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HM Model Expands to Ears, Noses, and Throats


 

After five years in the department of otolaryngology/head and neck surgery at the University of California at San Francisco (UCSF), Matthew Russell, MD, is joining the faculty as an assistant professor. Normally, such a career arc is commonplace. But Dr. Russell’s new job title—ENT hospitalist—is worth noting. In fact, it could be groundbreaking.

When Dr. Russell begins work this summer, he might be the only otolaryngologist in the country whose entire patient census and surgical pipeline will be generated by admissions to his hospital. Although there are otolaryngologists around the country who spend the majority of their time working with inpatients, nearly all work an clinical outpatient service as well.

“The hospitalist model turns the traditional ENT practice on its head,” Dr. Russell says. “An otolaryngology practice we think of as being centered around the clinic, and the clinic and referrals is where we generate our operative cases and our patient load. The question really becomes: Can you sustain a practice without a clinic-based model?”

David Nielsen, MD, executive vice president and CEO of the American Academy of Otolaryngology-Head and Neck Surgery, says that while there is no current groundswell for the model, he can envision physicians being drawn to it for two reasons: an aging cohort of otolaryngologists and younger physicians looking for work-life balance.

The hospitalist model turns the traditional ENT practice on its head.


—Matthew Russell, MD, oto-hospitalist, University of California at San Francisco

And while the otolaryngology world at large has not yet answered in unison, the presence of what some are calling an oto-hospitalist is the latest in a series of what HM pioneer Robert Wachter, MD, MHM, has termed “hyphenated hospitalists.” Dr. Wachter, chief of hospital medicine and chief of the medical service at UCSF Medical Center, a former SHM board member, and author of the Wachter’s World blog, says the needs of otolaryngology present the same set of circumstances that allowed internal-medicine-based HM to flourish.

“The forces,” Dr. Wachter wrote in January on his blog, “are the same: sick patients, highly specialized providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement.”

But just adding hospitalist to a job title is not the mark of HM’s presence.

“You can have any hyphenated medical specialist managing patients, but the question is, What are you getting out of it as a hospital or a hospitalist, or as an institution?” adds Gulshan Sharma MD, MPH, associate professor at the University of Texas Medical Branch at Galveston. “The hospitalists really have to figure out their boundaries.”

Dr. Russell says some physicians could be dismissive of the idea of an oto-hospitalist because they’re not clear about the role. They might picture a glorified resident constantly walking between wards to serve as a secondary opinion for other specialists. “There is a perception that this may not be a glamorous position,” he adds. “There’s an assumption that the position is nonsurgical.”

Dr. Russell’s workflow will include rounding and consultations across different wards, and he will assist with complex airway issues. But he also will perform surgeries and work on quality-improvement (QI) initiatives. For those who doubt the variety that a purely inpatient setting can deliver, Dr. Russell eagerly quotes statistics from a two-year pilot program UCSF ran before hiring him as a full-time ENT hospitalist:

  • 300 inpatient consultations the first year, not including ED and urgent care;
  • Sinonasal and laryngotracheal were the most common consults;
  • 200 procedures generated billings; and
  • 45% of procedures were laryngotracheal, 33% were sinonasal/anterior skull base, and 10% were otologic.

"The hospitalist movement, in general, fills a need for the acute-care setting and manages a different set of problems than is seen in the ambulatory clinics,” Dr. Russell says. “That same basic issue is found in otolaryngology. I think it’s an area that is perhaps underappreciated.”

Richard Quinn is a freelance writer based in New Jersey.

Hopkins Physician Sees Bright Future for ENT Hospitalists

In 2000, Nasir Bhatti, MD, associate professor of otolaryngology/head and neck surgery at Johns Hopkins University in Baltimore, started a program similar to the one at UCSF. At Johns Hopkins, Dr. Bhatti, and now his successors, acted primarily as an ENT hospitalist, although he maintained minimal clinic duties as well.

He says the oto-hospitalist model could work efficiently because it would allow physicians, by choice, to determine whether they wanted to focus on surgical procedures or nonsurgical medical services. Those who favor surgery and more intensive procedures could focus on those subspecialties without feeling distracted by the demands of less intensive duties, Dr. Russell adds. Also, Dr. Bhatti points out, the setup could create more revenue capture opportunities from consultations that currently are handled by nurse practitioners (NPs) and physician assistants (PAs).

“Lots of these consultations go unstaffed and, therefore, unbilled,” Dr. Bhatti says.—RQ

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