Patient Care

You Can See 40 a Day


Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.

This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.

Scope of Practice

There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.

But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.

Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.

What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?

As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.

Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.

Workforce Issues

In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.

While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.

Job Description

It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?

If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.

Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.

The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?

What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?

The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.

But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.

Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?

And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.

The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.

This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.

In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.

This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.

SHM will continue to do its part to help you at every step along the way. TH

Dr. Wellikson is CEO of SHM.

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