“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”
The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”
“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.”
Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.
“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.
NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.
“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.
Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”
That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?
“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”
Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.
“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.
Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”
Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”