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HM@15 - Myriad Points of View


 

HM’s evolution the past 15 years has helped to reshape patient care in the hospital. Hospitalists near and far, young and old, are most proud of their work.

But how do others view hospitalists? What do nurses, pharmacists, and surgical specialists—professionals who work with hospitalists on a daily basis—say about hospitalists and their daily contributions to medicine and the U.S. healthcare system?

The Hospitalist talked with an array of medical professionals to develop a 360-degree sense of how HM is regarded in the medical community, speaking with sources affiliated with organizations as those sources are inclined to have a more panoramic understanding of how their field views hospitalists. The views presented are those of the individuals and do not necessarily represent the stances of their organizations.

Pharmacy

Stan Kent, president of the American Society of Health-System Pharmacists, says he always thought that the idea of having doctors who worked exclusively in the hospital would be good idea—even before there was such a thing as a hospitalist.

“I witnessed the movement of internists and surgeons transformed from being hospital-based to more office-based,” says Kent, who also is an assistant vice president at Northshore University Health System in Evanston, Ill., where he oversees pharmacy services. “I always wished that there could be more consistency on the part of those physicians in taking care of the patients in the hospital.”

Once hospitalists became a fixture in hospitals, their familiarity with the hospital and knowledge helped pharmacists do their jobs better, according to Kent. With hospitals becoming more and more complex, with electronic medical records and the handling of cases that are more and more difficult, doctors generally are less efficient if they’re not intimately involved in the system.

Kristi Killelea, an inpatient pharmacist at Northshore, says that it’s easier to develop working relationships with hospitalists whom you frequently see in the hospital.

“From the inpatient perspective, I think the nice part about hospitalists is they are more familiar with inpatient medicine, which typically involves more intravenous-type medications,” she says. “It just makes it easier to deal with them because they see that a little bit more frequently.”

There are times when the gap between inpatient care and outpatient care shows, she notes, but that is uncommon. “Sometimes, if you’re looking for historical knowledge about the patient, about why they are doing what they’re doing with the medication, [hospitalists] can’t always contribute that because they’re not following the patient in their office,” she says. “But I think that’s more rare than the norm.”

Even as medication reconciliation continues to be an issue throughout the healthcare landscape, Kent and Killelea agree it’s not due to hospitalists. “Sometimes patients tell their PCP that they’re taking Lipitor, for example, but they don’t give them the strength and they don’t tell them how many times they’re taking it. Those instances become more cumbersome from a medication reconciliation standpoint,” Kent says. “Whereas if this information is gathered by the hospitalist, they are more accurate and complete, I think, in getting that history, and then doing the reconciliation.”

Quality Control

To date, there is no definitive data to show what effect hospitalists have on the quality of care at hospitals, says Robert Wise, MD, medical advisor to the Joint Commission’s Division of Healthcare Quality Evaluation in Washington, D.C.

He says a hospitalist can’t be judged on his or her own but has to be seen in the context of the system in which he or she is working. Hospitalists have in-depth knowledge of the complex processes and technology special to hospital care, but their work is only part of the entire “episode of care” for a patient.

“While the physician in the hospital is highly trained to deal with the unique clinical needs of that patient, it is also important that the team treating the patient has all relevant information from all clinicians who may have treated the patient prior to the acute episode,” he says.

“It is also critical that when the patient is discharged that there is as seamless transition back to the system that will continue to care for that patient. Those handoffs may or may not be working well.”

The handoff, to and from the hospital, is one of the most risk-fraught areas for patients. So what is gained from the specialized skills of hospitalists might be lost if transitions from the hospital are not done well, Dr. Wise explains. “The hospitalist concept, while adding a new level of expertise, also increases the fragmentation of care and, therefore, can lead to some increased risk,” he says. “That risk is mitigated by well-functioning systems that can both initiate and accept the transfers.”

The use and mastery of the electronic medical record is crucial to the successful handoff, he adds.

“Another issue that is often discussed is whether, as the number of [hospital]-employed physicians increase, that will impact the medical staff’s freedom to constructively challenge hospital administration or the board concerning issues of quality and safety,” Dr. Wise says. “While this remains a theoretical issue, as the number of medical staff members employed by the hospital increase, [it is important] that their voices on the issues of quality and safety of medical care remain unimpeded.”

He also says that the speed of the growth of the hospitalist field comes with a certain amount of risk.

“The current hospitalist system attempts to assure that seriously ill patients are being treated by physicians who are current and competent in the complicated, high-tech environment of the 21st-century hospital,” he explains. “It will take time to develop a number of the supporting systems. If the speed of growth is very rapid, it is possible that the supporting systems, both inside and outside of the hospital, will not be able to keep up. None of these possible problems are insurmountable, but all will take a significant amount of attention and resources to support this method to deliver care.”

The hospitalist concept, while adding a new level of expertise, also increases the fragmentation of care and, therefore, can lead to some increased risk. That risk is mitigated by well-functioning systems that can both initiate and accept the transfers.

—Robert Wise, MD, medical advisor, Division of Healthcare Quality Evaluation, The Joint Commission, Washington, D.C.

Orthopedic Surgery

Older orthopedic patients are at serious risk after surgery, but their chances are improved by the work of hospitalists, says Alexandra Page, MD, a member of the American Academy of Orthopaedic Surgeons’ National Health Care Systems Committee and a surgeon with Kaiser Permanente in La Jolla, Calif., who works with geriatric patients.

A major role of hospitalists in support of orthopedic surgeons is to help patients be “as tuned up as they can be prior to surgery,” she says.

For octogenarians, there is a 25% mortality rate in the year after a hip fracture. For a nonagenarian, the one-year mortality rate is 50%.

“That’s a real high risk, and we don’t even in orthopedics have a good sense of what those factors are that make them so high-risk,” says Dr. Page, adding that it is known that optimal levels of glycemic control can minimize perioperative complications like infection.

That makes it all the more important for hospitalists to get patients into the best shape possible. After the operation, hospitalists help control blood pressure and blood sugar, and take steps to minimize post-operative delirium.

“It doesn’t affect our ability to perform the surgery at a technical level, but ultimately it gives our patients better outcomes,” Dr. Page says. “That’s really what it’s all about.”

Dr. Page’s role as an examiner for the orthopedic boards gives her insight into how different hospital systems work. She says she hopes there can be more consistency in the role that hospitalists have in helping with orthopedic surgery patients, with patients being routinely admitted through the hospitalist service. “I think there’s still a lot of variability, in terms of who’s managing these patients,” she says.

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HM@15 - Patient-Care Partners

HM@15 - Patient-Care Partners

Relationships with other medical professionals are evolving, longtime hospitalist says

Twenty-five years ago, healthcare experts were forecasting something that Janet Nagamine, MD, RN, SFHM, thought was highly unlikely. “When I was an ICU nurse back in the 1980s, people projected that the hospital would become one big ICU,” recalls Dr. Nagamine, who has worked as a hospitalist since 1999 and worked in hospitals since 1986. “And at that time, I thought that was a crazy notion. How could the entire hospital be an intensive care [unit]?”

When she looks around now, she sees much more complex care being provided at hospitals—patients who would have died are in the ICU, those who would have been in the ICU are now on stepdown and telemetry units, and patients who would have been on the floors are being cared for at home.

“It really does look like an ICU,” says Dr. Nagamine, an SHM board member who works at Kaiser Permanente in Santa Clara, Calif.

That shift in acuity has helped carve a niche for hospitalist physicians—a role that has become more and more embraced by the array of medical professionals working in hospitals. With patients as sick as they are in hospitals, it’s much harder to manage their care from an office-based practice.

Dr. Nagamine says that at first there was some tension between PCPs and hospitalists, with PCPs wanting to continue seeing their hospitalized patients.

“Initially, that was a difficult challenge,” she says. Now, though, she says most of the tension has evaporated. “It’s really interesting how people respond to change,” she says. “In a relatively short time, it’s like that battle never happened.”

Hospitalists’ relationships with nurses, she says, were smooth from the beginning.

“It was almost an immediate partnership because, as a nurse who’s been at the bedside at 2 a.m. without an attending physician in-house, it was scary,” she says. “You have a partner in-house for the first time.”

Hospitalist comanaging of complex cases with specialists has evolved, too, but Dr. Nagamine says it remains an area in need of improvement, particularly on weekends and other off hours when a hospitalist might get “sideswiped” with patients.

“Just because we happen to be in the hospital does not mean that we should be the attending on certain types of patients,” she says. “We want to be nice. We want to help everybody. But sometimes we end up with patients that really aren’t appropriate for us to manage.”

Family Medicine

When one of his patients is admitted to the hospital and comes under the care of a hospitalist, his involvement doesn’t end, says Glen Stream, MD, president-elect of the American Academy of Family Physicians, who works with Rockwood Clinic in Spokane, Wash.

Dr. Stream continues to keep in touch with patients, and that has made for a good working relationship with hospitalists. It helps put patients at ease and helps with handoffs to and from the hospital, he says. “I don’t think you can overcommunicate in either direction,” he says. “The most complete medical information enables the best-informed decision-making for treatment decisions.” Such levels of involvement usually are welcomed by hospitalists, he says, adding “I’ve been able to be the hospital physician’s advocate.”

Meanwhile, HM has made his office-based practice more flexible and more accessible. “In my medical group, a number of my partners actually start seeing patients [in the office] as early as seven in the morning,” Dr. Stream says. “They can commit to being there for patients at that early hour.”

He points out that handoffs to and from primary-care doctors and hospitalists has improved, but it’s still a work in progress. “I think it’s gotten better over time,” he says. “I think there’s recognition—on both sides of those handoffs—that things could be improved. I think the commitment is there both for the ambulatory physicians, the primary-care doctor, the family doctor, and the hospitalist taking care of them.”

Although hospitalists generally are better compensation than family doctors, Dr. Stream says he isn’t aware of “any friction” from family physicians. “Our academy, our members, family physicians, believe that the work that [we] do is undervalued in our current healthcare system. But that doesn’t mean that we have to compare ourselves to hospitalists,” he says.

Nursing

Even as fragmentation of medical care has increased, the emergence of the hospitalist has helped to streamline care, says Joanne Disch, PhD, RN, president-elect of the American Academy of Nursing and clinical professor at the University of Minnesota School of Nursing in Minneapolis.

“There has become such increasing fragmentation of who is the team around the patient,” she says. But, she notes, “the hospitalist really provided a mechanism to promote continuity of care.”

Nurses, she says, have found hospitalists to be “somebody who can cover your back.” “When the system works right, the nurses do not have to seek out a physician and hope that they can either grab somebody or somebody makes rounds,” Disch says, noting a general frustration amongst her peers as to a lack of clarity in regard to who’s in charge. “What hospitalists inherently do, structurally, is provide a main physician who will be the accountable one in the hospital setting. You have a named person that the nurse knows, ‘Ah, this is who I need to go to.’ ”

Although most nurses welcomed hospitalists from the very beginning, she continues, the addition of MDs into the hospital setting did cause confusion, most notably over the roles of PCPs, referring physicians, and hospitalists.

“It wasn’t clear the extent of this individual’s responsibility and how to use them effectively, but over time my sense is that people … really find this helpful,” she says.

An area that might have room for improvement is hospitalist-nurse communication, with more “huddling” and discussions at shift change. Better communication with patients’ families also could be improved, she says. “[It] gets a little confusing sometimes,” she says. “Either everybody, or nobody, is talking with the patient and the family.”

Hospital Administration

The reaction of Craig Becker, a member of the American Hospital Association board and president of the Tennessee Hospital Association, was, at first, fairly dismissive. An idea being discussed in the industry—inpatient physicians working full-time in hospitals—would not be worth it, he thought. He couldn’t get past the notion that such an arrangement would be “a waste of money,” and that if someone tried it, it would just be in the clinical-care units.

Once a couple of hospitals started hospitalist services, he was more inclined to listen. “I was getting feedback from them, and they were saying: ‘Boy, this has made a big difference, both in patient care and financially,’ ” Becker explains. Once he noticed HM programs popping up in small, rural hospitals, Becker knew “this was a movement whose time had come.”

In Tennessee, where hospitalists were almost unheard of a decade ago, hospitalists now work in every shape and size of hospital, some with fewer than 100 beds. At one hospital that employs its own hospitalist, there are just 58 beds and an attached nursing home, Becker says.

Showing that hospitalists have been worth the cost is really as simple as looking at the length of stay, he says. “If you can knock six-tenths of a day off a stay, that’s pretty significant savings,” Becker says.

Becker notes other positives the HM model has brought to Tennessee hospitals: They make the jobs of hospital administrators easier because specialists and referring physicians are happier.

“They can spend more time doing whatever they want to do on a personal basis or in their offices,” he says. “So I think just in terms of improving relationships with the medical staffs, hospitalists have been a real plus.”

Tom Collins is a freelance writer based in Florida.

I think that patients more and more understand our role. Part of that is communication.

—Janet Nagamine, MD, RN, SFHM, Kaiser Permanente Medical Center, Santa Clara, Calif., SHM board member

HM@15 - Patients Benefit from Honed Relations Between Hospitalists, Staff

As the working relationships between hospitalists and other medical professionals have been refined through the years, so has the experience of the patients under their care, those working in the hospital say.

Glen Stream, MD, president-elect of the American Academy of Family Physicians who works with Rockwood Clinic in Spokane, Wash., says he likes to help bridge the gap between the patient and a hospitalist whom the patient probably never met before.

For example, he tells patients, “ ‘Oh, Dr. Jones is the hospitalist looking after you. He’s a really excellent physician and I agree with the things that they’re doing. I look forward to seeing you when you come home,’ ” Dr. Stream explains. “And, because I stop by, I’m going to be familiar with what was going on and what the issues were and what the follow-up should be. I think that that helps me, as their doctor, but also think that it’s a positive thing for the patient.”

Alexandra Page, MD, a member of the American Academy of Orthopaedic Surgeons’ National Health Care Systems Committee and a surgeon with Kaiser Permanente in La Jolla, Calif., says that while no hard data is available, she thinks hospitalist involvement in orthopedic procedures improves patient care.

She says her “gut feeling” is that the mortality rate would tend to fall where hospitalists are more involved. But she also says that there might be room for hospitalists to become more involved in those procedures, to become familiar with the patient at an earlier stage.

“Would it make sense for a hospitalist … since a hospitalist team would be managing them post-operatively, to consider seeing them pre-operatively? That would be the other area where I think there may be potential growth,” she says.

Dr. Nagamine says more effort is being put into familiarizing patients with hospitalists.

“I think that patients more and more understand our role,” she says. “Part of it is the communication. When the primary-care physician or whoever refers them to the hospital, it’s nice that they explain that someone else will be managing their care. When they arrive at the hospital, we explain our role. In order to gain a patient’s trust, you have to show that you know something about them, you’ve read the chart, you’ve talked to Dr. Smith.”

That transition is something that has received more attention over time, she says, with doctors increasingly providing patients business cards with photos so that they can keep track of who’s who.

“It’s something we could still work on,” Dr. Nagamine says. “But we’re very focused on patient satisfaction and communication. There’s a lot of work going on in that regard.”

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