Published in the February 2005 issue of Today’s Hospitalist
When Valley Baptist Medical Center started a hospitalist program last fall, it joined the ranks of community hospitals that have turned to hospital medicine to improve quality, improve efficiency and serve their local primary care physicians. But what really drove the Harlingen, Texas, hospital to start a hospitalist program were educational considerations.
The hospital’s internal medicine residents had been urging the training program to give them a wider range of teaching cases. At the same time, continuity problems and scheduling issues made hospital officials realize that working solely with community-based physicians who wanted to teach was no longer adequate.
“We were trying to get the hospitalist program up and running primarily for the teaching program,” explains Steven A. Nahm, vice president for physician services at The Camden Group, a Los Angeles-based consulting company that helped Valley Baptist set up the new program. “The question was whether we should hire faculty to do the teaching, but this is a community hospital, so a hospitalist program was a really good fit.”
Gradual shift
Hospitalists are no stranger to graduate medical education. Since the beginning of the movement, some of the largest and best-known groups have been based at academic medical centers. At the same time, large community hospitals with well-established internal medicine training programs have long championed hospital medicine.
But for many hospitalists “particularly those working in small to medium-sized community hospitals “teaching hasn’t been part of their job description. Industry observers, however, say that a gradual shift might be taking place.
While there are no data on the number of hospitalists who are adding teaching duties to their job description, anecdotal reports say that a growing number of hospitalists are talking about adding resident education to the duties. While Valley Baptist reached that goal by tackling it head on, most hospitalists in both academic and community-based hospitals reach the same point through a more gradual process.
“Most teaching programs predate the hospitalist movement,” says Adam D. Singer, MD, founder and CEO of IPC-The Hospitalist Company in North Hollywood, Calif. “And hospitalists are often so young that they are not invited to be the teachers of their program.”
“But what happens, generally speaking, is that the hospitalists come on board, and because these doctors are so much more available than any other potential attending, they become the natural teachers,” Dr. Singer explains. “They are there, so the powers that be who are trying to staff the training program gravitate toward using hospitalists, primarily because we are available.”
The right mix
Consider the evolution that occurred at Valley Medical Center in Renton, Wash., a community hospital in the booming suburbs just to the south of Seattle. A University of Washington-affiliated family practice residency existed there, and its family practice attendings functioned as faculty. But because the family physicians didn’t have ICU privileges, hospitalists were asked to act as residents’ attendings when their patients were in the ICU.
“It really worked out great,” explains Lawrence Dell Isola, MD, a full-time hospitalist at Valley Medical since 2002. “The residents liked the hospitalists. The hospitalists liked the residents. So we went from one teaching case a day to two and then to three. I think the residents would say a lot of what they learn in the residency does come from us, in terms of inpatient training.”
Just last month, that relationship evolved further when a senior family practice resident asked to do a “hospitalist rotation” during one of his elective months. He wanted “more internal medicine inpatient experience,” explains Robert Bessler, MD, president of South Sound Inpatient Physicians, the company that employs Dr. Dell Isola and the other hospitalists working at Valley Medical.
So in addition to admitting and caring for nearly all the hospital’s unassigned patients and referrals from 85 primary care physicians, Dr. Dell Isola and his six hospitalist colleagues now choose three patients from their daily admissions that they think will make good teaching cases for residents.
Dr. Dell Isola is the first to acknowledge that supervising residents rarely saves the group time. While having someone to share the patient load can be useful, the hospitalists return any time they saved in patient care or paperwork to residents in the form of teaching.
He says that the hospitalists have learned through experience how important it is to select the right patients as teaching cases. “There are a certain number of patients you can treat more quickly yourself,” Dr. Dell Isola explains, “and many aren’t good teaching cases. Our model is successful because we share a limited number of cases with the residents.”
Too much success?
Across the country in Connecticut, the hospitalists at Norwalk Hospital have had tremendous success as both teachers and clinicians. Mark Kulaga, MD, says that the five-hospitalist program, which is in its sixth year, operates more like an academic practice than a community one. The hospitalists divide their time equally between clinical and teaching responsibilities.
And while that mix of patient care and teaching has been ideal for the physicians, Dr. Kulaga says that the group may be at a crossroads. The problem? The service has been so successful that the demand for hospitalist services is growing too rapidly, threatening to overshadow the group’s teaching mission.
In the group’s early years, the hospitalists cared only for the unassigned patients in the hospital and the inpatients from a local community health center. Now, some large groups of primary care physicians are referring their patients to the hospitalist group. Patient volume, Dr. Kulaga explains, is only projected to increase, which will further strain the group’s staffing.
“As we expand, there are only so many clinician-educators we can justify having,” Dr. Kulaga says. “We may look at the concept of having a parallel system that is a little more service-oriented. We are not sure how that is going to work out.”
To date, the group has been able to convince the hospital’s administration to keep expanding its number of fulltime hospitalists working as both clinicians and educators and to keep subsidizing those hospitalists’ salaries, benefits and overhead. That argument has succeeded, Dr. Kulaga explains, largely because the hospitalists have proven their cost effectiveness to the hospital.
In a study published in the April 2004 issue of the Journal of General Internal Medicine, Dr. Kulaga and his colleagues documented how the hospitalist clinician-educators had significantly lower (by 20 percent) lengths of stay and costs per case (18 percent lower) compared to community-based physicians caring for their patients in the hospital. The same study also reported that the residents found that having hospitalist clinician-educators teaching them improved “the quality of attending rounds, bedside teaching and the overall inpatient experience.”
Dr. Kulaga notes that those findings have made a huge difference when the group has to talk to hospital administrators about financial issues. “One of the keys to our success is that we have been able to justify ourselves,” he says.
Covering costs
Not all community-based teaching programs using hospitalists, however, have been able to convince hospitals to pay them for the time they spend teaching.
When the hospitalists at Emory Crawford Long Hospital, a community hospital that is part of Emory Healthcare in Atlanta, wanted to expand the number of teaching teams from one to two, they were responding in large part to demand from the housestaff, who consistently give their ward rotations high marks. Despite all the accolades, however, the hospitalists had to raise the money themselves to cover the cost of growing from 10 to 12 hospitalists.
“When we expanded to five teams (two are the teaching teams), we really had to beef up our service,” explains Val Akopov, MD, head of the hospital medicine service at Emory Crawford Long Hospital. “We had to do this without taking a financial hit.”
Without any subsidy from the hospital or program for teaching, the hospitalists had to commit to working harder. So they beefed up their consultation service, recruited more patients from community doctors and convinced more surgeons to turn to them. The bottom line was that the program increased its patient census by at least another 18 patients a day.
“The group was committed to it, so we did it,” Dr. Akopov says. “We have had to be extra diligent in growing our referral patient base. We are still working within the constraints of the same budget requirements and productivity targets. It took some work and some time to beef up our clinical work in order to make the targets.”
Antidote for burnout
Despite those challenges, Dr. Akopov is quick to add that the payoff was increased job satisfaction. For the hospitalists in the group “there are now a total of 12 “who love teaching, there are more months to rotate with the housestaff now.
“If you do just shift work day in and day out, that is a prescription for burnout and boredom,” he says. “Once you have an opportunity to do not only direct patient care but also teach housestaff, it really spices the job up and makes people happier.”
For doctors, the rewards of teaching often come in the form of increased professional satisfaction and less burnout. For hospitals, it’s teaching the type of efficiency-oriented, evidence-based inpatient medicine hospitalists are becoming known for. And trainees gain from improved teaching and learning opportunities during their inpatient rotations.
Dr. Kulaga from Norwalk Hospital credits teaching for the fact that not one of the five hospitalists have left the program.
And at Valley Medical Center just outside of Seattle, the teaching service is successful and growing because many hospitalists say that teaching is their favorite part of going to work every day. “The part of the job we find most gratifying is working with residents,” Dr. Dell Isola says.
Community-based benefits
Physicians aren’t the only ones to benefit from these types of teaching programs. Several studies published in the last year all concluded, like Dr. Kulaga’s, that hospitalists make impressive teachers “more so, usually, than nonhospitalist primary care physicians or subspecialists who attend on medicine wards. In addition to Dr. Kulaga’s study, there has been research from the University of California, San Francisco (UCSF) and Emory that has focused on effects of hospitalist attendings on trainee satisfaction in academic hospitals.
What’s interesting, however, is that many experts say they hear anecdotally that the gains are even more dramatic in community teaching hospitals. “In a community setting, in the old model before there were hospitalists, you had housestaff by and large working with 50 or 100 primary care physicians whom they didn’t see very often, who certainly were not selected because of their teaching skill, and who often did not have time to teach,” says Robert Wachter, MD, a hospitalist and professor of medicine at UCSF and co-author of a study in the Sept. 27, 2004, Archives of Internal Medicine on hospitalists as inpatient attendings.
“With hospitalists, not only are you having teachers who are selected to teach and are better equipped to do it and who read about inpatient medicine,” Dr. Wachter explains, “but now you have one attending. It much more replicates what we have always had academia. It’s a much more favorable teaching environment, so it should be substantially better. That’s what you hear anecdotally, at least.”
James Castillo, MD, a third-year resident at Valley Baptist in Texas who in January was the first resident in that hospital’s new hospitalist-led inpatient rotation, echoes this view. After only four days in this new rotation, he had already seen diseases, treatments and ways of operating he hadn’t even glimpsed in the preceding two-plus years of training.
For one, he saw pathologies he hadn’t encountered before. (All the teaching cases before the hospitalist rotation began came from a community health center. Now he was also seeing patients with private insurance.) He learned how hospitalists begin discharge planning on the first day of a hospitalization. He was getting a crash course on coding, documentation and billing, which he never had to worry about before. And he was picking up tips on communicating with primary care physicians.
Taste for teaching
Even before the rotation, the idea of inpatient medicine had intrigued Dr. Castillo. This firsthand experience was helping to seal the deal. He now wants to try to launch his internal medicine career as a hospitalist.
But perhaps just as importantly, he has also become persuaded that as much as he wants a career as a hospitalist in a community hospital, he wants a job that includes some teaching too. For that reason, Dr. Castillo says, he is now in negotiations to join Valley Baptist’s new group when he finishes his residency this summer. He is definitely not seeking to join the hospitalist group in a nearby competing hospital.
He acknowledges that the other hospital has a lot going for it. It’s newer. It’s partly owned by doctors in the community. It provides high quality service.
“I could stay in this area and go to another hospitalist program that does not have teaching,” Dr. Castillo says. “But I like this model. I like being a clinician, and I want to continue to teach.”
Deborah Gesensway is a freelance writer in Toronto, Canada.
Community-based hospitalists as teachers: a few caveats
While proponents of the hospitalist movement say that incorporating teaching into a busy practice at a community hospital is a win-win situation for everyone involved, most are quick to add the caveat that incorporating teaching into a busy private practice has to be done well, and not on the fl y.
“If people think they’ll do a little teaching on the side, it will fail,” says Jeffrey Hay, MD, medical director of inpatient services for Healthcare Partners in Los Angeles. Dr. Hay also works as a consultant on hospitalist issues with the Los-Angeles based The Camden Group.
Dr. Hay and other experts say that common traps include community hospitalists who bite off more than they can chew, typically because they fail to think through schedules and workload. Another problem? Hospitalists who act like cowboys, using and teaching residents as they wish, but never in sync with the training program.
Sometimes problems can be something as minor as hospitalists who make their residents late for regular conferences and other educational requirements. In other instances, physicians will cross a much more serious line and violate the work hour limits on housestaff.
(Several sources say that those work hour rules may hurt the ability of community-based hospitalist programs to get involved in teaching. As academic teaching programs try to cope with the work hour restrictions, some are actually pulling residents away from community-based teaching sites so they can bulk up staffing in teaching hospital clinics.)
Finally, experts say, it is important for a community-based hospitalist group to avoid doing too much teaching. “You don’t want to hurt the business goals of the hospitalist group,” Dr. Hay says. “The goal shouldn’t be to make teaching a principal part of their business, but to add some professional satisfaction, add some attractiveness to the group to help with recruiting and to give it more clout in the hospital and community.”
