Mark Kulaga, MD
Associate Program Director
Internal Medicine Residency
Norwalk, CT 06856
Pamela Charney, MD
Joseph Cleary, MD
Mark Kulaga, MD
Eric Mazur, MD
Stephen O’Mahony, MD
Jason Orlinick, MD, PhD
Andrea Peterson, MD
Michael Marotta, PA
Norwalk Hospital, Norwalk, CT
Academic Community Hospital with 250 beds
Affiliated with Yale University
Our patient population is wonderfully diverse, both economically and socially. Located in the heart of affluent Fairfield County, Norwalk is nevertheless a true small city and home to vibrant communities of African Americans, Latinos, and multiple other immigrant groups. The Hospitalist Clinician-Educator program was originally created to provide inpatient care for indigent patients (who predominantly attend the Norwalk Community Health Center) and for those patients without a local primary care physician. In recent years, as more community internists have chosen to use the hospital medicine service, our payer mix has substantially changed to include many more patients with private insurance and/or Medicare.
All physicians are general internists employed by the Norwalk Hospital.
Dr. Eric Mazur, Chairman of the Department of Internal Medicine, is the program founder and administrative leader. He serves as the primary liaison between the hospitalists and the Chief Executive and Operating Officers of the hospital.
Total Number of Patients Served Each Year
On average, each hospitalist admits 350 patients per year. When this threshold is exceeded, a new hospitalist has been added to the group. In the first few years of service, our hospitalists covered 20-25% of the total number of medical admissions to the Norwalk Hospital. As use of the service by local internists has increased, this percentage has grown to 40–45%. It is projected that the Norwalk Hospital hospital medicine service will admit over 2200 patients this year.
All hospitalists receive a fixed annual salary. The hospital subsidizes 50% of each Hospitalist Clinician Educator position and bills the faculty practice income for the remaining 50%. Faculty practice income is generated through direct patient billing facilitated by a billing agency not affiliated with the hospital. The hospital also provides an annual stipend to the faculty practice for the indigent care supplied by the hospital medicine group. Our compensation model does not utilize an incentive bonus system, although yearly bonuses derived from surplus faculty practice revenue are provided at the discretion of the Chairman.
All hospitalists admit and co-manage patients with resident teams who provide 24/7 in-house coverage. Each hospitalist typically works Monday through Friday from approximately 7–8 a.m. until 5:30–6:30 p.m. depending on patient census. Hospitalists, along with other members of the full time faculty, provide nighttime backup coverage from home for the residents. Weekend coverage responsibilities are also shared with other members of the teaching faculty. Weekend moonlighters, all of whom are board-certified or board-eligible internists from nearby communities, assist full-time faculty members with coverage on Saturdays and Sundays.
Communication Strategies/Role in Education
All of our hospitalists are highly rated by medical residents for their effectiveness as teachers and supervisors. For many, they also serve as important mentors and role models. In addition to traditional educational roles on the inpatient service, our hospitalists have developed several innovative teaching conferences, which include: teaching skills workshops; weekly medical informatics sessions; a monthly medical quiz game incorporating content from core educational conferences; a multidisciplinary Morbidity and Mortality Conference in which residents from the internal medicine and radiology departments are key participants; and a series of conferences in which end-of-life issues and physician professional development are explored in great depth.
Our hospitalists have also established a formal medical consultation service with a specially designed curriculum for the residents. We have also developed a hospital medicine elective where medical residents experience what being a hospitalist is “really like.” This elective has also been used to remediate struggling residents. Our hospitalists also have prominent administrative hospital roles; one is the Director of Graduate Medical Education, and 2 others serve as Associate Program Directors for the Internal Medicine residency. In addition, they have presented their academic work at regional and national meetings of the American College of Physicians and the Society of General Internal Medicine.
Challenges Now and in the Future
Our biggest challenge can be summed up with one word: growth. Up to this point in time, a major strength of our program is that it has been able to grow incrementally and deliberately. We have never “rushed” the hiring of new hospitalists and thus have been able to recruit physicians with similar academic backgrounds and career goals. This has resulted in a cohesive group of hospitalists who support each other in every way and work extremely well together.
A major concern in hospitalist medicine is the concept of “hospitalist burnout.” We have successfully addressed this issue by limiting the number of hospitalist admissions and weekends on call, actively participating in medical education with resident physicians, and serving in important administrative roles within the hospital. As we expand to meet the growing demand for our inpatient care services by primary care physicians, we are finding it more difficult to strike a balance between our service duties and academic interests. We are working closely with our department chairman, who is a true advocate of “hospitalist career building,” to find creative ways to achieve this goal. We believe that it is the balance between service and education that has allowed us to attain a hospitalist retention rate of 100% since the inception of the group.
Goals of Hospital Medicine Group
In addition to providing outstanding patient care and resident teaching, the goals of our group are commensurate with many of the current trends affecting the field of medicine and include:
- Quality. As quality moves to the forefront of medicine, we believe that hospitalists are the logical champions and effectors of inpatient quality care. Our hospitalists have been involved in a number of quality improvement projects, such as the establishment of multidisciplinary patient rounds, which serve to advance care and achieve high levels of core measure compliance; stroke center development; and the design of inpatient diabetes management protocols. Our hospitalists have also been heavily involved in the implementation of computerized physician order entry at the Norwalk Hospital and have written numerous order sets for specific diagnoses. We expect these projects to result in demonstrably improved quality beyond the improvements in length-of-stay and core-measures adherence already achieved. We believe that our involvement in quality, both now and in the future, adds value to our role as hospitalists from the point of view of hospital administrators. It also provides us with enhanced job satisfaction and multiple opportunities for career development.
- Patient safety. This is another “hot topic” in the field of medicine where we feel that hospitalists can and should have a substantial impact. As mentioned before, our hospitalists have played prominent roles in the successful implementation of computerized physician order entry, a process that has been shown to result in major improvements in patient safety. Our hospitalists also serve on the patient safety committee and are an important link between residents and ancillary staff when housestaff raise safety concerns. In the future, our hospitalists hope to have an even greater role in such important safety areas as infection control, management of delirium in the elderly, venous thromboembolism prophylaxis in the medical inpatient, and the prevention of patient falls.
- Research. Clinically and educationally oriented research is encouraged among all full-time hospitalist faculty. We recently published data on the financial and educational benefits of our hospitalist model in the April 2004 issue of the Journal of General Internal Medicine, but we feel that more needs to be done. In particular, we plan to better quantify how hospitalists achieve the reported cost-saving benefits. We also plan to further assess the roles of hospitalists in the education of medical residents in the community setting, a topic that is vastly underrepresented in the medical literature. Hospitalist faculty will also participate in a formal evaluation of the Multidisciplinary Rounds Process and will mentor residents in their personal research projects.