Many or most specialties in medicine are adopting a hospitalist model, at least to a limited extent. In fact, hospital care of adult medical patients wasn’t even the first place the idea was adopted.
In talking with people from hundreds of institutions it seems clear the idea appeared earlier and grew more quickly in pediatrics than adult medicine. And in the past 10 to 15 years, fields like obstetrics (“laborists”), psychiatry, gastroenterology, and many others have slowly begun to adopt the hospitalist model.
One of the most recent disciplines to join the parade is general surgery. And when comparing the forces in play for hospitalists in the early 1990s to the current situation for surgical hospitalists, I think we may be close to a surge in surgical hospitalists similar to what we’ve seen with medical hospitalists in the past 10 years.
When I say surgical hospitalists, I’m referring to surgeons with a nearly exclusive inpatient practice. Other terms such as surgicalist, acute care surgeon, and traumatologist overlap to some degree but have ambiguous meanings.
For some months I have contacted all the surgical hospitalist practices I can find to learn what forces led to their creation and how they are structured. Several common themes are emerging:
Prevalence: There are probably no more than 20 to 40 surgical hospitalist practices, but many institutions are considering the idea. This is similar to the situation for medical hospitalists in the early to mid-1990s.
Driver to start program: In every program I’ve found, the main impetus to start it was to address the burden of emergency department (ED) call for existing general surgeons. Like primary care, ED call is regarded as unattractive because it is unpredictable (lots of night and weekend work), usually has a poor payer mix, and many general surgeons have seen the “center of gravity” of their practice move away from the hospital toward an ambulatory surgery center over the past 10 years or so. Additionally, many general surgeons are increasingly uncomfortable caring for trauma patients because of recent changes in that field. (For an excellent discussion of the changing nature of general surgery and trauma care see “The Acute Care Surgeon” in The Hospitalist, May 2006, p. 25.)
Case volume: General surgery case volume tends to go up at a hospital that puts a surgical hospitalist program in place. When existing surgeons are relieved of ED call they increase their volume of (mostly elective) surgery. The availability of surgical hospitalists may mean fewer emergency cases presenting to the ED are referred elsewhere (which may happen when non-hospitalist surgeons are required to take ED call). These changes in case volume and the timing of the operations (e.g., volume of night surgeries may go up) may require adjustments to operating room staffing and scheduling. Presumably this increased volume would not occur in an area oversupplied with surgeons.
Economics: Like nearly all medical hospitalist programs, surgical hospitalist practices are not viable without financial support in addition to collected professional fees. In all cases I am aware of, this support comes from the sponsoring hospital.
While the cost may be similar to what the hospital might have paid for existing surgeons to take ED call, hospitals seem to be getting a better return on that investment with surgical hospitalists. A small group of surgical hospitalists can handle the increased volume and all ED calls, improving clinical and service quality. Some institutions report that surgical hospitalists are much more attentive to billing for nonoperative work than their predecessors.