Practice Economics

Hospital-Focused Practice


 

As regular readers of The Hospitalist are aware, essentially every specialty in medicine is adopting the hospitalist model to some degree. After the “legacy” specialties of medicine and pediatrics, the model has more recently been embraced enthusiastically by neurologists, obstetricians, and general surgeons. But even fields like dermatology and ENT have put a hospitalist version of their specialties in place in at least a few places.

Did you know there is a Society for Dermatology Hospitalists? Did you know that the Neurohospitalist Society has its own journal? Did you know OB hospitalists have a really neat website, and the Society of OB/GYN Hospitalists is scheduled to have its first annual meeting in Boulder, Colo., Sept. 23-25?

It’ll make your head spin if you think about it too long. All of this raises a number of issues, including the need for more precise terminology to describe these fields and their practitioners.

The Need for Better Terminology

For example, now that we have neurohospitalists and psychiatric hospitalists, is it time to start attaching a modifier or prefix every time we use the word “hospitalist,” including when referring to “medical” hospitalists? I don’t think so. For the time being, I propose that when used alone, the word “hospitalist” still refers to a doctor who provides general medical care for adult inpatients. But I think any other use of the word does require a modifier, as in “peds hospitalist” or “GI hospitalist.”

(I think my view makes sense, but then, I’ve tried for years to ensure nocternist, with an E—NOCTernal intERNIST)—is the preferred spelling over nocternist, with a U. But Google returns nine hits for the former and 365,000 for the latter. Looks like I lost that one.)

Terminology for general and trauma surgeons is tricky. There is an emerging field of acute-care surgery, distinct from general surgery, which some argue passionately is nothing like a hospitalist model, and they tend to be offended if one uses the latter term. So, for now, we’ll need to use both “acute-care surgeon” and “surgical hospitalist” carefully. Although there are meaningful distinctions between acute-care surgery and a “standard” general surgery practice devoted to the hospital, there is an awful lot of overlap in the Venn diagrams of their expertise and what they do. But for now, it looks like we should expect both “acute-care surgeon” and “surgical hospitalist” to appear commonly, and the context will determine whether the terms could be used interchangeably.

While “obstetric hospitalist,” or “OB hospitalist,” is a perfectly useful term, I think it is great when laborist is substituted, at least in informal communication.

We still need a way to speak of all of these clinical roles (I don’t think we can properly call them specialties yet). I propose that we refer to all of them as specialties within the realm of “hospital-focused practice.” I’ve borrowed this term from the American Board of Internal Medicine’s Recognition of Focused Practice in Hospital Medicine, the new pathway to Maintenance of Certification.

And what about those doctors in each specialty who continue to practice in the traditional inpatient and outpatient model? Let’s call them “traditionalists.”

Career longevity is still a matter of speculation, but the majority of those who have transitioned from traditional to hospitalist practice in their fields are convinced they will have a longer career than if they hadn’t made the switch.

Hospital-Focused Practice

A rational vocabulary is only one of many significant issues raised by the growth of hospital-focused disciplines. In January, I participated in an SHM-convened, and AHA-supported, meeting of 11 practitioners who were hospitalists in neurology, obstetrics, general surgery, medicine, pediatrics, and ENT. (Sadly, the invited dermatology hospitalist couldn’t make it.) The meeting was filled with interest and sharing of lessons learned in each field. We discussed questions, and I have provided a very brief answer to each based on the conversation during the meeting and my own work with practices across many different specialties that have adopted the hospitalist model:

What are the reasons each specialty is turning to this model, and what is its prevalence? Hospitalists have appeared in a specialty largely to fill the void left by the traditionalists who no longer want to care for unattached patients admitted through the ED, or who want to leave the hospital altogether for a solely outpatient practice.

What are typical staffing models, night coverage arrangements, and provider career sustainability? These vary a lot by specialty, but laborists typically work 24-hour, in-house shifts. Surgical hospitalists usually work 12-hour shifts if they are in-house all the time, or 24-hour shifts if they take call from home. Neurohospitalists essentially always take call from home (did you even have to ask?).

Career longevity is still a matter of speculation, but the majority of those who have transitioned from traditional to hospitalist practice in their field are convinced they will have a longer career than if they hadn’t made the switch.

What are the effects of this practice model on clinical quality, patient outcomes, healthcare economics, and liability? It will be really difficult to get convincing research data on the quality effects of the hospitalist model in many fields. After more than 15 years in operation, research about the quality effects of the medical hospitalist model is not robust enough to satisfy some. But OB hospitalists may be the exception here. There is hope that their continuous, on-site presence will reduce complications from emergencies, and in doing so might reduce malpractice risk.

What is the prevalent financial model? The experience across a lot of healthcare settings to this point is that professional fee revenue alone usually is not enough to support a hospitalist practice model in any specialty. Just like medical and pediatric hospitalist models, the hospital in which the doctors practice usually provides additional financial support.

Hospitals usually are willing to do this because they are able to reallocate dollars spent paying for numerous specialty doctors to take ED call with poor performance, and instead use those dollars to support a hospitalist practice in that specialty that promises a better return on the investment.

Join us in November for a meeting to understand the implications of hospital-focused practice. Those of us at the January meeting of specialty hospitalists thought that it would be valuable to convene a much larger meeting to think about issues like those above and others. At the Nov. 4 meeting in Las Vegas, we plan to hear from such national figures as CMS’ chief medical officer, physicians practicing in a hospitalist model, and hospital and healthcare executives. The meeting will be structured to promote interaction and communication from attendees.

I hope to see you in Las Vegas. We have a lot to learn from one another.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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