The Pediatrics Picture
The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2
In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.
Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.
In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.
The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).
Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”
One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.
To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.
“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”
As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”