I don’t know if, in the future, hospitalists will all be well versed in core internal medicine hospital-based procedures, or if we will not have a clue as to how to perform them.
That uncertainty stems from the fact that, within the context of a still-maturing specialty, what one hospital asks us to do can be radically different from what we are asked by the next.
In my first job, I performed hundreds of central lines and intubations. It was a 24/7 program, and the majority of the procedures occurred at night. Because we were the only doctors in-house at night–save for the ER physicians–at a 500-bed community hospital, we filled a very important need.
Most members of my group were comfortable doing procedures. However I found that the fact that we performed procedures could make it hard to recruit new hospitalists. Unless they had been doing such procedures for years, even experienced hospitalists were gun-shy about coming to a program that required such a skill set. I also found that the level of procedural competence varied greatly among new residents.
In my current position at Virtua Memorial, my group was asked to consider providing night-time intubation coverage. We do have anesthesia in-house 24/7, but that group often finds itself in surgery or dealing with an OB epidural in the middle of the night, so they would prefer to be used only as backup. That means that all the hospitalists will be completing a refresher course in intubation with anesthesia in the OR.
Many of us who have not intubated in years still have reservations about this change in practice. If it turns out that the hospitalists of the future wind up not having a clue about how to do procedures, it will be because of the same concerns.
For one, hospitalists may do too few procedures to feel comfortable about their skills. They worry about new malpractice exposure that arises from doing procedures. And they have little, if any, financial motivation because procedures are poorly paid.
Paradoxically, this last concern–about low reimbursement–is the big reason why I think we’ll end up doing many procedures; other physicians would rather spend their time doing interventions that pay more. Given our growing round-the-clock presence and the fact that no one else wants to do central lines, hospital administrators will increasingly look to hospitalists as the most cost-efficient solution.
I also believe that the growing use of nocturnists–who generally practice when no subspecialists are around–will fuel that expectation. In large hospitals, I think we’ll see the growth of “proceduralists,” hospitalists who staff in-house procedure services. But in most hospitals, I suspect the volume will never be great enough to support this type of program.
I personally believe that we need to become more comfortable doing procedures and that the more competent a hospitalist is with procedures, the better. I tend to think that we would all want to be skilled in techniques of emergent access, either vascular or airway. That’s because the hospital is our home and we need to be able to handle emergencies that occur within its walls.
And the more we can offer a hospital as a distinct specialty with a somewhat distinct procedural skill set, the more the hospital will likely offer us.