But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”
Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”
Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.
“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.
This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4
Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.
Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”
Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.
Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”