Hospitalists and the Future of Health Care
By Laura Freeman
Hospitalists such as UAB's Ronnie Mathews help reduce the length of hospital stays, reduce costs, and increase patient satisfaction.
The elderly lady with pneumonia was breathing well at morning rounds. But when Ronnie Mathews, M.D., stopped by her hospital room that afternoon, he noticed her breathing was growing more distressed. He quickly moved her to intensive care and began treatment, preventing respiratory failure.
The patient didn’t have to wait for a nurse to call her primary physician, or for her doctor to rush through traffic. Because Mathews is a hospitalist—a doctor specializing in inpatient care who does not have a separate private practice—he was instantly able to check her condition and take action.
Less than 10 years ago, hospitalists were a new concept and rare; today, the specialists are found in most major hospitals. The UAB Hospitalist Service was the first hospitalist group in Alabama when it opened in 1998, says medical director James Lyman, M.D. Eight hospitalists, in addition to five nurse practitioners, now staff the expanded service.
The specialists have become popular because “there are tangible benefits in having a hospitalist available 24/7 to monitor patients and coordinate their care,” Lyman explains. “We can assess and respond to emergent changes in their conditions. National studies have shown reduced length of stays, reduced costs, and increased patient satisfaction” as a result.
“Hospitals have become complicated places,” Mathews adds. “We understand how to navigate hospital processes and guide the patient. We are familiar with new technologies that might be beneficial, since we use them every day. We’re also able to follow up as soon as test results come back, which saves time and money and gets patients home to their families faster.”
The physical presence of a doctor also reassures family members, Mathews says. “We can answer questions, handle acute situations, and play a preventive role, helping to improve glucose control and prevent infections and other complications.”
Just as heart patients are referred to a cardiologist, general medicine patients can be assigned to the UAB hospitalist unit at the discretion of referring physicians. Primarily, UAB hospitalists work with patients admitted for an acute medical illness or a combination of illnesses. “Working with the complexities of caring for patients with acute conditions is a different kind of medicine,” Lyman says.
Hospitalists have a set of skills that primary physicians have come to appreciate because it benefits their patients and their practices. “Primary physicians don’t have the stress of needing to be in two places at once—they don’t have to choose between seeing patients at their office or rushing to the hospital if another patient is having problems,” Mathews says. He notes that physicians in private practice may have only one or two hospitalized patients on any given day. “With increasing time pressures, it can be a relief for them to have a hospitalist watching over these patients.”
Many primary physicians still come by the hospital to check on their patients, but they can visit when their schedules allow, knowing their patients are in good hands. “We stay in touch with each patient’s doctors to keep them in the loop—briefing them on tests, findings, medications, and developments—and we work closely with them when the patient leaves the hospital,” Mathews says.
Mathews adds that hospitalists also serve a purpose beyond the patient’s bedside, helping to enhance processes throughout the entire medical enterprise. Because they practice only within the hospital, “hospitalists see what is working and what can be improved, so we can be advocates for patient care.”
In particular, hospitalists often make recommendations related to quality management and patient safety and satisfaction. These may include increasing the efficiency of processes in the emergency department so that patients don’t have to wait as long for rooms, identifying computer or equipment problems, or developing procedures to prevent medication errors.
“Hospitalists are ideally suited to recognize opportunities for improvement,” Lyman says. “We may care for patients in only one unit, but we can help thousands who come through the hospital.”
Growing Role in Geriatric Care
Hospitalists are likely to play an increasing role in health care, particularly in the field of geriatrics, where physicians are facing an aging American population that requires more frequent hospitalizations for complex conditions. Hospitalists have been an integral part of the care team in UAB’s Acute Care for Elders (ACE) Unit since it opened in July 2008 at UAB Highlands hospital.
Hospitals stay in close contact with patients' primary physicians to keep them updated on test results, changes in condition, and other news.
The goal of the unit, according to its medical director, UAB geriatrician Kellie Flood, M.D., is to anticipate and prevent new geriatric problems in elderly patients while managing their acute care. “Geriatric patients in a hospital setting may be prone to developing acute confusion, falls, pressure ulcers, incontinence, and other problems less often seen in younger patients,” she says. “They may have multiple geriatric issues in addition to their acute medical problem. They are also at increased risk of experiencing functional decline during a hospitalization compared to a younger adult.”
No one person has time to adequately address all of these issues, “so we work proactively as an interdisciplinary team,” Flood explains. The ACE Unit team includes physical therapists, respiratory therapists, occupational therapists, nurses, dietitians, pharmacists, social workers, volunteers, and a pet therapist—with hospitalists acting as the attending physicians.
The hospitalist model is a perfect fit for the ACE Unit, says Flood. “Our team meets every day to discuss how patients are doing and what we’re observing from a geriatric standpoint. Are they eating? How’s their muscle strength? Are they depressed or showing signs of cognitive decline? We do medication reviews to make sure they don’t have multiple prescriptions putting them at risk for an adverse drug event, a fall, or confusion. We work to promote mobility and cognitive stimulation to help them avoid developing new complications.”
Studies show that the ACE multidisciplinary team model of care helps to improve function, reduces length of stay, increases patient satisfaction, and results in better outcomes—findings that are similar to survey responses about hospitalist care. “We use what has proven to work and build on it,” Flood says.
Communication and Compassion
Becoming a hospitalist doesn’t require additional medical training—most hospitalists have completed residencies in general or internal medicine—but it does require some key expertise. “You need high-level interpersonal and communication skills to explain what’s happening to the patient and work closely with the referring physician,” Lyman says. “You should be adept at using information technology for systematic communication and the appropriate handoff of records when patients are discharged. A hospitalist also has to be comfortable with multitasking. It’s not uncommon to be reviewing a chart when a pager goes off, sending you to treat an unstable patient. You have to be able to change with the events of the day and go with the flow.”
Patience also is paramount, Mathews says. “If a patient doesn’t have a primary physician or comes to the emergency department and records aren’t available, we have no baseline. We have to begin at the beginning to get a good medical history.”
Lyman echoes that point: “The first time you meet a patient, it’s usually in an acute situation with the patient and family under stress. You have to develop the doctor-patient relationship.”
Despite the challenges of working in a hospital all day, Lyman and Mathews enjoy being hospitalists. Their schedules are more predictable than those of other medical specialists, and both men agree that inpatient medicine is exciting and dynamic. “We see a variety of patients and many interesting cases,” Lyman says. They also are proud of what they have accomplished as hospitalist pioneers in Alabama and are eager to see how their field evolves and influences health care. “There are many rewards, and I enjoy what I do,” Mathews says.