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Hospitalists learn to look beyond a cure

December 2008

Published in the December 2008 issue of Today’s Hospitalist

For Asha Ramsakal, DO, the exchange was a perfect reminder of why she decided to work at a cancer center. A new patient took one look at her, smiled and said, “Dr. Ramsakal, I remember you.”

It turns out that Dr. Ramsakal had recently seen the 78-year-old patient with multiple myeloma at the H. Lee Moffitt Cancer and Research Center’s outpatient direct referral center for pain management. Now the patient had been admitted to the inpatient unit with bradycardia.

“I am able to provide some continuity of care because patients are readmitted for the same or different problems,” says Dr. Ramsakal, who was hired when Moffitt, a 162-bed hospital in Tampa, began its hospitalist program in 2004.

As cancer centers increasingly turn to non-oncology hospitalists to staff their wards, patients who would have once seen an oncologist for a wide range of medical problems are now seeing hospitalists instead. That resonates with “cancer center hospitalists,” who say the improved continuity of care benefits not only patients, but them as well.

As one of six hospitalists now at Moffitt, Dr. Ramsakal handles problems she says are well within her internal medicine training, such as uncontrolled diabetes mellitus, COPD, hypertension, GI bleeds, chest pain, arrhythmias and respiratory failure, to name a few. She also treats more than her fair share of conditions common among cancer patients, such as VTE, dehydration, sepsis and neutropenic fevers.

But diagnosing and managing diverse conditions are only part of the reason she likes working as an academic cancer center hospitalist. Dr. Ramsakal says she’s also attracted to the camaraderie of working with a multidisciplinary team; the intense yet rewarding relationships with patients; and an environment that values the hospitalist’s expertise.

While working in a cancer center may have a devoted, if small, following among hospitalists, the job clearly is not for everyone. For one, hospitalists must be able to work closely in a team, and they must have the emotional fortitude to improve patients’ lives in often difficult times.

But perhaps more importantly, physicians who work at a cancer center must accept a different definition of “success” because so many patients don’t beat their disease.

Why do it?

This new role that hospitalists are discovering at cancer centers doesn’t translate into a financial windfall. Most instead say that the pay in cancer centers is at the “high end” of hospitalist salaries at best.

Instead, hospitalists like Barbara C. Egan, MD, say that connecting with patients is one of the best things about working with the gastrointestinal oncology service at Memorial Sloan-Kettering Cancer Center in New York. That’s because she sees patients, who are often critically ill, on multiple occasions during their last months.

“I decided long ago that I wanted to be a hospitalist because of the intensity of work, but this adds the continuity of care that I miss not being an outpatient doctor,” says Dr. Egan, assistant chair for inpatient affairs for the department of medicine.

Hospitalists say they see each of their patients “usually about 15 “at least twice a day, and then again when families come in, times when it’s hard for oncologists to get away from their practice. Dr. Egan works from 7:30 a.m. to 6 p.m. and carries a beeper Monday morning through Friday evening. Other facilities use moonlighters to cover nights.

Maria-Claudia Campagna, MD, a hospitalist at M. D. Anderson Cancer Center in Houston, notes that her primary care-like relationship with patients has produced a benefit that’s unusual for hospitalists: People tend to keep in touch. She recently received an e-mail from a recent patient, for example, telling her that he was feeling better.

Why hospitalists?

Cancer centers are adding hospitalists in part to enhance efficiency. Moffitt, for example, wanted to minimize transfers to other facilities by bringing that expertise in-house. “The transfers were inconvenient, and 90% of those consults could be handled by a well-trained internal medicine hospitalist,” says Richard Gross, MD, chair of Moffitt’s department of internal medicine and founder of its hospitalist program.

The growing opportunities for hospitalists in cancer centers reflect several other trends. One is the increasingly outpatient nature of cancer care, in which oncologists, like primary care physicians before them, want to spend more time in the office and less time in the hospital.

Workforce issues also come into play. Recent figures show that there will be a shortage of more than 4,000 oncologists by 2020, and that an increasing number of oncologists over age 50 will retire over the next 15 years.

Dean F. Bajorin, MD, co-chair of the American Society of Clinical Oncology’s workforce advisory group, says that many of these vacant positions will be filled by women, who tend to take off more time early in their careers, want to work part time and tend to see fewer patients per week. When you factor in the aging U.S. population, Dr. Bajorin says, the oncology workforce is ill prepared to meet the demand for cancer services.

Delineating roles

Despite that expected shortfall, cancer center hospitalists are adamant that they’re not trying to replace oncologists. While hospitalists consult with subspecialists to handle oncologic complications such as cord compression, for example, oncologists are the only ones to order chemotherapy.

Instead, cancer centers are turning to hospitalists to take the burden of general care off of oncologists. Jason Fromm, MD, who was hired at Shands Hospital at the University of Florida in Gainesville two years ago to run an oncology ward previously staffed by oncologists, says the situation works because a large part of his practice is managing symptoms such as pain, nausea and shortness of breath.

Dr. Gross says that’s a fairly typical set-up for hospitalists. “It’s a validation of how valuable and important hospitalists can be in the esoteric world of cancer care,” he says. “Common things are still common.”

Nonetheless, most centers were concerned that oncologists might balk at having hospitalists on their floor or treat the new doctor as a resident.

“I was worried at first that I was not going to be respected, but I found the complete opposite to be true,” Dr. Egan says. “From day one, the oncologists were very supportive and never made me feel like second fiddle. Instead, they defer to me for internal medicine issues.”

While there are no hard data on the results of having hospitalists in cancer centers, Moffitt is encouraged by early reports noting high patient satisfaction. Sloan- Kettering, which has just begun to look at the impact hospitalists are having on inpatient care, is considering expanding hospitalists to other services.

And M. D. Anderson “which has four hospitalists in GI medical oncology, as well as three treating leukemia patients and two for stem cell transplants “is hiring two more medical hospitalists this winter for genital/urinary patients. The lymphoma and thoracic departments are requesting hospitalists as well.

No turf battles

One reason hospitalists are succeeding at cancer centers is that they often become more proficient than oncologists in some areas, says Alex Adjei, MD, PhD, chair of the department of medicine at the 132-bed Roswell Park Cancer Institute in Buffalo, N.Y. The center has five hospitalists and plans to add one more next year.

“The longer you’ve been out of training,” Dr. Adjei explains, “the more remote you are from antibiotics or DVT management because you don’t do it a lot. Somebody who manages this all the time is more efficient.”

There are cost benefits as well. “If oncologists get paid more than hospitalists and hospitalists can deliver at least equivalent care, then the cancer center could realize cost savings,” says Steven Martin, MD, chief of general internal medicine at Sloan-Kettering.

There’s no turf battle in large part because oncologists, who are used to depending on midlevel providers and radiologists, are the ultimate team players, says Dr. Bajorin, who is attending physician at Sloan-Kettering and professor of medicine at Weil Medical College of Cornell University in New York. “From our perspective,” he says, “we wholeheartedly welcome working with inpatient specialists.”

“It’s not people stepping on each other’s toes,” Dr. Bajorin adds. “We’re talking cancer here. We want patients to have excellent care.”

Getting up to speed

While the demand is clearly there, one question is whether hospitalists are ready. While hospitalists can start working at a cancer center without special training, extra experience in a cancer setting would undoubtedly lessen the steep first-year learning curve.

Start-up includes learning the specifics of cancer drugs and the nuances of particular cancer complications. Discussions with families can be challenging, particularly when they involve end-of-life issues like advance directives and palliative care.

Hospitalist programs in cancer centers often address these challenges by offering their own pain and palliative care team and service, monthly lectures on pain management and end-of-life issues, peer-to-peer coaching, team rounding, and even mock interviews to teach communication skills. In some instances, new hires are assigned to shadow a more experienced hospitalist.

While some hospitalists, like Dr. Egan, are the attending of record during a patient’s hospitalization, an oncologist usually checks in daily and is contacted as needed as are specialists for something like an endoscopy for a GI bleed. But chemotherapy decisions and discussions about prognosis are referred back to the oncologist.

Still, certain professional and personal interests might make cancer centers a better fit for some. And while the collaborative nature of cancer center care may not appeal to independent-minded hospitalists, it is a necessary attribute to treat the patient population at hand, explains Judy L. Smith, MD, medical director for Roswell Park Cancer Institute.

“We need the expertise of both hospitalists and oncologists to manage patients well,” she explains. “The best cancer care is provided by a team of dedicated providers.”

Rewards and defining success

Everyone acknowledges that working with cancer patients full time can be emotionally draining. To get some breathing room, Dr. Ramsakal changes rotation every two weeks and takes an active role in internal medicine resident education. And Dr. Egan is on the cancer GI ward for half a year in two-week blocks, spending the rest of the year on administrative work.

But Dr. Egan also says the work is rewarding “if hospitalists are open to a different definition of success. “Narrowly defining success as making my patients ‘well’ would mean I would be a failure most of the time,” Dr. Egan says. Instead, she finds professional satisfaction maximizing patients’ quality of life through pain control or a transition to hospice care. “If I can help my patient achieve a dignified, painless death, I feel very rewarded.”

Dr. Fromm says that hospitalists who define success as a cure or as merely prolonging life are probably not going to be happy working in a cancer center. He defines success as turning misinformation to good information or living as long as possible symptom-free.

When she thinks of defining success, Dr. Ramsakal offers a spectrum of cure vs. comfort examples. She recalls preoperatively clearing one 50-year-old patient who had pancreatic cancer that was surgically resectible. He developed surgical diabetes that she was able to control with insulin “and he was discharged cancer free.

She also thinks of the 62-year-old patient with metastatic prostate cancer who was admitted with shortness of breath due to bilateral malignant pleural effusions. His wife explained that while they appreciated everything Dr. Ramsakal was doing to make him comfortable, they had accepted that he was going to die soon and were ready to go to home with hospice.

“There I was, recommending chest tubes and aggressive diuresis,” says Dr. Ramsakal. “Patients accept their mortality sometimes before we do.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.