Published in the April 2007 issue of Today’s Hospitalist
While the majority of practicing hospitalists are still drawn from the ranks of general internists, a growing number of hospitals are creating specialty “and even subspecialty “hospitalist programs to ease the burden on private practice specialists and improve inpatient care.
These new specialty hospitalist programs are designed to solve problems that are familiar to medical hospitalists, including the growing number of ED unassigned patients, the shrinking pool of specialists taking call and the recruitment efforts that stall when inpatient coverage isn’t available. The programs are likewise running into well-known obstacles, such as turf and trust issues between specialty hospitalists and their outpatient colleagues.
But if the rapid growth of medical hospitalist programs is any indication, the new specialty adaptations of the hospital medicine model are here to stay. Here’s a look at how surgical, hepatic and psychiatric hospitalist programs are creating new options for specialists and medical hospitalists alike.
The rise of "surgicalists"
In 2004, the general surgery program at Thomas Memorial Hospital in South Charleston, W. Va., was slowly but surely falling apart. Four of the eight general surgeons had left town due to rising liability rates and unmanageable workloads, while two of those who remained had opted out of taking call. Something had to be done before the surgery program dissolved entirely.
The hospital could have tried to recruit new surgeons, but what it really needed was a way to allow its current physicians to reduce their call burden and focus on more profitable private, elective case surgeries. Leaders decided to try a novel approach: starting a surgical hospitalist or "surgicalist" program, with the help of Delphi Healthcare Partners Inc., a physician staffing and practice management company based in Raleigh, N.C.
Richard A. Fogle, MD, was the first surgeon to sign on. After 25 years of private practice, he’d had it with reimbursement hassles, overhead and staffing shortages, but he still wanted to practice surgery. "I just didn’t want all of the headaches of running a practice," he says.
Today, Dr. Fogle is one of two "surgicalists" at Thomas Memorial who perform what he calls "bread and butter" surgeries, including hernias, gallbladders, appendectomies and a few vascular surgeries. He works a two-week on, two-week off schedule, providing 24/7 coverage and averaging two procedures a day, plus two or three surgical consults. The other general surgeons augment Dr. Fogle’s two-physician call coverage a few days a month on a voluntary basis.
When Dr. Fogle began, he saw mostly unassigned emergency room patients. But as the other surgeons became more comfortable with his role and realized that he wasn’t going to compete for patients, he started doing more consults and handling an occasional referral from a primary care physician.
For the hospital, limiting staff surgeons’ call and allowing them to target more private, elective surgeries has paid off handsomely. At the end of the first year, the hospital had billed enough to easily cover the $800,000 cost of the new program, and it still came out $1.6 million in the black, according to David L. Joyce, Delphi’s president and CEO. Even more importantly, after hearing how the hospitalist program had cut the call burden, one of the surgeons who’d left decided to rejoin the group, while a new surgeon signed on as well.
Delphi is hoping that another surgicalist program started two years ago at Samaritan Hospital in Troy, N.Y., produces the same results. The company has also created successful ob/gyn and orthopedic hospitalist programs across the country.
One of the hurdles for the surgicalists at Thomas Memorial and Samaritan was establishing trust among staff surgeons.
"My colleague and I went out of our way to make it clear that we weren’t there to step on anyone’s toes," Dr. Fogle says. "We kept explaining our roles in meetings and at social functions. We emphasized over and over that we weren’t there to compete."
It helps, he adds, that there’s more than enough work to go around. "The surgeons tell us that they’re already doing all the work that they can take on."
Scott R. Chudow, MD, director of the surgicalist program at Samaritan, says he is still ironing out turf issues. "The surgeons are relieved to not be taking as much ER call, but there is a degree of suspicion," he notes. "Surgeons are always a bit paranoid; there’s only one pie, and it can be cut into only so many pieces. They always think that they can do a little more."
Nevertheless, the surgicalists, who are independent contractors for Delphi (the hospitals grant them medical staff privileges) are thrilled with their new situations and salaries. That’s because they make about as much as they did in private practice and work only half a year, and they get to focus exclusively on surgery.
"I get to do what I’ve always wanted to do and spend more time with patients without being sidetracked," says Dr. Chudow. Dr. Fogle agrees: "Finally, I can enjoy practicing medicine and not worry about the rest of it."
Managing psychiatric inpatients
Psychiatric hospitalist programs don’t pull in the revenue that surgical programs create. But they do help manage large, challenging patient populations and stabilize overworked medical staff, which experts say make them invaluable.
The psychiatric hospitalist service at Methodist Healthcare System in San Antonio, Texas, began in 2003 after private psychiatrists in the community started giving up their inpatient practice, primarily because of increases in ED call volumes. At the same time, the system, which has five hospitals throughout San Antonio and is the largest provider of inpatient psychiatric care in south Texas, started seeing more uninsured psychiatric patients showing up in its emergency rooms.
Liza Jensen, Methodist’s director of behavioral health, notes that the hospitalist program had several goals: adding additional physicians to the ER call rotation, reducing the uninsured burden on the remaining medical staff, maintaining managed care provider quotas, and offering psychiatrists who didn’t have admitting privileges a mechanism for handing off inpatient care.
The hospital now works with Psychiatric Inpatient Management Services, which provides four psychiatric hospitalists (including one child and adolescent specialist) who work weekdays and one weekend per month. They share call with private psychiatrists, with each group accepting an equal number of uninsured patients.
That reduces the number of uninsured patients that the private psychiatrists accept. The goal of the hospitalist program is to generate income to cover salaries and benefits. David Gonzalez, MD, the director of the hospitalist group, used to be the chief psychiatrist at a Texas state hospital. He saw the new position as an opportunity to transition into private practice.
"I’d always worked in the public sector, and I thought this would be a good way to gradually learn about billing, coding and other issues I’d have to deal with if I went into the private sector," he says. Other psychiatrists in the group have taken the opposite route and transitioned out of private practice.
An issue of timing
At BryanLGH Health System in Lincoln, Neb., the psychiatric hospitalist program is only six months old, but it has already made a huge impact.
According to Larry P. Widman, MD, the group’s director, its three psychiatrists are employed by the health system. They divide their time between inpatient care and providing care to the chemical dependency and partial hospitalization programs, as well as some care in the outpatient center and in some underserved areas.
Two big pluses of the new program are the efficiency of patient screenings and the timeliness of psychiatric consults, according to Brian Bossard, MD, who directs the medical hospitalist program at BryanLGH Medical Center.
"We used to have to wait and wait for consults," Dr. Bossard says. "Now, a psychiatrist can see the patient within a few hours, and we can triage a patient to the psychiatric unit much more quickly." That has taken pressure off the medical hospitalists, he adds, and resulted in shorter lengths of stay for psychiatric patients.
At both Methodist and BryanLGH, psychiatric hospitalists and medical hospitalists work as a team. The psychiatrists perform the mental health screening and assessment, while medical hospitalists perform a history and physical within 24 hours of admission and manage patients’ medical issues throughout their stay.
Timely screenings are particularly important, Dr. Gonzalez says, when patients need to be held in the psychiatric unit, sometimes against their will. "The law requires that patients must be evaluated by a clinician within an hour of being held," he says. "Having a psychiatric hospitalist on site makes that much easier."
A subspecialty focus
When it comes to subspecialty hospitalist programs, not all are staffed by subspecialists. At California Pacific Medical Center in San Francisco, for example, a hepatology/gastroenterology hospitalist program is composed of generalists who have a special interest in the field.
According to Morris Flaum, MD, who is CEO of a multispecialty physician foundation that is affiliated with California Pacific, the hepatology/GI program was started because of the scarcity of hepatologists available to care for the hospital’s liver transplant and complex liver disease inpatients. The medical group’s hepatologists had originally planned to recruit a hospitalist who was a hepatologist, but when it couldn’t find one willing to focus on inpatient care, it hired a general medicine hospitalist instead.
In stepped Guy Lubliner, MD, fresh from an internal medicine residency at Barnes-Jewish Hospital in St. Louis, Mo. "I’d had no specific hepatology experience, so I knew this position was going to be a challenge," he says. "I saw it as a way to round out my education, learn about complex liver and gastrointestinal medicine, improve my skills, and become a better hospitalist."
He ramped up quickly, reading journals and rounding daily with a hepatologist for four months. He soon realized that although his patients were hospitalized for liver issues, they often had multiple conditions, including diabetes and coronary artery disease, which his training had prepared him to manage.
"While specialists focus on treating the liver, the hepatology hospitalists are able to think more broadly and diagnose a variety of non-hepatological disease, from bacterial endocarditis to rheumatologic conditions," Dr. Lubliner says.
Pam K. Grewall, MD, who joined California Pacific two years ago, recalls a case in which she discovered mildly elevated calcium levels in a patient about to undergo a liver transplant. Other physicians might have readily dismissed the finding “which turned out to be an indication of a parathyroid adenoma that had to be removed before the transplant.
"Hospitalists are trained to catch subtle signs like that," she says. "When you’re trained in internal medicine, it’s all in the details."
Over five years, the group has expanded to four hepatology hospitalists who focus primarily on liver transplant and complex gastroenterology patients. Two physicians provide 24/7 coverage on a week-on, week-off basis.
Both Drs. Lubliner and Grewall enjoy the challenge of their work, although Dr. Grewall recalls having some reservations when she first began.
"I was worried about limiting myself to hepatology and GI," she says. "I thought that I might lose my skills in other areas, but that’s definitely not the case. I still use my breadth of knowledge, and every day I learn something new."
Dr. Lubliner occasionally considers becoming a hepatologist, but for now, he’s happy where he is. "If you’re truly an internal medicine physician at heart," he says, "the desire to subspecialize shouldn’t exist."
Yasmine Iqbal is a freelance writer based in Wallingford, Pa., who specializes in health care.