Published in the January 2015 issue of Today’s Hospitalist
ROAM THE HALLS of Hoag Hospital in Newport Beach, Calif., and you’ll find a cadre of intensivists, neurohospitalists, GI hospitalists and OB/GYN hospitalists working alongside the 40 full-time hospitalists. But one thing you won’t find are “surgicalists.”
Just a few years ago, surgical hospitalists were about to become the new big thing in U.S. health care. But as some hospitals have discovered, bringing surgicalists ” who steer clear of elective surgeries and outpatient practice to focus instead on emergency surgery “on board hasn’t been easy.
Weston Chandler, MD, president of Pacific Hospitalist Associates, which provides hospitalist services at Hoag, says that’s a shame for his colleagues, who value specialties that have adopted the hospitalist model. “Having someone readily available for consults and procedures is great,” he says. “These physicians come and see patients right away without hassle or pushback. It just gets done.”
But not all surgeons share that view. Individual surgeons have led resistance to the model, in no small part because they don’t want lucrative call payments from hospitals to end. Others may be reluctant to give up an independent practice to be a more engaged partner with a hospital.
But many factors now coming together may spark renewed interest in the surgicalist model. Hospital executives want to end pay-for-call systems, which they say are rife with problems. Administrators are also looking for staff members who can be better team players and pay more attention to quality metrics and patient satisfaction.
There’s also growing evidence that surgicalists may be good not only for patient care “with fewer complications and lower lengths of stay “but for local surgeons. Rather than seeing in-house colleagues poaching potential patients, local surgeons in hospitals with surgicalists should see their number of elective surgeries bump up, due to more surgicalist referrals.
“Surgicalist adoption has been really slow in certain areas, and there was an initial spurt of interest that then stalled a bit,” explains John Maa, MD, a staff surgeon at Marin General Hospital in Greenbrae, Calif., and one of the model’s pioneers when he practiced at the University of California, San Francisco. “But it’s picking up again.”
Giving up call pay?
No one knows exactly how many surgicalists are practicing today. Other subspecialty hospitalists “including neurohospitalists and OB/GYN hospitalists “have their own membership societies that keep tallies of how many practice in the U.S. (There are an estimated 1,500 of neurohospitalists and about the same number of OB/ GYN hospitalists.)
But surgicalists have no medical society. Anecdotally, analysts believe that some local surgical practices now dedicate one partner as a de facto surgicalist or take turns among themselves as surgicalists for a week or so, much like physicians in primary care groups used to do in the early days of hospital medicine. Proponents of the surgical-hospitalist model also point out that “again, like in hospital medicine’s early days “part-time surgicalists don’t achieve the same efficiency and standardization as full-time surgicalist colleagues.
Dr. Maa also notes that the surgicalist movement faces this hurdle: There’s no consensus yet on what to call the emerging specialty.
“Surgeons don’t like the term ‘surgical hospitalist,’ ” he says, because they associate the term “hospitalist” with someone who has been medically trained.
Among trauma- and critical care-trained surgeons, one group is advocating to use “acute care surgeon,” while another faction blanches at using that tag for surgeons who aren’t fellowship-trained. Still others are coalescing around the surgicalist label being promoted by national management companies competing for hospital contracts.
A much bigger barrier to the growth of surgicalists is the pay that surgeons often receive for taking call. Over the last several years, it has become common for hospitals to pay general surgeons around $500 for one 24-hour call shift, although $1,500 isn’t unheard of. For orthopedists, call pay typically runs between $1,200 and $1,500 per shift, but payments can hit $2,700.
According to A.L. Jackson Slappy, MD, director of care coordination for surgery at Atlanta’s Emory University Hospital and an early leader of the surgicalist movement, call pay developed because surgeons found taking ED call to be “financially very difficult.”
Based on community feedback, as many as 40% of the patients who come to the ED “are either unfunded or underfunded, and sometimes need to spend a week or more in the hospital,” says Dr. Slappy. “Call pay at least means you will earn something if you take call.”
John Nelson, MD, one of the founders of the medical hospitalist movement and the director of the hospitalist program at Overlake Hospital in Bellevue, Wash., is a strong supporter of the surgicalist model. Dr. Nelson points out that even when they’re paid to take call, many general surgeons consider ED call “nothing but a nuisance: weekends, nights, un- and underinsured people, patients more likely to sue.”
But some surgeons, Dr. Nelson adds, “say they can’t live without that money.” For them, call pay has become essential, and they typically lead local opposition to surgicalist programs. “It’s an unfortunate stalemate,” he says.
At his hospital near Seattle, Dr. Nelson notes that while discussions have been underway to put a surgical hospitalist program in place, nothing has happened. “Our existing surgeons are a little bit resistant,” he points out. “They see it as competition.”
That concern is not without some merit. As Dr. Slappy notes, many surgeons who thought they could build a practice based only on elective surgeries have found otherwise, so call pay remains a key factor.
A strong business case
Despite such resistance, several factors are reinvigorating interest in the model. One is a growing body of evidence that surgicalists improve the quality of care.
Dr. Maa was lead author of a study published in the November 2007 issue of the Journal of the American College of Surgeons (JACS). That research found that redesigning the general surgery service at UCSF to include three surgicalists improved both patient and ED-physician satisfaction and cut in half the wait time for surgery for patients presenting with acute appendicitis.
And a new study in the July 2014 issue of JACS makes “a strong case,” Dr. Maa says, for having surgicalists care for emergency surgery patients at nontrauma hospitals.
At Sutter Medical Center, Sacramento, where the study was carried out, researchers found that having four general surgeons dedicated to the emergency service “rather than having community-based surgeons rotate call “produced similar mortality rates but fewer complications and readmissions. Surgicalist presence also appeared to cut both lengths of stay and hospital costs. Perhaps just as importantly for surgeons, the study concluded that deploying surgicalists didn’t affect the “operative volume of the nonacute care surgeons at the same facility.”
Sutter’s surgicalist program is provided by Surgical Affiliates Management Group Inc., a national company that got its first contract in 2000 and now has 17 trauma, general surgery and orthopedic surgery programs, mostly in the West. The company’s first program was in a hospital that wanted to become a trauma center, so it needed round-the-clock surgical coverage, explains Leon J. Owens, MD, Surgical Affiliates’ president and CEO and a trauma surgeon on staff at Mercy San Juan Hospital in Sacramento, Calif. Expansion came when other local hospitals sought a solution to call-coverage problems.
“We successfully took the service model developed for trauma and applied it to acute care emergency surgeries,” Dr. Owens says. “In addition to improving care, we also found that we significantly reduced costs by becoming efficient and decreasing length of stay.” Group members also “decreased variation in how we practice because we had people almost exclusively devoted to acute care surgery patients.” The hospital had a reasonable return on investment, “the ED docs weren’t pulling their hair out trying to get surgeons to cover,” and the surgicalists could work two or two-and-a-half 24-hour shifts per week.
“They have the rest of the week off,” Dr. Owens points out, “and they earn a normal salary.” Surgical Affiliates also employs nurse practitioners and physician assistants who work a week at a time, providing the continuity “that keeps the service functioning properly.”
The surgicalists also run an outpatient clinic to follow up on patients they operate on, but they don’t see any elective surgical patients.
Changing the culture of surgery
One of the model’s biggest benefits will sound very familiar to hospitalists. As Dr. Owens explains, surgicalists prove to be a better “partner” with hospitals than many community-based surgeons. “It’s very hard for a hospital to coerce independent doctors to participate in things as simple as SCIP (surgical care improvement project) measures or antibiotic prophylaxis,” he points out.
That points to another barrier to broad acceptance of surgicalist programs: the culture of surgery itself. While health care economics, reporting requirements, value-based purchasing and accountable care all require tight coordination between physicians and the hospitals where they work, surgeons have been among the doctors least interested in being employed by health systems.
“Surgeons are very independent people and interesting to manage because they have strong personalities,” notes Julianna Lindsey, MD, MBA, a medical hospitalist based in the Dallas-Ft. Worth area who co-founded the national physician management company Synergy Surgicalists with two orthopedic surgeons. “Orthopedic surgeons seem to be the holdouts.”
But hospitals increasingly are seeking “and paying for “physician partners who pay attention to hospital needs. If community-based surgeons are unwilling to take ED call, says Dr. Lindsey, the result can be financially devastating for hospitals working on ever-tighter margins.
“If you have days that go uncovered, that’s lost revenue for the hospital,” she points out. “You have to transfer patients out of your hospital or health system, and hospitals make most of their revenue from surgical patients.”
Synergy Surgicalists’ model is slightly different than Surgical Affiliates’. Some of its surgicalists work five days straight, day and night, and are done for the rest of the month; some work 12-hour shifts. “It depends on the contract,” Dr. Lindsey says.
Interest from administrators
According to Dr. Lindsey, hospital and health system administrators are reaching out to companies like hers more than individual surgeons.
“It has been a hard sell to the local guys that we are not here to impinge on their practice in any way,” she says. “Slowly but surely, they are coming around.”
Both the experience and data of Synergy Surgicalists and Surgical Affiliates indicate that having surgicalists in the hospital doesn’t hurt community surgeons’ business. That was the same conclusion reached in the Sutter research.
“We help local physicians build a practice by relieving them of ED call,” Dr. Lindsey says. In her experience, surgeons who no longer take ED call “can become 20% more productive in their office, and that is incremental revenue for them and for the hospital.”
Hospital administrators are also increasingly interested in surgicalist programs to have more physicians willing to work on committees and quality improvement.
Given today’s “focus on outpatient practice, there is less activity between practitioners and their hospital, so the traditional medical staff model to support hospital operations and activities is more challenged every year,” explains Larry A. Mullins, DHA, president and CEO of Samaritan Health Services, a five-hospital system in central western Oregon. “We need new physician practice models,” both “to make sure that the hospital can fulfill our ER coverage mission” and to govern itself.
“Certainly, hospital medical staffs are not what they were 20 or 30 years ago.”
Dr. Mullins has become a big advocate of the surgicalist model, signing up with Synergy Surgicalists in the last year. That contract was “mainly driven by our need to provide comprehensive orthopedics call coverage for our emergency room and being challenged to do that with local practitioners.” As many as eight orthopedic surgicalists now cover emergency surgery at Good Samaritan Regional Medical Center 24/7. A few are local orthopedic surgeons who work some of the shifts.
Meanwhile, hospitals and groups trying to structure surgicalist programs are running into unanswered questions of what to pay and how to schedule.
One wrinkle that makes surgical hospitalists different from their medical counterparts is that surgeons right out of residency may not be good stand-alone surgicalist candidates. “Hospitals don’t want to risk hiring only those surgeons just out of residency,” says Emory’s Dr. Slappy. “Hospitals want surgeons with a proven track record” and experience with many different kinds of operations.
But hiring mid-or late-career surgeons as surgicalists has its own risks in terms of satisfaction and turnover. In many centers, particularly busy nonacademic community hospitals without residents, “your lifestyle as a surgicalist can be filled with long hours,” Dr. Slappy notes.
“Unless you are very careful with a good match between workload and lifestyle expectations, this is going to be a surgical subspecialty with the potential for burnout.”
In addition, he says, no one has yet figured out what size hospital “or what level of trauma coming into the ED “makes a hospital the right fit for surgicalist services.
“It is evolving,” Dr. Slappy says. “A lot of people are waiting to see what happens and if a dominant model will emerge.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Two booming other “ists”
WHILE SURGICALIST PROGRAMS are slowly expanding into markets around the country, other “ist” programs have been proliferating. From ENT, gastroenterology and oncology hospitalists to psychiatric and pediatric hospitalists, nearly every medical specialty has taken a page from hospitalists and reorganized itself to improve both physician lifestyles and patient care.
John Nelson, MD, who heads up a hospitalist program outside Seattle, is also a principal with Nelson Flores Hospital Medicine Consultants. One of the most frequently-asked questions he fields as a consultant, he says, is “how to adapt the hospitalist model to other specialties.”
Dr. Nelson has met a dermatology hospitalist and he knows of discussions among some cardiologists. Overwhelmingly, he adds, “hospitalists welcome such colleagues to their institutions.”
Here is a snapshot of two of the fastest growing hospitalist specialties.
- Neurohospitalists: David J. Likosky, MD, is president of the three-year-old Neurohospitalist Society as well as a medical hospitalist/neurohospitalist and medical director of the EvergreenHealth Neuroscience Institute in Kirkland, Wash. According to Dr. Likosky, 1,500 neurohospitalists now practice nationally, equally split between academic and community hospitals.Demand continues to be strong, he says, particularly because hospitals that want to be accredited as stroke centers function best with onsite neurologists able to treat patients with tPA on very short notice. Such hospitals can make a strong financial case for employing neurohospitalists.In addition, says Dr. Likosky, inpatient neurology practice has changed. “Between needing to know how to use computerized order entry to understanding who to consult with, it’s much more complicated than it used to be.” And with many neurologists now subspecializing in movement disorders and multiple sclerosis, “they aren’t as comfortable with inpatient neurology care.”The most common inpatient neurology issues that neuro-hospitalists deal with are acute mental status changes, seizures and acute stroke. Many outpatient-oriented neurologists “don’t have as much experience with these,” Dr. Likosky notes, “and they may not have much interest in them either.”
- OB/GYN hospitalists: OB/GYN hospitalists, also known as “laborists,” have a wide range of practice types, from delivering all the babies born at night in a hospital to managing high-risk obstetric patients and consulting on medical patients with gynecologic issues. That’s according to Robert J. Fagnant, MD, immediate past president of the Society of OB/GYN Hospitalists and an OB hospitalist at Intermountain Health Care’s Dixie Regional Medical Center in St. George, Utah.His practice started about four years ago. For the last two years, Dr. Fagnant says, he and his colleagues have provided full-time, 24/7 coverage, functioning essentially as “maternal-fetal medicine extenders.” He and his group also take care of high-risk obstetrical patients for many community OB/GYNs across southern Utah, northern Arizona and Nevada.It’s an expensive service, but many hospitals, like his, have decided it is money well-spent. Several of those hospitals are contracting with Ob Hospitalist Group, based in Greenville, S.C., which provides 24/7 OB/GYN coverage in more than 75 programs in 20-plus states. Dr. Fagnant and his colleagues are employed by Intermountain’s physician arm.”I know one program where the money saved on malpractice settlements and on not having to defend cases pays for the program,” Dr. Fagnant points out. In his case, having OB hospitalists in-house means that “instead of delivering sick babies, we are keeping babies inside their moms a lot longer so we can deliver more mature, healthy babies” who need less NICU care. “For the ones who need to come out, we are getting them out in a more appropriate time.”They also work closely with medical hospitalists treating pregnant patients with medical issues. Dr. Fagnant and his OB-hospitalist colleagues take extra training in areas like fetal monitoring and managing post-partum hemorrhage.
“Because we’re always onsite, we can identify areas of care that need a fast response,” he says. “Our presence and the fact that we have more training than community providers in dealing with emergencies results in better care.”