Published in the December 2009 issue of Today’s Hospitalist
Little by little, the hospitalist service at Gundersen Lutheran Medical Center in LaCrosse, Wisc., has become the admitting service for nearly all medicine patients, no matter what the subspecialty.
First came nephrology, gastroenterology, pulmonary and infectious diseases. Then, except for patients with STEMIs or specific interventions, the hospitalists began admitting most cardiology patients.
The same thing happened with strokes. The hospitalist service at the 325-bed tertiary care referral hospital “10 physicians, eight physician assistants and two nurse practitioners, plus residents “has been able to absorb those services with no problem.
But then came hematology, followed by oncology. Despite plenty of discussion, commitment, preparation and planning, the hospitalists have found that these two new service lines “particularly oncology “are in a league all their own. All the other service line expansions, says Mary Frances Barthel, MD, hospitalist director, “were a lot easier.”
Since the hospitalists began admitting for hematology in 2004 and oncology in 2008, Dr. Barthel says, most of the initial kinks have either been worked out or are in the process of being resolved, and the hospitalists have no plans to backtrack. But the lessons learned have led to major changes in the way the Gundersen hospitalist group is organized.
Most dramatically, the new services are pushing the physicians toward unit-based staffing. Other necessary innovations include regular multidisciplinary rounds, a planned admission process, and expanded relationships between hospitalists and palliative care.
Teaming up with subspecialists
When the hospitalists began admitting hematology patients, it quickly became clear that the hospitalists would need to view hematologists much differently than the other subspecialists they already worked with.
With most subspecialists, Dr. Barthel explains, a consult is usually for “an additional opinion or an opportunity to ask for a procedure.” The day-today management of the patient, however, is basically the hospitalists’ responsibility.
With leukemia or lymphoma patients, however, the hospitalists clearly needed help from hematologists, not only in chemotherapy orders but in coordinating much of the day-to-day decision-making. As a result, the hospitalist group instituted daily multidisciplinary rounds that include representatives from nursing, social work, physical therapy, nutrition, pharmacy and pastoral care, as well as the consulting hematologist.
Those rounds have helped hospitalists and hematologists identify which issues fall into each provider’s bailiwick. A good example is fluid management, which can vary based on the type of chemotherapy the patient receives. Hematologists may write one order for fluid management that’s very specific to that chemotherapy, only to have hospitalists write another order because of the patient’s heart disease.
“Before we were able to have the face-to-face, there was always the question of who has got the ball,” Dr. Barthel explains. “The ball was getting dropped because everyone thought the other person was in charge.”
To further cement their working relationship, the hospitalists have begun moving to unit-based staffing. That should give them more continuity with these patients, who typically are hospitalized for long stretches at a time, and their hematologists.
This spring, the hospitalist group also instituted a process for planned admissions for lymphoma patients who may need four to six rounds of inpatient chemotherapy, all scheduled. Dr. Barthel says that move has likewise helped improve continuity for both patients and providers.
Blindsided by the time commitment
Comanaging oncology patients, on the other hand, required “a whole different set of lessons,” Dr. Barthel says. A big problem? The hospitalists felt blindsided by how much time it takes to care for hospitalized solid-tumor patients, most at the end of their lives.
“We’ve been able to absorb the volume,” she says, “but we did not anticipate how much more time these patients would take.”
That additional time isn’t for clinical care but for family conferences, discussions about end-of-life wishes and advance care planning. Dr. Barthel says the hospitalists were surprised to learn just how little attention those issues receive in the outpatient setting.
“We didn’t appreciate the degree to which we had this population of patients who might be dying and not prepared to discuss end-of-life issues,” she explains. “We were really surprised at the number of patients who came in without an advance directive or a recent conversation about code status. And these are patients who have been living with cancer for years.”
As a result, the hospitalists found themselves spending far more time with these patients and their families than they do with heart attack, stroke or elderly patients at their end of life. While hospitalists typically spend between 15 and 30 minutes during rounds with individual patients, plus an occasional family meeting, oncology patients require “an hour a day,” Dr. Barthel points out, “and a family meeting every day.”
“It’s different with oncology patients,” she explains. A good example is the woman with breast cancer who has had chemotherapy on and off for five years but now has disease progression and comes to the hospital sick.
“These patients fight and fight and fight,” she adds. “They get so used to living with their disease that they are less apt to recognize changes for the worse.” Discussing end-of-life issues dredges up all the fear, anger and disappointment these patients have tried so hard to avoid, Dr. Barthel says. “This population is completely different from patients who come in, have a stroke and die.”
Complicating matters, some patients find it “disruptive” that their care is in the hands of physicians whom they’ve never met, after years of dealing very closely with a primary physician or oncologist.
“We step into patients’ care at the point where they are the sickest and the closest in some cases to death, and they don’t know us,” says Dr. Barthel. “Yet we are the ones who are now the primary physicians, making the decisions.”
The learning curve
Another challenge was establishing another new subspecialty relationship and delineating the roles of both the hospitalist and the oncologist. When the hospitalists first agreed to admit these patients, they thought the oncologists would continue to be involved in direct patient care decisions.
But a major reason why the hospitalists took on oncology patients was that Gundersen Lutheran was opening a new cancer center. When the number of referrals from the surrounding community skyrocketed, the oncologists started spending much more time in clinic.
“Most of their consult time is spent with new patients or those receiving inpatient chemotherapy,” says Dr. Barthel. “They spend much less time with patients admitted after progression who have a complication of their disease or of their treatment.” As a result, the hospitalists have had to learn more about how to manage different complications and which medications and procedures can help alleviate symptoms.
Partnering with palliative care
Since the hospitalists agreed to admit oncology patients, they’ve spent a lot of time figuring out how to make the service work. One key focus, Dr. Barthel says, has been finding ways to partner with the hospital’s very strong palliative care service.
One initiative in the works would have that service “intervene pre-hospital with advance care planning.” In that way, hospitalization “and a bedside meeting with a hospitalist “wouldn’t be the first time that patients would be considering code status and advance directives.
Another approach is discussing how to staff the palliative care service, which includes some hospitalists, so the physicians in that service can become the primary providers for some oncology patients.
All in all, however, Dr. Barthel says the hospitalists don’t regret their decision to take on the new service line.
“We had a lot of discussions about it ahead of time,” she points out, “and we recognized the benefits to our organization of freeing up our oncologists to be in clinic.” Those benefits have proved to be real, she says, and hospitalists’ initial fears that they wouldn’t have the clinical skills to take on an oncology service turned out not to be true.
Instead, she says, “what we didn’t anticipate was the time all the advance care planning and end-of-life decisions take.”
Deborah Gesensway is a freelance health care writer who covers U.S. health care from Toronto.