David A. Hoffmann, MD, is medical director of a hospitalist group in Chambersburg, Pa. The group is made up of half family practice and half internal medicine hospitalists. Like so many other hospitalists, he’s seen tremendous growth in the number of surgical co-management cases his group handles at Chambersburg Hospital (see “The Surgical Surge,” December 2007, p. 1). His group tries “to make inroads with the surgeons,” he says. “We send a member of our group to their meetings, and we work with them on management protocols [such as DVT prophylaxis]. I can see the benefits of getting to know what’s going on down there [in the OR]. The truth of matter is, [despite co-management], sending the patient to the OR is like sending someone into outer space for the hospitalist. The rocket goes off, and you don’t see the patient until they come back in for a landing.”
Depending on the location of hospitalist groups, involvement as first assistants could represent additional opportunities for family medicine physicians, Dr. Hoffmann believes.
Air Force Maj. Heather Cereste, MD, agrees that the degree of symbiosis between surgeons and hospitalists likely will continue to be a location – and hospital-specific phenomenon. While serving in Iraq, she had significant experience with surgical procedures, and felt that from an internist’s perspective, she was more valuable to the surgical team. During her third-year residency in Maine, she observed many who planned to go into family practice assisting with gastrointestinal procedures and the like. “Certainly, in a smaller setting, with fewer available resources, the more autonomous a hospitalist can be, the better,” says Dr. Cereste, co-director of the geriatric medicine service at Wilford Hall Medical Center, Lackland Air Force Base, Texas, and chair of the bioethics committee.
Though surgical assisting is an intriguing idea, such a set up “could have its own set of unintended consequences,” especially for a private model hospitalist group, says Brian Bossard, MD, medical director of Inpatient Physician Associates in Lincoln, Neb.
Dr. Bossard has personal experience with this configuration. When an internist in his hospitalist group began to do surgical assisting, the privately owned group (which contracts with Bryan LGH Hospital in Lincoln to provide hospitalist services) did not find this advantageous. The physician’s surgical participation was at times disruptive for the group, since he was unable to be immediately available and on call or to run codes while in the OR.
“It’s not clear to me that there would be an advantage to have a hospitalist [assisting in the OR], as opposed to another physician extender such as a physician assistant or a nurse practitioner,” says Jack M. Percelay, MD, a pediatric hospitalist at Saint Barnabas Medical Center in Livingston, N.J. Co-management of surgical patients is another matter, however, and Dr. Percelay does see value in having hospitalists help with maintenance of lines, wound care, and other post-surgical management duties.
“There is a certain set of procedures we’re supposed to master, such as vascular access and airway support,” Dr. Percelay continues. “But our value as hospitalists is in our cognitive skill set. I don’t know any hospitalists who consider a scalpel as one of their routine tools.”
Bryan Fine, MD, a pediatric hospital at Children’s National Medical Center in Washington, D.C., recently joined a general hospitalist group after spending three and a half years as the hospitalist in charge of medical management for the gastroenterology service. His opinion of hospitalists assisting in surgery? “I think it’s definitely valuable if it’s done in the context of a larger goal and to gain credibility from a hospital administrative level,” he suggests. However, he said, professional satisfaction for a hospitalist might be limited since he or she essentially would be serving as a physician extender.