Eric M. Siegal, MD, SFHM, vividly recalls the moment when he realized “scope creep” had become a problem. A hospitalist partner who was working a night shift admitted a young man who had been in a high-speed motor vehicle accident. The hospitalist did so because the general surgeon did not want to come into the hospital.
Dr. Siegal, currently the medical director of critical-care medicine at Aurora St. Luke’s Medical Center in Milwaukee, remembers looking at his partner and asking, “What the hell are you doing admitting a trauma patient? You’re an internist!”
Dr. Siegal’s partner responded, “I’m just trying to show value.”
“That was an ‘a-ha’ moment for me,” says Dr. Siegal, a member of SHM’s board of directors. It was at that point he began to understand that the expansion strategy used by many HM services—to demonstrate value by agreeing to comanage or admit patients for their primary-care (PCP) and specialist colleagues—had produced some unintended negative consequences. “Hospitalists,” he says, “are like the spackle of the hospital. Sometimes spackle is good; it hides flaws and imperfections. But at other times, people use spackle to fix major structural problems.”
Scope creep, mission creep, scut work: There are numerous ways to describe the phenomenon. In basic terms, hospitalists have been pressured to expand their scope of practice to manage all hospitalized patients. Hospitalist leaders differ about how much of an issue this really is, as managing hospitalized patients is the definition of hospitalist work. Burke T. Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member, points out that “one man’s scope creep is another man’s practice-builder.” John Nelson, MD, MHM, co-founder and past president of SHM and medical director of hospitalist services at Overlake Hospital in Bellevue, Wash., says the expanding service trend is prevalent, but whether “it’s a problem depends on your point of view. The same stressful evolution occurs in every specialty. We are not unique in that regard.”
The trick, according to HM leaders, is to understand the dynamics that drive scope creep, then work proactively to address the problem.
Evolving Scope of Practice
It was not so long ago that hospitalist groups, seen by many in medicine as the new kids on the block, were perceived as a threat to their primary-care and specialist colleagues. To establish themselves, hospitalists began to demonstrate value by comanaging patients for their surgical colleagues, especially orthopedists. Some studies, notably those conducted by Mayo Clinic-based hospitalists, appeared to demonstrate that using hospitalists to help comanage orthopedic surgical patients results in improved outcomes.1,2
Dr. Siegal, however, points out that a closer parsing of those studies reveals that such outcomes as decreased time to surgery and length of stay (LOS) were better for patients with complex medical comorbidities, rather than all patients, which supports his argument that hospitalist comanagement makes most sense when applied to select groups of surgical patients.3
Hospitalists are like the spackle of the hospital. Sometimes spackle is good; it hides flaws and imperfections. But at other times, people use spackle to fix major structural problems.
—Eric M. Siegal, MD, SFHM, SHM board member, medical director of critical-care medicine, Aurora St. Luke’s Medical Center, Milwaukee
As HM sprouted roots, clinicians across the country began to see an increase in requests for their services from primary-care physicians (PCPs) and subspecialists, as hospitalists freed them from rounding on patients and allowed them to concentrate on procedures for higher billings. Over the past 10 years, the expansion has been rapid, converging with multiple factors: increasing numbers of uninsured patients, an aging physician workforce, and diminishing reimbursement, to name a few.