To Your Health -- CHRC Newsletter
The PAMF Hospitalists
Fall 2003
William M. Cheng, M.D.
Director, PAMF Hospitalist Department
As medicine in the 21st century becomes increasingly complex, specialized, and fast-paced, PAMF continues to stay abreast with innovations in health care practices. Medical care in the hospital has become especially sophisticated, with many new diagnostic and treatment options surfacing every year. To meet this challenge, PAMF launched its new Hospitalist Department in 2000, aimed at furthering the quality and efficiency of patient care in the hospital.
What Is a "Hospitalist"?
Hospitalists are physicians typically trained in Internal Medicine or Family Practice who specialize in hospital inpatient care. They are experienced in dealing with the types of acute medical illnesses that bring a patient into the hospital, like pneumonia, meningitis, gastrointestinal bleeding, and angina, and are also skilled in procedures like spinal taps. In addition to their specialized medical knowledge, hospitalists are intimately familiar with the inner workings of the hospital, and are able to facilitate interactions with ancillary services like physical and occupational therapy, respiratory therapy, social services, and nursing case management.
The concept of the hospitalist has been around for over 10 years, but has only recently become more prominent. The combination of rapid advances in acute hospital care and increasing time constraints in the ambulatory clinic have led to a division of labor, in which hospitalists take care of all inpatient responsibilities, allowing primary care physicians (PCPs) to spend more time with their patients in the clinic. This division of labor has also led to significant benefits in terms of reduced length of hospital stay, thereby helping to rein in the growing costs of healthcare in this country.
How Does the PAMF Hospitalist System Work?
The PAMF Hospitalist Department is comprised of seven full-time hospitalists and seven PCPs who work as part-time hospitalists every couple of months. At Stanford Hospital, one of the premier teaching hospitals in the world, hospitalists act as attending (i.e., supervising) physicians for a team of resident physicians and medical students. When a PAMF patient is admitted to the Stanford Medicine ward (and sometimes the Cardiology ward), he or she can expect to be seen by one of the hospitalists in conjunction with the resident team. All management decisions are discussed thoroughly amongst team members, but ultimately, the hospitalist is in charge of the patient's care.
At Washington Hospital, where there are no resident physicians, the hospitalists work solo, taking care of patients on weekdays during the day, from 8 AM to 5 PM. At night and on weekends and holidays, patients are seen by one of the PCPs from PAMF Fremont, with care being transferred back to the hospitalist during normal hours.
At both locations, the hospitalist system strives for continuity of care, so that a patient sees the same physician day after day. In general, the hospitalist who admitted a patient will continue seeing that patient throughout the hospital stay, with occasional breaks on the weekends when a colleague will cover. In this way, the patient doesn't have to meet a brand new doctor every few days, and the doctor is able to become very familiar with the patient and his or her illness.
Being trained in Internal Medicine or Family Practice, the PAMF Hospitalists are experienced in managing a wide range of medical problems. Of course, there are many times when specialty consults like Cardiology, General Surgery, and Neurology are necessary. Most of the consultants at Stanford are PAMF physicians, although some specialties like Cardiovascular Surgery are covered exclusively by Stanford faculty, and others like Orthopedics may occasionally share responsibilities with other experienced physicians from the community. At Washington Hospital, PAMF relies on the many outstanding specialists from the Fremont community. At both locations, the hospitalists are able to maintain close ties with all of these specialists by virtue of their frequent interactions in the hospital setting; hence, a strong relationship of trust and cooperation has developed, which further strengthens patient care. For the hospitalist, a specialty consultation is simply a phone call away. In the same respect, hospitalists are always available to other specialties if a medical consultation is required. For example, if a patient admitted to the Orthopedics ward develops shortness of breath, the orthopedic surgeon may ask the hospitalist on call for a prompt evaluation.
After a patient is discharged home, the hospitalist will often see him or her at a follow-up clinic visit within one to two weeks, which allows close monitoring during recuperation as well as addressing issues that may not have been urgent in the hospital. In addition, a summary of the patient's hospital stay may be entered into PAMF's Electronic Medical Record, allowing the patient's PCP to understand at a glance what happened during the hospitalization. After this one-time visit, the patient resumes routine follow-up visits with his or her own doctor.
Is My Primary Care Physician Involved in My Hospital Care?
Because of the division of labor between the hospital and the outpatient clinic, primary care physicians no longer see their patients in the hospital. Instead, there is a constantly open line of communication between the hospitalist and the primary care physician, from admission to discharge, with frequent updates from the hospitalist regarding diagnosis, condition, test results, and treatment plan. The hospitalist can obtain valuable background information from the primary care physician that may significantly influence management decisions. The primary care physician and hospitalist thus work as a highly effective team, maximizing the quality and efficiency of patient care.
Will I Always See a Hospitalist in the Hospital?
Not always. By virtue of their training, hospitalists take care of patients with illnesses that fall in the scope of Internal Medicine and Family Practice training. As a broad generalization, these are non-neurologic medical problems that require treatment with medicines rather than surgery. However, patients with primarily surgical, neurologic, oncologic (cancer), and obstetric/gynecologic illnesses are admitted by those respective specialists. In addition, although hospitalists are able to treat many cardiac cases, serious problems like heart attacks are seen by cardiologists. As mentioned above, hospitalists are always available to these specialists for medical consultation as needed.
How Do I Contact My Hospitalist?
Patients may expect their hospitalist to come by every day, usually in the morning. Oftentimes, the hospitalist may stop by more than once a day, especially in more serious or unstable cases. Any time they stop by, hospitalists are always happy to answer questions from patients or family members. For urgent questions during the day, a patient's hospitalist may be reached through the PAMF operator. After hours, a particular hospitalist may be more difficult to reach; however, there is always a hospitalist on call who can offer advice or assistance.
An Example Case:
Mr. Smith is a 72 year old gentleman with a history of emphysema who comes to the Stanford ER for fever, worsening cough, and shortness of breath. He is initially evaluated by Dr. Green, the ER physician, who obtains a chest X-ray that shows pneumonia in the right lung. Dr. Green feels that Mr. Smith needs to be admitted to the hospital for treatment and monitoring, so she calls Dr. Black, who is the on-call PAMF hospitalist. After a brief discussion over the phone, Dr. Black agrees that Mr. Smith should be admitted.
Mr. Smith is then seen in the ER by Dr. White, the on-call resident physician from Dr. Black's Medicine team. Dr. White takes a full history and performs a physical exam, then writes initial orders for Mr. Smith to be transported to the medicine ward and started on intravenous antibiotics. Soon afterwards, Dr. White meets with Dr. Black to discuss the case and finalize the treatment plan; Dr. Black then sees and examines Mr. Smith, and answers questions from him and his family. After this initial visit, Dr. Black then leaves a message for Mr. Smith's primary care physician, Dr. Silver, summarizing the reason for hospitalization and treatment plan.
Over the next two days, Dr. Black meets with Dr. White in the morning to discuss Mr. Smith's progress, after which Dr. Black visits Mr. Smith in his hospital room. This is turning out to be a severe pneumonia for Mr. Smith, and on the third hospital day, he is feeling somewhat worse despite antibiotics and respiratory therapy. Dr. Black returns in the afternoon to reassess how Mr. Smith is doing; he seems to be tiring out, and Dr. Black is concerned that he may require mechanical ventilation. Therefore, Dr. Black calls the PAMF ICU specialist on call, Dr. Brown, who promptly arrives to evaluate Mr. Smith. Dr. Brown agrees that temporary mechanical ventilation would be prudent, and works with her team to transport Mr. Smith to the ICU. Dr. Black sends a message to Dr. Silver, Mr. Smith's primary care physician, notifying him of this turn of events.
Fortunately, Mr. Smith improves in the ICU after a couple of days under Dr. Brown's care, and is able to come off the ventilator; he is then transferred out of the ICU back to Dr. Black's team. Again, Dr. Black notifies Dr. Silver of Mr. Smith's progress, and continues to coordinate care with the medicine team. After speaking with the physical and occupational therapists who have been working with Mr. Smith, it soon becomes apparent that before he goes home, he will need a short rehabilitative stay at a skilled nursing facility, due to the weakness and deconditioning caused by his severe pneumonia. Dr. Black discusses this with Mr. Smith, his family, and the nursing case manager, who then arranges for transfer to an appropriate skilled nursing facility once Mr. Smith is ready to leave the hospital.
One week after admission, Mr. Smith has improved enough to be discharged to the nursing facility. On that day, Dr. Black calls Dr. Silver directly to discuss Mr. Smith's hospital course, his discharge medications, and his continued treatment plan. Once Mr. Smith has arrived at the skilled nursing facility, Dr. Silver, his primary care physician, resumes care. Mr. Smith rapidly regains strength and endurance, and is back home after a week of rehabilitation.
Conclusion
Like many of PAMF's innovations, the hospitalist system was developed with one primary goal in mind: advancement of patient care. The combination of highly qualified physicians, a close familiarity with how a hospital works, and an emphasis on communication (be it with patient, family, primary care physician, or specialist) allows the PAMF Hospitalist Department to deliver state-of-the-art medical care. And as medicine continues to make giant steps forward in disease management and diagnosis, PAMF will be ready to keep pace.
