Lone hospitalist. It sounds adventurous. It might mean having the chance to set the stage for a hospital medicine program—working exactly the way one wants to and enjoying the feeling of indispensability.
But it’s not for the faint of heart, as those who’d done it attest. There’s the potential for having no starting patient base, or being overwhelmed because there are few to no physicians to share coverage. Having the chance to educate the hospital and its staff about hospital medicine can be a blessing—and a curse.
An example of a lone hospitalist who has experienced the joys and pains of her position is Patricia M. Hopkins-Braddock, MD, an assistant professor of pediatrics at Albany Medical College in N.Y. She was hired as the only pediatric hospitalist in the pediatrics intensive care unit (PICU) at Albany Medical Center. This is her fourth year in that position. Having become the residency program director at her institution in January, she works every day plus one weekend a month, alternating weekly between a pediatrics floor and a long-term care facility and sedation service for children.
“I like the fact that I have turned into the go-to person for problems within the hospital continuum,” Dr. Hopkins-Braddock says. “I also have to say that that is probably one of the things I like least. I have that presence in the hospital and the understanding of the way the floor works. I also do pediatrics sedation. Somehow I become the solution for every problem. It’s good in its own sense, but it can also become very overwhelming.”
A Perfect World?
“If we could figure out a way for one person to function productively and efficiently by themselves, it would be wonderful,” says Cary Ward, MD, who works with hospitalist programs that are part of Catholic Health Initiatives, based in Denver, and is the chief medical officer at St. Elizabeth Regional Medicine Center in Lincoln, Neb. “There is a large group of hospitals that wants to have a hospitalist program, and those are the critical access hospitals.” At these hospitals, which never have more than 25 patients, several community physicians round at the hospital in the morning, finishing by 7 or 7:30 a.m., and return to their primary office bases. “These hospitals are often clamoring for someone to be in the hospital the majority of the day,” he says.
“You’ve heard the saying, ‘You’ve seen one hospitalist program, you’ve seen one hospitalist program,’ ” continues Dr. Ward. “I’ve been amazed at all the hybrid programs out there. At most small hospitalist groups, even those programs under the smallest census of 12 or 13 patients, hospitals still often bring in two doctors with alternate week rotations. “Many consider this the most feasible way to try to cover one hospital census at all times; however, some worry that this ‘feast or famine’ schedule may lead to burnout and this can be expensive for the hospital. To get only one physician to cover that kind of responsibility is a real challenge.”
And yet, some hospitals and hospitalists manage to do it. Of the 362 hospitalist groups that responded to SHM’s 2005-2006 survey “Bi-Annual Survey on the State of the Hospital Medicine Movement,” only nine groups (2.5%) consisted of one physician. Joseph A. Miller, MD, who staffs SHM’s Benchmarks Task Force and has been helping SHM build a national hospitalist database, estimates that of the 2,500 hospitalist groups in the U.S., 62 groups might have just one hospitalist.
Pluses and Minuses
Martin C. Johns, MD, a rural internal medicine and pediatrics hospitalist at Gifford Medical Center in Randolph, Vt., sees some definite advantages to being a lone hospitalist, a post he has held for the 1 1/2 years. “It allowed me the time to interact with all the other modalities and to establish with physician therapy, occupational therapy, care management, pharmacy, what was lacking in the previous model with a variety of docs covering,” Dr. Johns says. “I was trying to create standards that made sense for everyone. The establishment of my being the only hospitalist was determinant primarily on my ability to create those relationships and ensure that they were solid, and also to have the support of all the primary care doctors.”
Gifford’s administration was also supportive. “Because we are a critical access hospital, there are certain restrictions and requirements that we have to take into consideration with Medicare and Medicaid,” Dr. Johns says. “Being the sole hospitalist as we’re expanding allowed me to set the stage: what was lacking, what was missing, what we could improve on, what was already working quite well. [I incorporated] the help of the administration to fill in the gaps of what we needed.”
The primary nonclinical challenge for the lone hospitalist is finding patients to care for and doctors to share coverage. Christopher Farrar, MD, lead hospitalist at Anderson Hospital in Maryville, Ill., began the program there. His employer, the hospitalist company Inpatient Management Inc., based in St. Louis, Mo., manages 18 hospitalist programs in 12 states. “As I was ending my primary care role,” says Dr. Farrar, “this opportunity came available. I think that they weren’t expecting someone to jump in so quickly. They didn’t have the luxury of time to find another physician right away.”
There are now two physicians in the program there, and they are on the verge of getting a third. Dr. Farrar said he doesn’t think there are a lot of pluses to being the lone hospitalist. The most difficult part is avoiding burnout, he warns. Although there were plenty of patients and work for him when he first started at his institution, he wasn’t overwhelmed. But he was relieved when the company brought in a second physician with whom to share call. “I could have easily become overwhelmed quickly had it gone down that road,” he says.
Finding a patient base and physician call backup were not issues for J. Stewart Fulton, DO, medical director of the hospitalist program at Southern New Hampshire Medical Center in Nashua, when he began five years ago as the lone hospitalist. Foundation Medical Partners, a multispecialty group of 27 doctors directly affiliated with the hospital, recruited Dr. Fulton to start a hospitalist program. “I walked into an ideal situation,” he says. “I stepped into a group that had a patient base, that knew they needed hospital coverage, and were willing to support me as I grew to provide 24/7 coverage for myself.”
In July 1998, Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center, Boston, was the chief medical resident at that institution when his chief of medicine approached him about starting a hospitalist program.
In the late 1990s there was no model of that kind in Boston. “He hired me as our first full-time hospitalist, and I was referred to as a hospitalist—but nobody really understood what that meant,” says Dr. Li. “Looking back now, I didn’t even really understand what that meant.”
Tin M. Oo, MD, medical director for the hospitalist program at St. Mary’s Health Center in Jefferson City, Mo., practiced for seven months as a lone hospitalist but was hardly a new physician. He has been practicing medicine for 34 years in the U.S. and four other countries: Burma (now Myanmar, his native country), Sri Lanka, Malaysia, and Brunei Darussalam. Since he emigrated to the U.S. 15 years ago, he has served as an epidemiologist with the state Department of Health in Minnesota, matriculated into a three-year internal medicine residency program in New York and practiced there, and was in private practice in Chattanooga, Tenn.
When Dr. Oo first came to St. Mary’s, he taught his co-workers, the patients, and their families. “The hospital [and nurses] didn’t have any experience with hospitalists so they didn’t know when to call me and when not to call me,” he says. Dr. Oo got his first hospitalist experience in Chattanooga, Tenn., when he worked with outpatients and some inpatients. His prior experience moonlighting as a hospitalist as well as an emergency physician has helped him greatly as a lone hospitalist. “It was a good thing that I wasn’t just a hospitalist; that I had been in private practice and worked in the ER and as a hospitalist. I knew what the private doctors were facing, and what was coming across from the ER.”
For those who have not yet practiced medicine, Dr. Oo would dissuade them from taking a position as a lone hospitalist. “You have to have a feel for what the ER physicians or what the family practice/ internists, and what the specialists do,” he says. “You also have to be in the hospitalist’s shoes, at least from time to time.”
While all hospitalists need to be flexible, this may be particularly true for the lone hospitalist. Dr. Johns finds his dual internal medicine/pediatrics training serves him well. “I assist with patients, especially pediatrics, in the emergency department [ED], go up to [resuscitate the infant in] C sections, deal with all the pediatric issues and ER consultations during the day plus do all the general internal medicine care and adult care, which does make up the majority of what I do during the day,” he says. Two physician assistants have been brought on board to improve continuity on nights and weekends and decrease the workload of all physician providers.
Dr. Johns, whose title is associate medical director in charge of hospitalist services, finds the biggest challenge has been attaining and maintaining a commitment to quality on opposite shifts. Sharing coverage with several primary care physicians, he says, means there are differences in concepts of protocols for admissions, commitment to caring for the extra patients, and the physician’s comfort in his or her inpatient knowledge base.
Taking over after a previous night’s coverage, Dr. Johns is unsure which orders were carried out and which patients received what therapy, for instance. “The covering providers take care and make sure patients make it through to next day but often hesitate to alter the plan too much because they are not covering the following day as the inpatient provider.” A newly instated Thursday-through-Monday hospitalist service schedule has helped improve continuity of care and transfer of information through the weekend. But it is still not a perfect situation.
After 15 months as the lone hospitalist, Dr. Johns’ position has changed. He cares for patients during the day and during the opposite shift takes on administrative responsibilities, such as deciding on protocols and expanding services. That kind of juggling—without hospitalist colleagues—has required flexibility as well.
Plan and Set Boundaries
Educating the hospital taught Dr. Fulton a good deal as well, especially about his and their expectations. “The group that grasps the whole concept the quickest is the ancillary services (case management) and the nursing staff,” he says. He likens their receptivity to having a hospitalist to the workings of a pendulum: “There is nothing before this better way, and then they want more of it and they want it all the time. It really means needing to create boundaries”
Dr. Oo agrees that as a lone hospitalist it is important to set boundaries for your accountabilities. The administration of his hospital asked him whether he would take charge of rapid response calls. He declined, leaving that traditional role to the ED.
The year Dr. Fulton practiced as a lone hospitalist gave him a window of time to plan. “It really allowed me to hit the bumps in the road and figure things out so when I added partners, I was able to get them up to speed more quickly,” he says. “Hospitals continue to get busier and busier and that requires planning. I was tracking and trending the volume [of patients that] these 27 doctors were generating in the hospital so that I could anticipate how many doctors I needed. Hospitals continue to increase in volume. The intensity of medicine continues to increase. You always need to plan for one or two more docs than you think you need.”
For many lone hospitalists, sharing schedule coverage is a dilemma. Dr. Li, an assistant professor of medicine at Harvard Medical School in Boston and a board member of SHM, spent one year as a lone hospitalist before another full-timer joined him. “Everybody understands that as sole physician you really can’t be expected to see patients 24/7/365,” says Dr. Li.
Dr. Li’s recommendation for any hospitalist group of any size—but particularly early on when the hospitalist is alone or in a small group—is to match volume with staffing. “With every program that I have seen or been involved with, early on there is always a massive shift of primary care providers who want to refer patients to you after the program is up and running, Dr. Li says.
Another recommendation Dr. Li has for the lone hospitalist is to identify how you will quickly get help in urgent circumstances. “There is a real benefit to the whole service for having more than one physician on any given day,” he says. It takes only one critically ill patient to cause an upheaval in the schedule.
As recent SHM data show, a large proportion of hospitalists serve on hospital committees. But during his year as a lone hospitalist, Dr. Li focused on taking care of patients, relying upon consultants, and getting through the day.
“I certainly had very little insight at that point of the hospitalist model in terms of communications and leading a team and being the leader of quality in the institution,” he says. “Those were the furthest things from my mind.”
Dr. Fulton participated on committees even though he was a lone hospitalist. “I was involved because I was willing to do the extra work and to use that opportunity to educate and establish who we were in the hospital,” he says. When he was joined by his first two partners, he protected them from committee work because that wasn’t their initial responsibility,” he says.
For lone hospitalists, “you either need to anticipate being on committees and protecting time for it, or you need to anticipate protecting yourself from the committees in order to provide your service,” says Dr. Fulton. “That’s sort of a slippery slope because if you lose the opportunity to become involved in committees, someone else will do it and then they’re making decisions for you that affect your practice of medicine in the hospital.”
Because Dr. Fulton would not sit in hourlong meetings, he took an indirect route—discussing issues with case managers on the floors in between patients or when they shared a patient.
Dr. Fulton advises the lone hospitalist to consider “who is boss” when he or she considers allocating time for committee involvement. Employment by a hospital versus a multispecialty group versus going out as a solo practitioner or working in a private group will determine whose agenda you have to fulfill. “If you are owned by the hospital, the hospital calls the shots; and you have to negotiate … where you put your efforts and your service. If they want you to be on committees, you need to negotiate less patient interaction. You can’t do both; you’ll begin to lose your mind.” TH
Andrea Sattinger is a frequent contributor to The Hospitalist.