Structure: Programs should have an outpatient clinic where the surgical hospitalists can provide post-operative follow-up. In most cases, each surgeon spends only half a day a week in the clinic.
Scope of practice: All surgical hospitalist practices take most or all ED general surgery calls. In some institutions, the surgical hospitalist also leads the trauma team. Other duties at a few institutions include things like managing a wound-care clinic and being on-call to place lines.
Opinion of other surgeons: Community private practice surgeons tend to support these programs, but most institutions limit or prohibit surgical hospitalists from accepting elective referrals. Community surgeons are still offered the option of remaining on the ED call schedule—as might be the case for surgeons new to the community. At least one institution reported that the presence of surgical hospitalists improved recruitment of non-hospitalist general surgeons. However, I am also aware of one program put into place largely at the insistence of the existing surgeons. Those same surgeons later insisted it be dissolved because they saw it as unwanted competition.
Staff needs: Surgical hospitalist practices nearly always require fewer doctors than a medical hospitalist practice in the same institution. This can lead to a tension between having the right number of surgical hospitalists for the case volume (often just one or two doctors) and enough to provide for a reasonable call schedule. Existing groups have adopted a number of strategies.
Groups with only two doctors often have each work seven on/seven off. The doctor on-call for that week takes all night call him/herself. In some practices that have a medical hospitalist in-house all night, it could be reasonable to have routine calls on the surgical patients (e.g., sleeping pills, laxatives, low urine output, fever) first paged to the medical hospitalist, who refers the call to the surgical hospitalist only as needed.
At least one practice has hired enough surgeons so the call burden on each is reasonable. This might be more staff than required for the patient volume: Four surgical hospitalists each work 12-hour shifts in a seven on/seven off schedule. During the seven consecutive night shifts (worked by each surgeon one week in four), patient volume is low.
Some practices hire community surgeons as moonlighters or consider using nurse practitioners or physician’s assistants as first responders at night.
Demographics: Surgical hospitalists are usually midcareer doctors, not surgeons who have recently completed their training. Many say they have gotten burned out with the stress of operating a private practice and prefer hospital work to office work.
Where Will It All Lead?
In every institution I have made contact with, the medical and surgical hospitalists have a good working relationship. Each is available to the other for consults, and they work together so frequently that they can begin to build a greater sense of teamwork. It is important that both groups jointly develop guidelines, such as who admits which type of patients.
If, like primary care doctors, general surgeons and a handful of other specialties with significant hospital volume (such as obstetrics and gastroenterology) move largely to a hospitalist model, U.S. healthcare will have made a remarkable transformation. In the span of my career we will have gone from a system of most doctors seeing patients in and out of the hospital to a division of physician labor such that most doctors practice almost exclusively in only one setting or the other.
I can see how this could be a good thing for patients and medical professionals, but that isn’t a given. For it to turn out we must preserve the elements of the earlier system that worked well and mitigate new problems and complexities. We will need well-designed research to show the economic and quality effects of the hospitalist model on non-primary care fields such as general surgery. We face growing challenges in ensuring excellent communication between inpatient and outpatient caregivers—something that doesn’t work ideally in all medical hospitalist practices.