Generation Next
Variations on a Theme
The dermatology HM model at UCSF more closely resembles a consultative practice model. UCSF’s dermatology hospitalists do not admit patients. Still, says SDH’s Dr. Fox, because of their conversance with inpatient care and round-the-clock availability, dermatology hospitalists are invaluable. They help colleagues “puzzle out” the causes of cutaneous manifestations of system disease, quickly initiate state of the art treatment for hospital-acquired skin conditions, and improve outcomes for hospitalized patients with skin diseases.
“We see our charge as being multifold,” Dr. Fox explains. “We provide continuity of care for patients who are frequently hospitalized; we keep up with the medical literature; we are comfortable with and know the nuances of hospital operations; and we provide education to residents, house staff, and colleagues.”
Re-examination of her career goals prompted Dr. Wald to seek additional training. She chose geriatrics and became board-certified in that subspecialty. “Geriatrics was both clinically appealing and has a great patient-safety angle,” she says.
Dr. Wald’s advice to hospitalists who share her interest in geriatrics but do not have the time to complete a 12-month fellowship: Attend a mini-fellowship course on geriatrics. Many institutions offer such courses, including Mount Sinai and UCLA.
“Four of the hospitalists on our geriatric service have attended UCLA’s mini-course. In addition, SHM offers geriatrics-themed sessions in many of its CME offerings,” Dr. Wald says. “These efforts to ‘geriatricize’ hospitalists are a great and necessary approach to addressing the care needs of the aging inpatient population. There will never be enough geriatricians, so hospitalists are important partners in this work.”—GH
In Denver, the Acute Care for the Elderly (ACE) service operated by the internal-medicine hospitalist group has only informal ties to the Department of Medicine’s Geriatrics Division, Dr. Wald says. Although not a closed geriatric-care unit, the service concentrates elderly patients on one inpatient service and introduces the tenets of geriatric care—multidisciplinary approach, functional assessment, early discharge planning, mitigating the hazards of hospitalization, and patient and family-centered care—into a hospitalist milieu.
Surgical hospitalist models also vary by setting, and continue to evolve as surgeons examine processes to determine what works and what doesn’t. At UCSF, the original model relied on surgeons taking call for seven days running. “You probably couldn’t do that continuously for your career,” says Dr. Maa, who worked the seven-day call schedule for 3 1/2 years.
The program has been modified so that the surgical hospitalists now work three- or four-day stretches.
Another successful variation involves one surgeon taking all the daytime shifts, while others rotate in for the PM shifts and weekends.
A Win-Win for Hospitalists?
Does the proliferation of specialty hospitalists create competition for patients? That could be a possibility, says Dr. Frost, should other specialty hospitalists become interested in providing care for the “bread and butter” pathologies.
“For instance, if neurohospitalists were interested in evaluating and managing patients with TIAs (transient ischemic attacks), or cardiohospitalists were interested in managing patients with low-risk chest pain, then there could be some competition,” Dr. Frost says. Although possible, he senses it isn’t a likely scenario.
What’s more likely, according to neurohospitalist Dr. Likosky, is cross-fertilization between specialties, where hospitalists who interface with their specialty colleagues gain the benefit of on-site, in-service education. “Many hospitalists feel that they were not adequately trained in neurologic illnesses, and yet, by default, they have become the first-line providers of inpatient neurologic care nationally,” Dr. Likosky says. “The neurohospitalist model is a way of getting at that issue. I don’t think that we are in competition. I think we are welcome partners.”
