Monday, June 17, 2013

From hospitalist as clinician to hospitalist as off-loader: how we've changed!

I should know because I was involved in the movement nearly from the beginning. Back then the distinctive was that hospitalists were doctors who, having ascended a steep learning curve from practicing exclusively inpatient medicine, had a special degree of expertise and skill to meet the challenges of caring for the incredibly ill and complex patients who populate the hospital. In short, we were (once) valued for our clinical skills.

Right in line with this was the understanding that effective use of such skills would require enough time to spend with each patient. After all being a good clinician takes time. Practicing evidence based medicine takes time. This led early programs to define who and what they were clinically and to carefully structure coverage arrangements with appropriate restrictions. No one in their wildest imagination had any notion of taking over the hospital or admitting for everyone. At least not in the beginning. But hospitalist leaders started planting the seeds of that idea a few years ago.

I saw trouble brewing then and have blogged my concern many times since. I once made fun of the trend I observed as the hospitalist role was devalued and transitioned from expert clinician to utility player:

Hospitalist skill set, year 2000:
Management of CAP and HCAP
Management of sepsis
Management of venous thromboembolism
Management of DKA, adrenal crisis and other endocrine-metabolic emergencies
Management of COPD, asthma and ARDS, including ventilator management
Management of renal, fluid and electrolyte problems
Management of acute decompensated heart failure
Management of toxicologic emergencies
Providing consultation for complex and difficult diagnostic problems
Providing consultation for medical complications in surgical, subspecialty and general medical patients

Hospitalist skill set, year 2010:
Tweaking Press Ganey
Tweaking clinical documentation (DRGs)
Creative coding
Bed control
Admitology, roundology and dischargology for surgical and subspecialty patients
Cosmetic charting (performance measures)
Secretarial (CPOE)

So I recently found another published example of the trend in a recent issue of Today's Hospitalist: Universal admitters: hospitalists' new identity? The article cites the growing trend of hospitalists admitting nearly all comers regardless of the clinical need. This according to the article off-loads the specialists, expands the hospitalist's niche and serves the business needs of the institution. Several program leaders were interviewed. To their credit they paid lip service to the concerns about hospitalists becoming overburdened or taking on duties outside the scope of their training. Ultimately, though, to my disappointment, they seemed to one degree or another complicit with the new agenda.

For example:

"The greatest difficulty for hospitalist groups is not recognizing the value in being on the front lines of caring for the majority of patients," Dr. Bossard says. "Going into meetings with the idea that we're going to try to protect our turf and reduce the number of patients we carry by establishing rules to protect us won't work."

I have a little different view of protecting turf. If only the specialty services would protect their own turf! But they seem eager to give it up while hospitalists at the organizational level seem all to willing to capitulate and take it on.

Clinical skill has all but vanished as the raison d'etre for hospitalists. And in the article it's missing from the discussion of all the things the hospitalist “brings to the table,” for example computer skills:

Another factor driving hospitalists toward more admissions: Subspecialists are frustrated with electronic medical records. It makes sense to hand off the computer work associated with being the admitting physician to hospitalists, who log in much more screen time.

Though mentioned as an aside that paragraph says a lot about the changing agenda: the move toward hospitalist as secretary, H&P provider and off-loader.


Guilherme Brauner Barcellos said...

In Brazil, where we are at the begging of the movement, some "leaders" want us to start as your "hospitalist year 2010". It's an important barrier to hospital medicine grow as a medical specialty here. Guilherme -

A Williams said...

It is a barrier to growth. Doctors who have any sense of professionalism would not go into the area of hospital medicine because of the issues such as outlined in the article. I for one think the Specialty of hospital medicine should define who we are and not allow others to define us.

R. W. Donnell said...

We have two definitions of hospital medicine here, the original one and the new one. It is indeed a stretch to reconcile the new definition with any sense of professionalism.