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Published August 09, 2010, 12:00 AM

Doctors in Demand: Shift toward hospitalists

Days of seeing the same doctor in the clinic and the hospital are disappearing
Leon Vangerud breathed deeply as the doctor pressed the stethoscope against his 83-year-old chest and back.

Leon Vangerud breathed deeply as the doctor pressed the stethoscope against his 83-year-old chest and back.

“You’re not getting dizzy anymore?” Dr. Muhammed Shaikh asked.

“Once in a while. Not bad,” Vangerud said.

Shaikh isn’t Vangerud’s primary care physician, but he admitted the Fargo man to Innovis Health when Vangerud came to the emergency room suffering from dizziness.

And, as a hospitalist, Shaikh continued to treat Vangerud – having his pacemaker adjusted, ordering a cardiology consult and taking him off his medication to see if that was causing the dizziness.

Shaikh, director of the hospitalist program at Innovis, represents a shift in patient care that caught fire in the 2000s and shows no signs of cooling off.

The days of patients seeing the same doctor in the clinic and hospital are disappearing, rapidly being replaced by a team concept that keeps primary care physicians busy with outpatients while hospitalists treat the sicker patients admitted to the hospital.

“They’re kind of the quarterback of the coordination of care for the inpatient stage,” said Todd Forkel, Innovis’ senior vice president of operations.

Since launching its hospitalist program two years ago, Innovis’ roster has grown to five full-time hospitalists and two physicians who fill in part time.

The former MeritCare Health System was closer to the movement’s ground floor, starting with three hospitalists in 1998 – just two years after the term “hospitalist” was coined by Dr. Bob Wachter in the New England Journal of Medicine.

Now, the newly merged Sanford Health System has 20 hospitalists in Fargo. During the year ending June 30, they saw 7,742 patients at Sanford Medical Center in Fargo, according to a hospital spokesman.

Fargo’s other hospital, the VA Medical Center, hired its first hospitalist in 2002 and now has six on staff, said Peggy Wheelden, public affairs director.

Hospitalists, it seems, are here to stay.

“There is no looking back,” said Dr. Mohamed Sanaullah, hospitalist director at Sanford.

But the sea change has rocked the boat for some patients who feel they’re losing their primary physician’s personal touch.

Carmelle Pinsonneault, a 78-year-old retired nurse from Fargo who suffered a stroke last October, didn’t want to label hospitalists as “not good at all,” but said her experience with a local one was negative.

“I could not get him to stop and talk to me. Always in a rush,” she said. “And he was not my doc. They decided on this guy. My doctor, I didn’t see him.”

Sanford and Innovis officials said they do their best to explain to patients the role of hospitalists and why they’re still in good hands.

Growing field

In simplest terms, a hospitalist is a doctor who specializes in the practice of hospital medicine.

Following medical school, about 82 percent of those who will become hospitalists are trained in general internal medicine, while the rest are trained in pediatrics, family practice or a subspecialty, according to the Society of Hospital Medicine (SHM).

Nationwide, the number of hospitalists has mushroomed over the past decade, from a few hundred to currently more than 30,000 practicing in more than 3,300 hospitals. Hospitalists practice in 80 percent of hospitals with more than 200 beds, SHM spokesman Brendon Shank said.

Demand for hospitalists is high. Sanford has dealt with a recruiting crunch the past two years, relying on internal medicine docs to help out, Sanaullah said.

Still, there remains a lack of public awareness about hospitalists, he said. Some new patients are still surprised when their primary care doctor isn’t the one taking care of them.

“That’s a very valid concern when they say, ‘Well, I see you for the first time now. I’ve seen … my primary care provider the last 15 years. Why should I not have him here?’ ” he said.

Sanaullah said he reassures patients that hospitalists have complete access to their medical records and frequently communicate with their primary care physicians.

Roland Dille, retired president of Minnesota State University Moorhead, recalled when a Sanford hospitalist walked into his hospital room to treat him for a bladder infection.

“He had 10,000 pages of computer stuff on me,” Dille said with a dose of hyperbole.

The 85-year-old, who jokes that “I’m not a hypochondriac, but I have some of the symptoms of one,” said he’s been treated by hospitalists several times, “with, I think, some success.” Still, he misses the knowledge of his personal history that a primary care physician brings.

“As good as (Sanford) is, as good as its staff is, and it’s unmatched in my mind, I have a feeling now and then I’m losing out by not having someone who has a real personal interest,” he said.

Vangerud, the Innovis patient, said he’s “always” had positive experiences with hospitalists there.

Some primary care doctors still follow their patients into the hospital at Innovis, though Forkel said the facility is transitioning away from it.

Otherwise, primary care physicians at Innovis may make courtesy visits to hospital patients, but the hospitalist still oversees the patient. Sanford also doesn’t allow primary care physicians to treat patients under hospitalist care, even if the patient demands it – which rarely happens, Sanaullah and Shaikh said.

There are exceptions: At both Sanford and Innovis, surgeons and obstetricians still follow their surgical patients and expectant mothers into the hospital.

Dividing duties

A driving force behind the hospitalist movement is the desire to allow primary care doctors to focus on their clinic patients.

The days of primary docs doing hospital rounds are “remarkably restricted” as they treat more clinic patients and must maintain clinical competency, said Dr. Danielle Scheurer, a hospitalist at the Medical University of South Carolina in Charleston and SHM’s physician advisor.

“The inpatient environment keeps becoming more complicated because patients are sicker and they’re staying for shorter periods of time, and the care that you have to deliver is increasingly intense,” Scheurer said.

Proponents say the constant presence of hospitalists allows for faster, more responsive treatment.

“If a person is sick and is septic, if you wait a few minutes sometimes, it can lead to a difference of life and death,” Sanaullah said.

The most recent study at Innovis found patients’ average length of stay was reduced by 13 percent since the hospitalist program took effect, Shaikh said.

Having hospitalists always on duty also means primary care docs don’t have to be on call, he said.

Continuity of care, costs

At Innovis, hospitalists work 12-hour shifts seven days in a row, for a total of 84 hours, and then are off for seven days before their next rotation. The idea, Shaikh said, is to provide more continuous care by the same physician.

For patient safety and to prevent burnout, Innovis and Sanford limit hospitalists to seeing no more than 16 patients a day.

Whether hospitalists are cost-effective is still under debate, Scheurer said.

If productivity is based solely on patient billings, most hospitalist programs run a deficit, she said.

However, a lot of literature and evidence suggest hospitalists save money when factoring in the efficiencies of their constant presence, shorter patient stays and fewer unnecessary admissions, she said.

Another potential – but less tangible – financial benefit is improved quality of care, which can be reflected in public reporting of quality measures.

“So it makes your medical center look better than regional competitors,” Scheurer said.

More growth expected

Innovis and Sanford officials anticipate hiring more hospitalists as admissions increase, and the Society of Hospital Medicine predicts the hospitalist count will grow to more than 40,000 in the next few years.

As the concept has matured, hospitalists have branched out into several areas of the hospital, including neurology, oncology and critical care, Scheurer said. They’re also taking leadership positions in hospital initiatives to improve patient safety and quality of care, and some have moved into administrative roles such as chief medical officer.

The American Board of Internal Medicine this year recognized the field’s maturity, creating a certification with a “focused practice” in hospital medicine.

As the nation’s health care system transforms, Forkel expects hospitalists to be at the forefront.

“The hospitalist, in all facilities and in all facets, will play a huge role in the industry being able to be successful to manage in this new environment,” he said.

Readers can reach Forum reporter Mike Nowatzki at (701) 241-5528

At a glance

What is a hospitalist?

A hospitalist is a physician who specializes in the practice of hospital medicine. Their activities include patient care, teaching, research and leadership related to hospital care.

How many are there?

Currently, there are more than 30,000 hospitalists practicing in more than 3,300 hospitals and in 80 percent of hospitals with more than 200 beds.

Sanford Health has 20 hospitalists in Fargo, Innovis Health has five plus two part-timers, and the VA Medical Center has six.

How much are they paid?

In a 2005-2006 survey, the average hospitalist received $193,000 annually in salary, bonus and benefits.

What’s driving their growth?

Two major factors are stricter work-hour restrictions being placed on doctors and the need for someone to teach and evaluate quality improvement in hospitals. Hospitalists also free up clinic doctors from having to do rounds, allowing them to see more patients in increasingly busy clinics.

Source: Society of Hospital Medicine and Dr. Danielle Scheurer, SHM physician adviser

Hospitalist movement affects med schools

Medical schools have felt the effects of the growing hospitalist movement.

It’s been estimated as few as 2 percent of all internal medicine residents are actually going into internal medicine. Most of them pursue sub-specialties or become hospitalists, said Dr. Joshua Wynne, dean of the University of North Dakota’s School of Medicine & Health Sciences.

“It’s not necessarily all bad,” Wynne said. “Having hospitalists in hospitals provides a need, provides important medical care, and that’s good. But the downside of it from a societal point of view, I think it’s clearly been related to or has caused an exacerbation of the shortage of primary care docs.”

However, the UND School of Medicine is bucking the national trend toward more hospitalists, Wynne said, as students are disproportionately interested in become primary care doctors.

– Emily Hartley