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.”