed by Catholic hospitals hospital system has much that needs to be done. are direct employees, while others are employed The hospitalist is in a unique position to look by individual contract or group contract, accord- around and see what needs to be improved, dive ing to the 2012 American Hospital Association in and fix the system.” annual survey, the most recent data available. THE ROLE OF THE HOSPITALIST CONTINUES TO DEVELOP till in its adolescence, the hospitalist dency,” she said. said. “We also have more at stake. When Smovement is grappling with train- The hospitalist often serves as the you are employed by the hospital, you ing and certification issues, expanding quarterback, Schulwolf said. That means have more reason to make sure that all of duties, physician work shifts and how to coordinating with the patient’s primary the guidelines are met.” serve rural areas. care physician during the patient’s hospi- The reputation of the hospital is also Elizabeth Schulwolf, MD, a hospitalist tal stay as well as coordinating post-hos- the reputation of the hospitalist. “We for eight years, is an assistant professor pitalization care at home or in a recovery have found that our [patient] satisfaction and medical director for hospital medi- facility, she said. scores are on par, sometimes better, than cine at Loyola University Medical Center Marianne Hamra, MD, a hospitalist other physicians,” she added. in Maywood, Ill. She believes hospitalists who was recruited in 2011 to create a Hamra was given latitude to develop need additional training with an empha- program for St. Francis Hospital in Roslyn, the hospitalist program at St. Francis, the sis on neurology, hospice and palliative N.Y., said it’s easier for a physician who is last Long Island hospital to have such a care and consultative medicine, as well as in a hospital all the time to assess what program. The impetus was the chang- quality initiatives. works there and what doesn’t. ing health care landscape. “There are so “We’re seeing a growing complexity “We are very much aware of readmis- many new criteria and guidelines set for of patients,” Schulwolf said. “We’re all sion rates, numbers of days and other us by CMS [Centers for Medicare and seeing patients with multiple complex measures that the primary care physician Medicaid Services] that hospitals need to problems. Many surgeries are being per- doesn’t have time to consider,” Hamra comply with — readmission rates, core formed late in life.” measures,” she said. Few academic programs offer a hospi- “We have a wide base of Initially the St. Francis medical staff talist track, and, generally, internal medi- was hesitant, mostly because they were cine residents are ready to practice hos- physician referrals who not familiar with hospitalists or hospi- pital medicine after residency, she said, want the patient admitted talist programs. “After our first year, we adding that a small number of hospital- under our care. The were widely accepted,” Hamra said. “We ists in her program do a rotation on surgi- have a wide base of physician referrals cal co-management. In co-management, nurses are happy that we who want the patient admitted under the surgeon manages the surgery-related are around all the time, our care. The nurses are happy that we treatments, and the hospitalist manages because we can answer are around all the time, because we can the patient’s other medical needs. answer their questions. The length of “It is a unique knowledge base, and it their questions.” stay, the readmission rates, mortality takes time to learn it outside of resi- —MARIANNE HAMRA, MD and complications are all lower when you 28 MAY - JUNE 2014 www.chausa.org HEALTH PROGRESS PHYSICIANS COSTS AND CARE “It’s a very large cost for most hospitals,” said In their article, Wachter and Goldman, who is Wachter. “Most hospitals support their program now dean at the Columbia University College of to the tune of $100,000 per FTE [over billable Physicians and Surgeons in New York, concluded services]. The return on investment seems to be that hospitals’ need to control costs while provid- shorter lengths of stay, lower costs, higher quality ing quality care brought about the new model for and better coordination because these doctors are inpatient care. working to improve systems of care.” Cost control and quality care are still driving The hospitalist’s role is continuing to evolve. forces, intensified today by publicly reported per- Because the hospital is his or her home base, the formance measurements as well as new govern- hospitalist is uniquely qualified to look for ways ment regulations and insurer demands. So, though to improve how hospitals function, leading some Wachter and other hospitalists acknowledge hos- of these physicians to take on administrative and pital medicine programs require an investment, managerial roles, Wachter said. they see bottom-line benefit over time. Hospitals also have come under pressure from With hospitalists on staff, most hospitals find that fatigue. We had to look at what is sustain- codes dramatically decrease because there is less able. It works for us, but it might not be the best for every hospital.” opportunity for conditions to go unchecked. Mercy Medical Center had hospitalists before the name “hospitalists” existed; compare it to [those of] internists and a physician to do other things. Some three of those on staff have worked in family practitioners.” use the time off for teaching or getting the field for 18 years or more. Ahtaridis St. Francis has seven full-time hos- involved with projects at the hospital said that with hospitalists on staff, most pitalists, 12 others who work per diem level.” hospitals find that codes dramatically have a regular eight-hour shift with Burke T. Kealey, MD, a hospitalist with decrease because there is less opportu- some weekend duty. Two others are HealthPartners Medical Group based in nity for conditions to go unchecked. The nocturnists, hospitalists who work night Bloomington, Minn., said the physicians conventional hospital model was for a shifts, usually the conventional 12-hour in his group also work a seven days on, physician to see his or her patient once a shift, seven days on and seven off. On seven off schedule. “There are a couple day, before or after clinic hours, meaning average, each hospitalist sees about 15 of advantages,” he said.