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"House doctors" and/or hospitalists?

November 2007

A current ad for a “House Physician” in the Philadelphia area reads: “Position will provide house coverage including medicine and ICU and handle a variety of acute care situations including triaging patients to/from the ER. We offer a competitive salary and comprehensive benefits.”

What does it mean to provide “house coverage?” Although no one would argue that hospitalists have redefined the concept of inpatient care, many programs struggle with this issue, particularly those that provide 24/7 coverage without interns or residents.

In my new position as hospitalist medical director for the Virtua Healthcare System in Mt. Holly, N.J., the issue of how to manage–or change–a house-doctor network is much on my mind. I now head up a program with 13 hospitalists and multiple house doctors. In short, the situation that currently exists between house doctors and hospitalists during the night shift is that their roles have comingled.

Having started my career in the Midwest, I wasn’t familiar with the concept of house doctors until I started working in the Philadelphia area.

Typically, house doctors provide acute care–under the loose supervision of an attending. They write admitting orders, triage acutely ill patients and provide the nighttime “Tylenol” and “sleeper” orders. They usually don’t bill for their work because theirs is a service that hospitals provide to community attendings.

At the first hospital I worked for on the East Coast, house doctors performed all the H&Ps, which an attending would later co-sign.

We phased out the day-time house-doctor shift and H&P service, but continued the night house-doctor shift. I have since left, but I know that the hospital is struggling with how to eliminate the house doctors completely without making hospitalists assume all that house-doctor work.

Obviously, non-hospitalist attendings who have not taken calls at 2 a.m. for 20 years don’t want a house-doctor service to disappear. But while house doctors make life easier for community physicians, they do potentially create issues in terms off the expectations of hospitalists who may be comingled with the house doctors. That’s because hospitalists have a strong sense of autonomy for their patients, and do not want to be asked to be physician extenders for other attendings’ patients.

Philadelphia, like most markets, has seen a tremendous growth in the number of hospitalists and a corresponding decline in number of house physicians. Yet, the need for the service hasn’t disappeared, which gets me back to my original question: What does it mean for hospitalists to provide house coverage?

We certainly provide house coverage for patients when we serve as attending or consultant. We also provide house coverage for both hospitalist and non-hospitalist patients in our roles with rapid response teams and code blues.

But many gray areas of house coverage fall outside those categories. Who, for instance, signs restraint orders or blood consents if an attending isn’t present?

Should hospitalists admit patients to the ICU for other attendings at night, then transfer those patients back in the morning? And what if a nurse doesn’t feel comfortable with some aspect of care for a non-hospitalist patient’s care, but the patient doesn’t meet RRT guidelines?

With the current hospitalist shortage and the need for 24/7 care, perhaps a good middle ground is the one we pursued in that previous position: having hospitalists team with house doctors, who cover the night shift. After all, how much curbside care are we obligated to provide at 2 a.m.?

But if we’re not perceived as indispensable 24/7, could that harm our profession? And if both types of physicians work in one hospital, how can we make sure that nurses, patients and administration won’t bring the same expectations that they have for house doctors to us?

Many times, I’ve heard the saying that if you know one hospitalist program, you know one hospitalist program. But as our specialty evolves, many of us are wrestling with the same issues, including if–and how–hospitalists should outgrow their house-doctor origins. I am very curious to hear how others are handling this issue, and hope you’ll use this forum to comment.