Cover Story
Doctors Wanted
By Jeanne Mettner | Illustration by Andree Tracey
Demand for hospitalists is booming, and primary care providers are responding.
Ten years ago, Charles Terzian, M.D., could have used a Star Trek transporter to get him from the clinic to the hospital. An internal medicine physician, Terzian practiced at an Allina clinic in downtown Minneapolis and admitted patients to Abbott Northwestern Hospital on the city’s south side. He often found himself visiting patients in the hospital in the early morning, driving downtown to the Medical Arts Building for clinic, then heading back to the hospital for evening rounds. “It became very difficult, very intense,” Terzian recalls. “And I had very, very long days, which did not make for a very balanced lifestyle. I always felt like I was working."
That changed in 2000 when Terzian took a job as a full-time hospitalist with Allina’s United Hospital in St. Paul and ceased his clinic work. Now medical director of United’s hospitalist service, Terzian typically arrives at 8 a.m., leaves by 6 p.m., and does the occasional overnight shift. Throughout the day, he sees anywhere from 12 to 15 patients—assuming responsibility for them at admission, managing their care while they’re in the hospital, coordinating their discharge, then handing their care back to their primary care physician. “There are still some days I can come in really early and work really late, but I also have a significant amount of time off and a lot of flexibility in my schedule,” he says. “If I want to leave work for a short while to attend one of my daughter’s programs at school, I can do it without having to cancel an afternoon of appointments.”
The Perfect Climate
Terzian is one of a growing number of physicians who have opted out of clinic-based primary care and into hospital medicine. Since 1996, when Robert Wachter, M.D., chief of hospital medicine at the University of California, San Francisco Medical Center, coined the term “hospitalist,” the field has grown from about 1,000 physicians to nearly 20,000, according to the Society of Hospital Medicine (formerly the National Association of Hospital Physicians). The society, which was created in 1997 to promote practice excellence through education, research, and advocacy, currently represents about 6,000 hospitalists in the United States. Demand is only expected to grow as hospitals recognize the benefits hospitalists bring in terms of patient care and their own bottom line. In fact, Wachter estimates that as many as 50,000 hospitalists may be needed in the next five years.
One might say that the hospitalist movement developed in spite of itself. Because hospitalists perform few procedures, Medicare and insurance companies do not often reimburse for their services adequately. “No one in their right mind would have invented a field whose primary task was to coordinate the care of really sick hospitalized patients because our insurance system undervalues two things—talking to patients and coordinating their care,” Wachter says. “From the get-go, those of us who were at the founding of this movement knew that we would be completely dependent on someone else with money saying that having hospitalists around would be good for patient care and it’s worth it to dip into our deep pockets to support that.”
Although hospitalist programs are not moneymakers for individual hospitals, hospital and health system administrators surmised that hospitalists’ focus on inpatient care could increase efficiencies in health care overall. By most accounts, that gamble has paid off. Published studies by Wachter and others have demonstrated that having hospitalists on board can shorten lengths of stay by 10 percent to 15 percent and decrease the cost of care by similar magnitudes; others have found cost differences in favor of hospitalists that are less substantial but still statistically significant. Studies have also indicated that having a generalist in the hospital full time can decrease the frequency of nosocomial complications such as pulmonary emboli and incidents of deep vein thrombosis.
At the same time health care institutions were beginning to take note of those findings in the late 1990s and early 2000s, a new generation of residents had decided they wanted a more balanced lifestyle than that of their predecessors. A 2005 American Medical News article noted that physicians were part of a nationwide trend in which younger adults were basing career choices on family and other factors. Residents who were spending the majority of their medical training in the hospital were seeing that hospitalist work offered fixed, finite hours. “That’s attractive,” explains Jo Ann Wood, M.D., M.S., lead hospitalist for the University of Minnesota Medical Center, Fairview. “The clinic is just different; even though you go home at the end of the day and your patient goes home, there’s still a lot of work involved with coordinating their care—making sure they get that MRI at the hospital, making sure someone calls them to give them their test results.”
Supply and Demand
As primary care providers debate the merits and pitfalls of the hospitalist movement, educators and hospital medical directors are trying to figure out how to train enough new physicians to meet the demand, which continues to exceed supply. “One of the big things we are tackling in this specialty is where we are going to get the 30,000 to 50,000 additional specialists that we need in the next five years,” says Burke Kealey, M.D., assistant medical director of hospital medicine at HealthPartners Medical Group.
Academic medical centers across the country are responding by beefing up residency programs to provide more appropriate training to residents who may want to move into hospital medicine. At the University of Minnesota Medical School, where as many as 25 percent to 30 percent of students interviewing for residency positions this year expressed an interest in hospital medicine, faculty are teaming up with Regions Hospital to create a three-month hospitalist pathway for the university’s internal medicine residency program. HealthPartners, which owns Regions, has offered a one-year post-residency fellowship program for the past six years that trains one to two physicians a year. Those physicians go on to become hospitalists as well as educators and leaders in the field.
Although there is no required training for hospitalists, the residency pathway will include several areas that are not currently emphasized within most residency programs, including surgical co-management, preoperative consultation, coding and documentation, quality-improvement research, multidisciplinary team rounding, palliative care, and pain management. Participants will also learn common hospital medicine procedures such as thoracentesis, paracentesis, and lumbar punctures at a simulation center and receive one-on-one mentoring from staff hospitalists. The first residents are expected to start on the pathway July 1, 2008.
According to Rick Hilger, M.D., who is heading up the pathway’s development, only a few internal medicine programs in the country have such a pathway in place. “The need is there,” he says. “Studies have shown that new staff hospitalists feel prepared academically to take care of patients, but they feel ill-prepared for the day-to-day challenges that hospital medicine presents.”—J.M.
|
As new physicians responded favorably to the idea of becoming hospitalists, established primary care providers were realizing that dropping hospital rounds made sense for them as well. For one thing, it saved time. “Even if they were billing for that [hospital] encounter, it may take 70 minutes total to drive to and from the clinic and spend time with a patient in the hospital, and in that same period of time, they may have been able to see four patients in their office,” says Lynne Lillie, M.D., immediate past president of the Minnesota Academy of Family Physicians and medical director of Woodwinds Health Campus in Woodbury.
A Matter of Dollars and Sense
Although no one in Minnesota has kept an accurate count of the number of hospitalists statewide, there’s no doubt among physicians that the field is burgeoning. Says Lillie: “In the metro area in particular, family physicians in droves are saying ‘We don’t want to go to the hospital,’ and the primary reason tends to be economics and lack of reimbursement for care management.”
Salaries have attracted some to the hospitalist field. As employees of a hospital, health system, or medical group, hospitalists earn $193,000 a year on average, according to a recent Society of Hospital Medicine Survey. That’s slightly more than what the average family physician might earn in another setting, which is $185,740, according to 2007 American Medical Group Association data, and on par with what internal medicine physicians make. The salary difference in Minnesota may be even greater. Anne Pereira, M.D., internal medicine residency director at Hennepin County Medical Center, notes that new graduates who choose hospital medicine can earn substantially more than what she makes as an academic general internal medicine physician. “Physicians doing both hospital and ambulatory medicine can look at the situation and say, ‘How can I tell my family I’m going to work twice as much and make so much less?’” she says.
Consequently, Pereira says that only 5 percent to 10 percent of the internal medicine residents at HCMC plan to do a mix of hospital and clinic work. Sixty percent choose a subspecialty, and about 30 percent opt to practice hospital medicine.
A Few Holdouts
Not all primary care providers have embraced the hospitalist trend. The physicians at Camden Physicians in north Minneapolis, Plymouth, and Maple Grove, for example, have decided to continue seeing patients at their affiliate hospital, North Memorial Medical Center. “We have a high degree of agreement within our practice that being a good family medicine physician means taking care of your patient in all care settings,” says Richard Gebhart, M.D., the group’s medical director, who every two months spends a week serving as the group’s hospitalist. “Most of us just maintain this gut feeling that if you know the patient and you know their history and their illness, it just makes things go better. And I think our patients feel reassured that we are there.”
Some family physicians are concerned that the hospitalist movement will attract some of their field’s brightest and best away from the clinic. “I think about who would take care of our patients, because the majority of care still needs to take place in the ambulatory care setting,” Lillie says. Also, family physicians are concerned that giving up hospital work will hurt their professional status. “When we go through our family medicine residency training, we are trained to care for patient in intensive care, to deliver babies, to take care of people in the hospital,” Lillie says. “If family physicians start to give up different areas of practice, how will we differentiate ourselves from nurse practitioners and other providers?”
Wachter acknowledges those concerns. But, he says, the tide has turned. “Family medicine is a field whose core premise is We can do everything—we can see you in the hospital, we can see you in the clinic, we can deliver your babies, we can do your surgery, so it doesn’t feel good for them to say that we are going to give up this piece of being there for our patients at a really crucial time,” he says. “Overall, though, when you look at the surveys of primary care docs today, the majority of them are positive about having a hospitalist program, particularly when one is in place already. They may not like the idea theoretically, but once they have one and use it, they realize it makes sense for their patients. They’re getting good care.”
Terzian agrees that once physicians have experience with hospitalists, they often become believers. He says the physicians in one of the clinics in the Allina system were adamant about continuing to make rounds in the hospital. Among other things, they were concerned they’d lose control of their patients’ care. “We spent a lot of time trying to convince them that we could take care of their patients in the hospital,” he recalls. “Finally, they made the leap, and now they said they’d never go back. Change is good if you accept it.”
Sheri Lofton, M.D., a family physician with the Allina Clinic in Cottage Grove, is one of those who cannot imagine going back. More than a decade after she began working with hospitalists, she still remembers the constant interruptions from the hospital while she was in the clinic—the pages about patients who were being admitted because of chest pain, for example, or about patients who were hospitalized already but needed new orders for medications. “Having to do both jobs was creating fragmented care for patients both in the clinic and in the hospital,” she recalls. Now she is able to concentrate on her clinic patients while feeling assured that her hospitalized patients are in good hands. “The hospitalists know their stuff,” she says. “And they’re there all the time.”
Keeping Care Seamless
Whether or not physicians embrace the hospitalist movement, they all face the challenge that it presents: continuity of care. “I call it purposeful discontinuity,” Wachter says, explaining that the benefits of having doctors onsite in the hospital inevitably results in a disconnect between the outpatient and inpatient worlds. “As hospitalists, we have to own that and figure out ways to fix it.”
Mark Seaburg, M.D., chair of the hospitalist program at Park Nicollet Health Services’ Methodist Hospital, has been working on the issue for more than a decade. Seaburg, who was on board when the first inpatient hospital physician began work at what was then called the Methodist Hospital Service almost 15 years ago, says communication between outpatient and inpatient providers—especially getting discharge summaries to primary care physicians—has been a challenge from the day the hospitalist program started. Seaburg says Park Nicollet’s electronic medical record, which was rolled out in February 2003, has solved many of the communication problems among hospitalists and primary care physicians within the Park Nicollet system. “Still, we do have some independent doctors who send patients to us and are not on our computer system, so getting the proper admission information and discharge summaries can be more challenging in those circumstances,” he says.
Terzian, too, says that technology has improved communication and the transfer of information. He says he can access Allina’s EMR, which is used by both its hospitalists and its primary care providers, from offsite. “If I am concerned about someone and I’m sitting at home at 10 p.m., I can look up his record, get a lab result, and make some management decisions for the next day. Instead of calling a colleague right then and there, I can enter the information into the system and write notes for the care coordinator or nurse or attending physician.”
To improve continuity of care in other ways, he and the other 25 hospitalists at United, 18 of whom work full time, adjust their schedules to help cover the times when admissions and discharges are heaviest. If a patient is in the hospital for longer than three days, he will write a summary of the three days’ events and send it to the patient’s primary care doctor. His group is also working with referring physicians to develop a standardized discharge summary form to ensure appropriate care management after hospitalization. The form will ask for specific information so that nothing falls through the cracks. “We’ve made arrangements with the Allina clinics that if a patient calls and says he or she was just discharged from the hospital, that’s the buzzword to get that person seen by a primary care doctor within three days,” he says. “We may not be providing the continuity of care ourselves, but we are certainly facilitating it.”
Still some say there’s no trick to making sure patients’ personal physicians get the information they need. “Improving transfer and continuity of care gets back to the old way, which is person-to-person contact,” says Burke Kealey, M.D., assistant medical director of hospital medicine at HealthPartners Medical Group. “Today’s technologies offer us so many ways to do that—text paging, cell phones—but you can also augment that with the tried-and-true personal phone call.”
Although he would not go back to clinic-based primary care, Terzian admits he misses having relationships with patients over longer periods of time. Working in the clinic, a physician sees patients both when they are well and when they are ill, he notes. A hospitalist only sees them when they are sick. When patients tell Terzian they hope to see him again, he says, “‘If I see you, it means you are back in the hospital. But I hope to run into you in the shopping mall sometime. It really would be good to see you there.’” MM
Jeanne Mettner is a Minneapolis freelance writer.