The appeal of a 24/7 hospitalist program may also affect a healthcare facility’s ability to successfully recruit quailifled physicians. With the knowledge that inpatients will be under the constant care of a trained on-site hospitalist, a PCP can anticipate a predictable schedule that allows for much better work—life balance.
John R. Nelson, MD, FACP, is co-founder of the National Association of Inpatient Physicians, now the Society of Hospital Medicine (SHM), a hospitalist, and the medical director at Overlake Medical Center. In the 1970s, working as an orderly, he found that, although the census was typically high, the night shift was not very busy. Most patients were routine cases awaiting tests, labs, and other simple procedures the next morning. Today patients are sicker on admission. Rapidly changing status at any time of the day or night presents a real challenge to medical staff. Nelson believes that the on-call system of 25 years ago has outlived its usefulness for patients, community physicians or PCPs and nursing staff. To meet the expectations of all involved, an on-site physician is necessary, he asserts. While PCPs are reluctant to return to the hospital after working a full day, the 24/7 hospitalist, by virtue of his role, expects to tend to patients’ needs and face various medical issues throughout his shift (4).
Mark V. Williams, MD, Director of the Hospital Medicine Unit at Emory University’s School of Medicine, emphasizes that on-site, in-person health care offers a vastly superior model to “phone practice” (5). In addition to providing immediate response — which nurses consider a value-added service — 24/7 hospitalists are able to evaluate firsthand changing medical conditions, says Lawrence Vidrine, the national medical director of inpatient services of Team Health in Knoxville, TN (6).
According to Winthrop Whitcomb, MD, SHM’s other co-founder and director of the hospital medicine program at Mercy Medical Center in Springfield, MA, a “new paradigm” has evolved for the practice of more efficient and effective hospital medicine. It is his perspective that the country is now experiencing a shift from a “push system” to a “pull system.” Inherently ineffective, the former model attempts to “push” the patient into the hospital relying on the attending physician’s availability to come to the hospital for the admission process. The newer “pull” system involves a hospitalist who expects to be called and a facility that has established inpatient capacity. When a patient is ready for admission, the hospitalist “pulls” that individual up through the system since capacity has already been built-in (7).
In an effort to improve the safety and quality of care patients receive while in the CCU, the Leapfrog Initiative Group in collaboration with the Health Care Financing Administration (HCFA) and the U.S. Office of Personnel Management set standards to achieve this goal in 1998. According to these principles, physicians are encouraged to have Advanced Cardiac Life Support (ACLS) training and the Fundamentals of Critical Care Support (FCCS) certification, which enable them to adequately and appropriately respond to acute patient status changes. Hospitalists who have earned these certifications can provide a different level of service and generate higher professional fees. At Covenant Health Care in Sagina MI, all hospitalists hold these credentials, according to Stacy Goldsholl, MD, director of Covenant’s hospital medicine program. In such cases, adequately trained hospitalists qualify as Leapfrog intensivist extenders (8). John Kosanovich, Vice President of Medical Affairs, reiterates the importance, both professionally and financially, of compliance with Leapfrog guidelines. In addition to strengthening the bottom line, ACLS/FCCS certified hospitalists contribute to improved quality of patient care (9).