Special Interests
HOSPITALISTS FROM ALL PARTS OF THE COUNTRY—and a few other countries—discussed a wide swath of topics during a community-based HM special-interest forum at HM10. Issues that were discussed included unit-based rounding, changes to Medicare consult codes, strategies for avoiding “dumps,” and working with specialists.
Two established community hospitalists—SHM co-founders John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM—moderated the one-hour session.
Dr. Jacquelin Holubka of St. Barnabas Medical Center in Morristown, N.J., listens during a special interest forum at HM10.
Much of the debate centered on defining a hospitalist’s role and relationships with others in the hospital. One hospitalist said he’d noticed significant changes in the 15 years since he began HM practice; however, some issues remain unresolved: Primary-care physicians (PCPs) still know the patients better, and medical specialists still want hospitalists to be their “interns.”
“We have two things to sell: your expertise and your availability. It’s up to your group to determine which one you want to sell,” said Tony Lin, MD, FHM, a hospitalist and chief of the Department of Internal Medicine at Kelsey-Seybold Clinic in Houston. “I don’t think you have to pick one. So I think you have to ask yourself: What does our group want to sell to the specialist? Sometimes you might have to turn them down to make that point.”
Dr. Lin also described a phenomena emerging in the Houston area: independent, one-physician HM groups taking root in community hospitals. “A lot of the surgeons are using them because they are willing to work as the interns and residents, the first people the nurses call at 2 a.m.,” he said. “There is a market for them.”
Dr. Nelson advised community hospitalists to avoid doing “the things that make you appear different from everyone else. Build social connections with specialists; call them by their first name; eat lunch in the cafeteria; and dress professionally.”
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One community hospitalist spoke of an ethical situation she regularly encounters at her hospital, which contracts with multiple HM groups. Anna Rodriguez, MD, of Chesapeake Hospitalists in Chesapeake, Va., explained that her group’s issue is acutely ill patients who are assigned to one of the other HM group services—which, unlike Dr. Rodriguez’s group, are not responsible for codes or 24/7 patient coverage. So what happens when the “other” group’s patient has a sudden deterioration and the hospital staff calls us to run the rapid response? Dr. Rodriguez asked the group.
Dr. Whitcomb suggested Dr. Rodriguez’s group, which is not contracted to run the code, work to iron that situation out. “Then, that is your job and contractually recognized,” he said.
“We get into the exact same situation in our hospital. We created a hospital medicine section and … established expectations for who responds to codes,” said Dennis Kold, MD, medical director of the hospitalist service Tri-Health in Cincinnati. “If the patient is declining, we will respond to code, but we have it set up where the expectation is that the [attending] will be in to take care of the patient in one hour, or if the patient is admitted overnight to the ICU at 10 p.m., that the [admitting] will be in the ICU to take care of the patient within four hours.” Dr. Kold added that when the attending doesn’t show up in time that penalties are enforced (e.g., taken off the ER call schedule, restriction of hospital privileges).
“If you are not dealing with rapid response, then you are just hurting yourself,” added Edward Rosenfeld, MD, a hospitalist with Lehigh Valley Medical Associates in Allentown, Pa. “You need to do it; that’s your code prevention.”