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Hospitalists: A growing trend in hospital care

Cover Story

Issue: June 2010

By: Mirene Benitez

Hospitalist programs are one of the biggest trends in the world of medicine, with a variety of models emerging at hospitals throughout the Bay Area. Utilizing hospitalists is a fairly new initiative in American medicine, with the term “hospitalist” first surfacing in 1996 in a New England Journal of Medicine article authored by UCSF’s Drs. Robert Wachter and Lee Goldman. The popularity of hospitalist programs is gaining traction as hospitals look for greater efficiencies and physicians seek more work-life balance.

“Hospitals need to be as efficient as possible and the quality of care needs to be as effective as possible,” says Lorraine P. Auerbach, FACHE, President and CEO of Seton Medical Center in Daly City. “Hospitalists bring an increased level of expertise focusing on inpatient care, which is more complex than outpatient care. They bring certain protocols, quality measures, systems and practices, and certain efficiencies that are beneficial for the patients as well as the hospital.”

With numerous admissions and discharges every hour, and a community physician base with increasingly busy offices, clinics, outpatient facilities, patients and hospitals all benefit from the full-time attention of qualified hospitalists. Nursing units no longer have to rely on on-call physicians to manage changing patient populations or the emerging needs of individual patients. A hospitalist program can calm the chaos, increase timeliness of care and improve patient outcomes even when, or perhaps especially when, a patient’s primary care physician is unavailable.

On site and on call

Labor and delivery, for instance, is a department all too familiar with the needs that arise when a doctor is absent. Obstetricians aren’t always available when their patients are ready to deliver. Having an OB hospitalist on site 24/7 significantly improves patient safety and can alleviate stress on the hospital, physicians, staff, and patients.

“It is to hospitals’ benefit to have hospitalist programs,” says Vicki Duncan, M.D., FACOG, a hospitalist at Good Samaritan Hospital in San Jose. “Things happen so quickly, especially in a unit like labor and delivery, that there’s not always time to wait for physicians to get in from home. It takes about 30 minutes. A baby in trouble cannot always wait 30 minutes. It makes medical sense to have someone there who is able to act in an emergency.”

Hospitalists are trained to devote most of their time to inpatient care. They may specialize in different fields of medicine such as obstetrics and gynecology or pulmonary critical care and become experts in the conditions they treat.

“The best thing about this job is the opportunity to have time to spend in patient care that allows you to focus, and allows you to be comprehensive and to deal with all the patients’ questions and the nurses’ questions without being distracted by outside interests,” says Irwin Shelub, M.D., of Seton Medical Center. “It allows you to be fully focused and fully committed, and I think doctors appreciate it because they train to take care of patients, not to do all these other things. Hospital management and the like are activities that are lifted from the doctor. They can be less the manager of operations and finances and more the manager of care.”

Bay Area models vary

Although many of the responsibilities of hospitalists are similar in different institutions, a range of models has been implemented in Bay Area hospitals. Seton Medical Center, for instance, uses a hybrid model, where an existing physician group provides services under the guidance of a hospitalist company.

“It is a combination of three parties contractually agreeing to provide hospitalist services, with each party having some proprietary interest in the enterprise,” Dr. Shelub explains. Auerbach further adds, “It’s sort of a three-way partnership between our group, the DCHMG (Daly City Hospitalist Medical Group); Cogent HealthCare, a hospitalist company; and the hospital, Seton Medical Center, so it’s a triangle as opposed to your typical two-way partnership, where the company brings in their own outside people.”

Good Samaritan Hospital in San Jose also has a hybrid model with two groups of hospitalists. The first group works only in the hospital, while the second group works both in private practices and in the hospital. This allows for community physicians to easily manage their practice and their time and ensures that there is someone available to do rounds and better serve patient and staff needs at all times. El Camino Hospital has two separate groups of hospitalists; one group takes care of community physicians’ patients staying at the hospital and the other group takes care of everyone else.

Benefits and challenges

Scheduling is one attribute that is especially attractive to hospitalists. Elaheh Firoozi, M.D., of El Camino Hospital in Mountain View, decided to become a hospitalist because of the set schedule and the ability to spend as much time with her family as possible. “Having a balance between family needs, academic performance and professional practice is very important to me. Being a hospitalist, I get to practice medicine and I have the flexibility to be with my family,” she says.

Dr. Duncan agrees that scheduling is great in comparison with running her own private practice. “When I’m on duty, I’m on duty. My only focus is to provide service. Once I leave the hospital, my time becomes my time. I can’t be called during dinner, I don’t have to miss functions…I have a life. I prefer this. I can deal with 24 hours and whatever they want done, as long as I am physically capable of doing it, it will be done within those 24 hours. When I leave, I am done.”

Although many hospitalists are doctors who had private practices in the past, many are also coming straight out of residency.

“I think that being a hospitalist is a good opportunity for young professionals coming out of residency to enter the real world of practice because it’s a good transition for them,” says Dr. Firoozi. “They have enough background in hospital medicine, and being a hospitalist will allow them to explore all the options of their professional life with regard to either going into fellowship, or staying in internal medicine.”

The American College of Physicians notes, “a handful of residency programs already offer special training tracks in inpatient medicine, and more are studying that option.” Hospitalists commonly do not have their own private practices and are committed solely to the hospital in which they are assigned to work.

There are challenges to being a hospitalist, however. “The times you spend in constant awry with answering calls and being responsive to nurses and their questions and patients and their questions could be a bit difficult at times," says Dr. Shelub. “From a global standpoint, balancing the need to be timely and efficient with the need to be thorough and comprehensive to ensure you provide quality care can be a challenge as well.” Dr. Firoozi agrees that the high volume for responsiveness can be a bit overwhelming and adds that shifts can also be a challenge. “If shifts haven’t been adjusted, there’s a high risk of burn out and medical errors.”

A service mindset

Many hospitalists feel a sense of loyalty to the hospital they are working with. They are happy to put their time and energy into their work to make the hospital run more efficiently and to provide better care for its patients. “You have to have a mindset for service,” says Dr. Duncan. “You’re providing a service to the hospital, you’re providing a service to the nursing staff, you’re providing a service to the attending physicians, and you’re also providing a service to the patient. We take some of the pressure off their shoulders.”

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