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TRENDWATCH: The Specialization of Hospital Medicine


 

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

  1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

A Day in the Life …

What’s a typical workday like for specialist hospitalists? TAKE A LOOK:

While specialist hospitalists’ days are busy, challenging, and demanding, Dr. Ottolini notes that they see interesting cases, get to hone their expert skills in their specific practice area, and enjoy the camaraderie of a professional clinical team. They also have the luxury of set shifts and the knowledge that they can go home and really be off the clock. Here’s a sample of various specialists’ schedules.

Mary Ottolini, MD, MPH (pediatric hospitalist): “I start my morning by examining new admits and patients likely to go home that day. Then I round with my resident and student teams. I review films taken in the last 24 hours, and then I conduct patient examinations and talk to family members. My afternoons often involve giving talks to residents and students. Also, because I’m a division chief, I talk with my staff and handle paperwork and other administrative duties.”

Rokea el-Azhary, MD (dermatologic hospitalist): “First, I round on the inpatient unit, then I do the same on the outpatient unit. I also consult at two Mayo-affiliated hospitals.

Sometimes, I will follow up on patients who I see in the clinics—patients who were discharged and I need to know how they’re doing. Throughout the day, I answer emergency room questions about anything with skin involvement—from poison ivy and sunburn to pressure ulcers and dermatitis.”

Thomas O’Brien, MD (psychiatric hospitalist): “First of all, I have to establish a relationship with the patients, but I only have a short time to do this—not weeks or months like I did in outpatient practice. However, I make it clear to my patients that the quicker I get to know them and understand the problems, the better I’ll be able to help them. It’s amazing how they’ll open up and respond. I’m in charge of behavioral health services in three hospitals, and I spend a lot of time responding to urgent situations and questions. These units gauge success by how quickly they can move cases and issues off their desks. Generally, I provide acute stabilization so that people can leave the hospital and go back to their outpatient therapist and treatments.”

Duncan Neilson, MD (obstetric hospitalist): “Rounding starts the day here. I review all labor patients and serve as physician on record for them until their physician of choice comes on deck. I deliver some patients, particularly those on the high-risk service. I usually only deliver private patients if their physician is tied up elsewhere for some reason. Most often, the attendings will deliver their own patients. However, I will assist as needed, and I am available to address any problems or emergencies that arise. I also do labor triage and oversee all labor activities.”—JK

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