Specialists: The Newest Entrants in the Hospitalist Movement

Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.

January 2009 

Career Resources Editor’s Note: The success of hospitalists in general medicine has sparked the development of similar models in a variety of surgical and medical subspecialties. Improving patient safety, economic and lifestyle considerations, as well as the increasing number of graduates going on to subspecialty training, have fueled this paradigmatic shift in medical care. Physicians in this environment benefit from shedding the administrative and financial burdens of private practice. However, those who value the humanistic dimensions of medicine that are fostered through longitudinal doctor-patient encounters should think twice before becoming a hospitalist. — John A. Fromson, M.D.

Obstetrics and the surgical specialties are among those experimenting with hospitalist staffing structures. 
By Bonnie Darves, a Seattle-based freelance health care writer. 

The hospitalist movement that has been steadily reshaping the delivery of care on medicine units is taking hold in a range of specialties, including obstetrics and orthopedics, to general surgery, neurology and mental health. Throughout the United States, hospitals are increasingly planning or implementing programs in which a core group of physicians provide dedicated on-site services, rather than moving between the outpatient and inpatient setting. General surgeons and obstetricians have constituted the first wave of hospitalist specialists, followed by orthopedic surgeons.

In most emerging models, physicians are either employed by the hospital or working on contracts provided by outside firms. Staffing and scheduling arrangements vary depending on the hospital’s and the community’s needs, but the structures mimic many used in internal-medicine and family-practice hospitalist programs.
Many specialty hospitalists work in the 12- or 24-hour shift model, like their counterparts in emergency medicine or internal medicine. Some, especially surgeons, may work in one-week block schedules during which they’re on call, while onsite, to treat patients who come in through the emergency department (ED) or, in some cases, are inpatients who require post-operative care. In yet another approach, some outpatient specialist practices are devising arrangements in which surgeons devote one day a week or one week a month exclusively to inpatient care.

Several factors, from economic realities to logistical and liability considerations, are driving the trend toward in-house specialists. These include the difficulties that hospitals have ensuring adequate ED backup and shortages recognized in specialties such as trauma surgery. Martin Buser, MPH, co-founder of the national consulting firm Hospitalist Management Resources, LLC, sees the worsening ED coverage problem as the underlying issue spawning what he calls “the ‘–ist’ movement.” “Hospitals can’t make it without surgeons, yet they’re having a hard time getting general surgeons and orthopedic surgeons, in particular, to take call — even with a substantial payment.” 

“At the same time, hospitals aren’t satisfied with the investment results of those stipends — some as high as $1,500 a day — in improving their EDs’ responsiveness,” Mr. Buser observes, and ensuring they meet the coverage requirements mandated by the Emergency Medical Treatment and Active Labor Act (EMTALA). A recent survey by Sullivan Cotter and Associates found that 86 percent of facilities provide on-call pay to their non-employed physicians — with obstetricians, trauma surgeons, orthopedic surgeons, and neurologists topping the list of those likely to receive such stipends.

Some hospitals are responding to this situation by moving toward employed or foundation model groups to ensure adequate coverage, Mr. Buser adds, especially for unassigned patients. His prediction, based on current demand, is that 80 percent of a hospital’s census will be managed by “ists” within a decade.
The call coverage conundrum prompted Kevin Hudenko, MD, a young general surgeon in Albuquerque, New Mexico, to devise a hospitalist-type model for his group of seven surgeons that serves Presbyterian Hospital’s two campuses.

“The old paradigm was to be on call two days a week from 7 a.m. to 7 a.m., and stay until you’re done. That could be a 30-hour day,” Dr. Hudenko explains. “Some of our partners weren’t interested in doing that as they got older because it’s disruptive… to get called to the ED to do a perforated bowel [repair] when patients are waiting in the office.”

The group challenged Dr. Hudenko to come up with a solution that allowed for shorter shifts, and fewer interactions with the clinic and the operating room (OR) for surgeons on call. His response was the “surgeon of the week” (SOW) program, in which one surgeon stays at the hospital eight to 10 hours a day weekdays, dealing with any need that arises; and two surgical hospitalists work alternating 12-hour shifts Friday through Sunday.

“The beauty is that when you are the SOW you have zero clinic and OR responsibilities — but you’re pretty busy. And if you get a call for an appendectomy at 4:30 p.m., you can set that up for the surgeon who comes on in the morning,” Dr. Hudenko says. He acknowledges that the group must be of a considerable size — six or more — to pull off the scheduling model. But he sees the flexibility and shorter shifts as a major draw in a specialty that’s struggling to entice young physicians into the fold.
“The drawback is increased handoffs and transfer of information — this model doubles the handoffs. But it’s a boon in terms of fresher surgeons and no fatigue,” Dr. Hudenko allows. “If you never work more than 12 hours you have 12 hours to recharge — and only having two or three call [duties] a month is a huge benefit.” That’s appealing to young surgeons inundated with job offers that promise call “only every fourth to fifth night — and you still have a decent salary and benefits, and the excitement of surgery.” To bridge the potential follow-up gap, many hospitals with surgicalist programs are establishing on-site clinics.

Robert Sewell, MD, president of the American Society of General Surgeons, cites several reasons why the hospitalist model is moving into his specialty. For one, many residents go on to fellowships to subspecialize, leaving fewer generalists in the workforce. And many general surgery practices face economic challenges. “The issue isn’t the work —most general surgeons love what they do. It’s the on-call issues and uncompensated ED care that has become a problem,” says Dr. Sewell, who practices in Southlake, Texas. The society’s estimate is that 20 percent of general surgeons now are either solely hospital-based or work in hospital-owned groups.
For general surgeon Scott Chudow, MD, FACS, the surgical hospitalist model offered a way to make the transition from a longtime private practice to an employed position, and gain a reprieve from the headaches of operating a business. “I like that I can focus on my patients and not worry about the business side and insurance coverage,” says Dr. Chudow, who directs the hospitalist program at NorthBay Medical center in Fairfield, California, and works in one- or two-week blocks, with one or two weeks off in between.

“The surgery and the patients are the best part of the job, and this allows me to concentrate on what I like best,” Dr. Chudow says.

OB Embraces Hospitalist Model
In light of the long-term relationships that obstetricians typically have with their patients, at first glance this specialty wouldn’t sound like a good fit for the hospitalist model. However, some early experiments in hospital-based OB are working out even better than expected. Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Oregon, started the OB hospitalist program in 2005 initially to address geographical and coverage issues that arose when Legacy opened a new hospital across the Columbia River in Washington, and perinatologists had to move between the two facilities.

“That was the problem we handed to the community by building another hospital, but the arrangement has worked out so well that we’ve changed the in-house faculty model at our largest hospital,” says Dr. Neilson, referring to Legacy Emanuel Hospital & Health Canter in Portland.

The concept was to ensure that OBs were on site to care for high-risk patients until the perinatologist arrived, and to take care of unassigned patients in the ED or those who end up in labor unexpectedly while traveling though the region. But the four OB hospitalists, who work six or seven 24-hour shifts a month, have found they can help out community OBs and family physicians as well.

“This model of having a physician onsite optimizes everyone’s skills — and it’s been a wonderful way for me to use all of my professional experience,” says Lani Miller, MD, whose two previous career chapters included private practice and serving as medical director of a hospital-based nurse-midwifery practice. “This also allows the family physicians who want to deliver to always have surgical backup.”

The main draws of hospitalist practice, for Dr. Miller, are these: She can focus on the aspect of OB-GYN practice she’s always liked best — staying with patients through labor and delivery — and it affords the lifestyle benefit of leaving behind the business aspects. She also appreciates the schedule flexibility and the opportunity to work with higher-risk, pre-term labor patients. “We do a lot of continuing medical education to be able to handle these patients, but before I rarely had the opportunity,” she explains.

The lifestyle factor drew Jennifer Kasirsky, MD, an OB hospitalist in Washington, D.C., to the emerging practice modality. A former Georgetown University faculty member who now works at INOVA Loudoun Hospital in Leesburg, Virginia, Dr. Kasirsky made the switch a few years ago so that she could spend more time with her young children. “I feel very fortunate to have found this job — and it’s a wonderful life for a working mother,” she says. “I’m the Girl Scout leader for my daughter and I coach my son’s soccer team. In private practice I’d never have been able to do this.”

Dr. Kasirsky serves a largely indigent population who tend to be higher acuity than patients she cared for in private practice. That’s a challenge she enjoys. “I did my residency at a trauma center, so I have experience working with high-risk patients. But I’m glad that I had those seven years in practice before becoming a hospitalist.”
Robert Fagnant, MD, vice chair of the American College of Obstetricians Committee on Ambulatory Practice, predicts that the OB-hospitalist model will flourish, as hospitals wrestle with coverage and liability issues, and community OBs remain overburdened. “I see it increasing, and I hope to see the model move into places where family physicians still deliver babies — so that those who do four or five deliveries a month could still do deliveries and know they have backup.”

Giant HCA-The Hospital Company, for example, has begun implementing OB-hospitalist programs at its Texas facilities, Dr. Fagnant notes, and other large systems and national entities will likely follow suit. “When hospitals can afford to have an OB on site all the time it’s an important safety [benefit], because we know that can’t be available all the time, immediately, and there are situations when you have only 10 minutes to get the baby out,” says Dr. Fagnant, a high-risk OB-GYN in St. George, Utah. “This [model] also potentially benefits most of the private practitioners — and could encourage the continuation of small and sole-proprietor practices.”

Trauma — the Next Fertile Terrain for Hospitalists?
As a specialty, orthopedic surgery is struggling to cope with many of the same issues that are stretching the working hours of general surgeons. Busy surgeons are increasingly eschewing call duty and electing courtesy staff status, increasing the burden on those who still provide ED backup. And as the field moves toward subspecialization, fewer orthopedic surgeons remain qualified or interested in generalist practice, according to Oakland, California, surgeon Thomas Barber, MD, chair-elect of the American Academy of Orthopedic Surgeons (AAOS) Board of Councilors.

Both trends are fueling the orthopedic hospitalist — or “traumatologist” — movement. “The hospitals need surgeons to cover their trauma volume, so many are starting to buy up practices, especially in rural areas,” Dr. Barber says, and some facilities are converting them to hospitalist, shift-model practices, AAOS members report. “This is such a new model that it’s hard to say whether everybody will be happy in the end, but it’s becoming popular. Our [AAOS’] concerns, of course, are whether there will be adequate post-operative follow up and coverage, but it’s so early in the evolution of this that we don’t have any evidence pro or con.”

The traumatologist career path is also gaining ground, Dr. Barber observes, among both established community surgeons and those recently out of training. Some orthopedic surgeons, especially young ones, are choosing it [hospitalist employment] as their primary practice modality, Dr. Barber offers, “because it doesn’t lock them into any one place.” Other surgeons are pursuing part-time hospitalist work to supplement their income, he adds.

“In unsettling economic times, it’s nice to have an option that could be temporary, without a lot of ties — no buildings, no staff, no cash outlay,” he maintains. “For surgeons who don’t know if they want to go into private practice — or join a big organization or go into academics — and want time to decide, it’s not a bad deal.”
For orthopedic hospitalist Wayne Mosley, MD, medical director of the orthopedic trauma program at Baptist Hospital in Pensacola, Florida, the practice model is attractive for many reasons. He likes the fast pace and prefers generalist work, and the flexibility hospitalist practice affords given his Army Reserve status. “I’ve been deployed to Afghanistan and Iraq four times since 2003, and it’s nearly impossible to have a private practice under those conditions,” says Dr. Mosley, who has been in the field just over a decade and work in a program set up by Delphi, the largest player in this program set up arena, “And I like the trauma work because it’s a continuation of what I was doing overseas — and that was my favorite job ever.” He also thinks the hospitalist model can improve care when patients and hospitals aren’t reliant upon on call surgeons who are juggling office and inpatient duties.

“From the physician standpoint, if you’re on call you often have to disrupt your patient flow and revenue stream. And if you’re the patient with an emergency who has to wait around while the surgeon finishes an elective case,” Dr. Mosley says, “you’re left behind to a certain extent.” He thinks the hospitalist model is a good fit in markets where the volume of orthopedic trauma is high and call coverage problems persist.

Another new hospitalist model entrant, behavioral health, is creating an interesting subspecialty — hospital-dedicated physicians who are primary care trained yet work solely with medical-surgical patients who have substance-abuse issues. David Frenz, MD, a family physician-hospitalist who is medical director of HealthEast Behavioral Care’s addiction-medicine service in St. Paul, Minnesota, sees his job as one that may soon be replicated across the country. Hospitals are often ill equipped to properly care for or readily transfer such dual-diagnosis patients, he says, who often have unnecessarily long lengths of stay as a result.
“You can make a fairly compelling case to the administration, in hospitals with behavioral health services, about the need for medical direction with these patients,” Dr. Frenz says, “many of whom are just languishing for a better treatment plan.”

The job’s appeal, for Dr. Frenz, is being is able to take care of a population he enjoys, in the hospital environment, as HealthEast Care System operates a dedicated 28-bed chemical dependency unit. “The fun part about hospital medicine is that there’s usually an acute problem you can either resolve or bring to some reasonable conclusion,” he says. “I also actually wanted to work with this population because these are patients who don’t get regular healthcare for the most part, so it’s gratifying when you can make a difference.”


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