Thursday, January 21, 2010

When the Hospitalist Service is Capped

It's the fastest growing "specialty" service in medicine: hospitalist medicine. These are the doctors who limit their practice to the care and management of patients admitted to the hospital. It has been wildly popular because it adds a shift-like work schedule to medical care for physicians while supposedly preserving their personal life. It also moves patients through the hospital faster, shortening length of stays. As one of our more esteemed hospitalist bloggers likes to boast: it's a "WIN-WIN!"

At least until the hospitalist service gets too busy.

It seems now that hospitalists services are limiting the number of patients they admit per day in response to their overwhelming "popularity." It's something akin to capping resident medical student ward services - they stop accepting patients when their census gets too full. I learned this today when a patient I was trying to manage with heart failure was just not turning the corner and needed to be admitted for more agressive inotropic therapy.

Finding an admitting physician becomes an interesting exercise when the patient's primary care doctor no longer admits to the hospital (or is on vacation as was the case today) and the hospitalist service is no longer accepting patients because they're "capped" and you're trapped in a busy clinic.

What becomes the pop-off valve? You guessed it: the Emergency Room. Even though the patient absolutely, positively does not need the Emergency Room.

So much for cost savings.

It appears hospitalist services are increasingly finding themselves overwhelmed with admissions and the promise of a reasonable lifestyle can be assured by either limiting the number of patients admitted to each hospitalist or hiring more of them. But new hires are becoming tougher to justify in this "do more with less" economic time in medicine. As a result, it appears existing hospitalists are quickly finding they've hit the peak speed of their clinical-care gerbil wheels.

In a 1999 National Association of Inpatient Physicians (NAIP) survey, 25% of hospitalists were at risk for burnout, and 13% were in fact burned out. While these burnout rates were significantly lower than those documented in similar surveys of intensivists and emergency medicine physicians at the time, others suggested that his rate could increase as the field matured.

News flash: At least at some hospitals, it looks like we're there.


Robert M. Wachter, MD; Lee Goldman, MD, MPH
The Hospitalist Movement 5 Years Later. JAMA. 2002;287:487-494.

Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001 Mar 26;161(6):851-8.


The Happy Hospitalist said...

Ah. Our service would never cap itself. Not in a million years. A service that caps itself is a sign the hospital needs to pony up some more economic support to support more hospitalists.

It's as simple as that. Those that don't will lose big time. For example, sending your patient to another hospital that does have a hospitalist willing to accept them.

Thos that say no have lost their value. Those that know how to

code right

can bring value to the subsidy they require to remain solvent. It's about convenience and value. If you're a hospitalist program and you're capping yourself, your aren't valuable anymore.

geena said...

I know you said you had a busy clinic day, but how long does it take to admit a patient and write a few orders to get them settled until you can get to them?

Not trying to be snarky... I don't really know what goes into directly admitting a patient to the hospital.

Mehul said...

The question that came to my mind is if the service is busy enough to cap, then they should also be profitable enough to hire more hospitalist and become "uncapped."

Stalwart Hospitalist said...

Happy --

There comes some point where the gain in revenue obtained by admitting one more patient is outweighed by the increase in risk to the already existing inpatients by the hospitalist having spread himself or herself too thinly.

Resident services have caps in order to avoid sacrificing educational capacity of ward rotations to potentially unlimited service needs. While this tension does not exist in the non-academic world, there is always the issue of whether I have the ability to spend enough time with my patients and whether I have the time during the day to ensure proper execution of discharges, etc.

I agree that a pattern of a hospitalist service capping themselves probably indicates the need to expand the service with more hospitalists. However, that does not necessary assist Dr. Wes on the afternoon in question.

Dr. Wes --

Hospital Medicine cannot have an umlimited capacity to admit patients -- there does come a point where patient safety (more so, I think, than "lifestyle considerations") can be compromised if any given hospitalist has too many patients.

Steve Parker, M.D. said...

A consultant has to turn me down just once before I drop him from my list of preferred consultants.

So I never turn down admit requests. If the work load is too high, the bosses need to hire more docs.

-Steve, hospitalist

Anonymous said...

Inpatient specialists? blah. That appellation can only be extended to a few of this tribe.
Most community hospitalists are just mill-hands doing shift work and waiting for the siren to blow.Their use of resources is no better than the old farts now ensconced in their offices living out the twilight of their professional years. Most use the specialist for all but the most trivial problem.
The rest are basically highly paid residents. I hazard a guess that most hospitalist programs are loss leaders for the hospital.
When a final accounting occurs hospitals will reevaluate their commitment and some programs like a once popular doughnut brand will exist no more

Anonymous said...

Dr. Wes, I don't mean to put you down, but don't you have admitting privileges? It sounds like your patient should be under your care (or that of another cardiologist) in the hospital.

- practice manager

DrWes said...

@geena and anony 12:48-

The patient was being followed on behalf of primary care physician for management of CHF by a nurse practitioner in our clinic since patient had significant confounding clinical problems (sorry, for privacy, can't go into details here).

Yes I could write orders and transfer his care to myself, but patient had others (including a cardiologist) who were involved in his care previously so efforts were made to re-establish inpatient care with those treating physicians.

@Stalwart Hospitalist-

Agree w/your assessment of quantity of patients vs quality of care. But also agree if hospitalists find volumes too high to permit teaching and still want to recieve referrals, they had better not say no. Unfortunately, unless sufficient manpower exists to accommodate the referrals and the burden falls on other already-busy hospitalists, burnout will be more common.

It is interesting to ponder the role of hospitalists as teachers. Often (but not always), these "teachers" are some of the most junior recently-trained doctors with limited clinical experience. I wonder what your thoughts are regarding that lack of experience as it affects the quality and scope of medical education going forward.

Stalwart Hospitalist said...

@Dr. Wes --

I was coming at this from the standpoint of a single academic hospitalist at a teaching institution, and that it may be very reasonable for an individual attending physician to have a limit to the number of contacts in a given day, for the reasons I cited above.

However, our division does not cap or refuse admissions per se -- if all hell is breaking loose, we have backup mechanisms and the ability to call in the cavalry to take care of patients and get the work done.

I only wanted to emphasize the point that the sanity of an individual provider, and the quality of care that his or her patients deserve, should not be sacrificed on the altar of revenue generation.

@Anonymous 8:32 --

Certainly most academic hospital medicine divisions require subsidies; however, I lay that at the feet of those who have determine the relative worth of non-procedural vs. procedural specialities; blaming hospitalists for being unable to "pay for themselves" is somewhat fallacious when they cannot set their own charges.

Back @Dr. Wes --

The field of hospital medicine is maturing, and there are now senior leaders in the field. Our own division's practice is to only hire hospitalists with previous post-residency experience (at least), and with the expectation that they will participate in the teaching mission of the institution. The literature in this area suggests that residents' feel that teaching hospitalists do a very good job at teaching general inpatient internal medicine.

The Happy Hospitalist said...

stalwart. It's not about limiting the number of patients. It's about hiring enough doctors so a cap is unnecessary.

If I was starting the day at 20 patient a day, I wouldn't cap myself, but I wouldn't accept it either. These kind of numbers, routinely, indicated that more bodies are needed in the trenches. If the hospital is unwilling to subsidize more bodies, I'm not going to be there very long. But then I'm not going to say no either.

When I quit because of high census, the program will be capped by default. Ie, it will collapse. But don't punish the referring doctors. If you do, your value is gone.

The Happy Hospitalist said...

anon 32. The next time you're coding and you're waiting for your community family practice or internist to return your call to find out what to do next, remember a hospitalist just saved your life.

I suppose every doctor that takes care of hospitalized patients are highly paid residents, considering that's were most of residency training occurs.

Recruiter Mark said...

As a recruiter, I've seen the popularity of hospitalists vastly increase over the past few years. We can certainly use a few more Hospitalists here in Texas!