The New Breed of Doctor Is In
BMC hospitalists preview medicine’s future
The half dozen white coats sweep briskly down stairs and through halls at Boston Medical Center. The leader, Muhammad Syed, is very familiar with this tiled, fluorescent-lit honeycomb: he’s a “hospitalist,” medicine’s newest specialty, a doctor who treats patients only here, not in an office. After leading his team on rounds, Syed peels away for some one-on-one with the sick, including a woman just admitted with cold-like symptoms.
The woman is elderly and on dialysis, and Syed wants to rule out the possibility of a more serious blood infection. Such medical detective work is part of a doctor’s job, but especially so in hospitals, which in this era of burgeoning outpatient treatment usually bed the sickest patients with the most complex problems. Syed probes for clues: “Your pressure was really high, and you had fever? So tell me when all this started.” “So did you get your dialysis?” “What about the runs? How many times do you think you’ve been to the bathroom?” “Do you know anybody else who’s sick?”
“So far, we’re still collecting information,” he tells her. “We don’t know too much yet.” He’ll wait for tests to come back later that day, he says.
Don’t be embarrassed if you haven’t heard of hospitalists. Nila Radhakrishnan directs BMC’s, and she had never heard the word until she became a resident. It was coined in a 1996 New England Journal of Medicine article. Back then, BMC had a lone hospitalist. Now, Radhakrishnan oversees 15 hospitalists, one of whom, School of Medicine Assistant Professor James Meisel, is a former primary care physician (PCP), the Norman Rockwell-esque family doctor who once roamed hospitals visiting patients, but increasingly is handing off that job to hospitalists.
Meisel explains why: “One of the hardest things about my job as a PCP would be having one or two or three or four hospitalized patients. I’d come in at 5 o’clock in the morning, round on those patients, talk to the residents, write the orders, go see my office patients, answer a couple of calls during the day, and probably go back at the end of the day, at 6, 7, 8 o’clock, to see the hospital patients.” That backbreaking schedule becomes more manageable when hospitalists take over the hospital work, he says.
The trend toward hospitalists has also been goosed by shortages of primary care doctors, who are paid less than specialists and have less predictable hours. “There’s a catastrophe in progress here,” says Meisel. “I don’t know who’s going to take care of me when I’m old.” Then there’s the new health reform law, which will boost the number of insured Americans, and almost certainly, the number getting hospital care.
The New York Times cites studies attributing shorter and cheaper hospital stays to efficiencies gained from hospitalists, who, the paper reports, tend to be younger, more tech-savvy, and more conversant with modern medicine’s efficiency drive than PCPs.
“Primary care and hospital medicine are very different sets and depths of knowledge and expertise,” Meisel says. “We know how to take care of critically ill people better. We know how to use the hospital systems to the best advantage.”
Midmorning, Syed squeezes into a room stuffed with nurses, care managers, and social workers, sharing information to coordinate patients’ stays and discharges. He discusses the woman with the cold symptoms, mulling over how long she might stay and her posthospital needs with a nurse case manager. He chats with a social worker about another patient with cancer.
“He actually looked very calm,” she says. “Yeah, he teaches English,” says Syed. “You know he’s a street musician?”
N. Stephen Ober (CAS’82, MED’86), codirector of BU’s joint MD/MBA program, thinks programs like his will be a hearty incubator of hospitalists, once more students are familiar with the specialty. The joint program is conducted by MED and the Graduate School of Management.
“It’s not like you wake up in the morning and say, ‘Gee, I think I’ll grow up and be a hospitalist,’” Ober says. But that career would land doctors with an MBA “in a very large, complicated organization where they can absolutely leverage their business skills.”
Hospitalists also work closely with a patient’s family physician. “My biggest partner as a hospitalist is the primary care doctor,” says Radhakrishnan.
To improve communication among PCPs, hospitalists, and hospitals, Radhakrishnan helped devise an electronic system, implemented at BMC in April, that sends patients’ discharge information to their primary care doctors. The Philadelphia-based Society of Hospital Medicine has launched a pilot program to improve discharges. Working with 65 hospitals (BMC is not involved), the initiative tags patients at risk for readmission and provides staff with discharge forms specifying hospital phone numbers, follow-up medical appointments, and health warning signs for the patient. The system will be reviewed in a year or two, according to the New York Times.
Give such efforts 10 years to iron out the kinks, Meisel advises. “This is in its infancy, or adolescence. When a jet flies from Chicago to New York and one tower hands off to the other, they do it with a lot more standardization than we do.”
Sometimes, hospitalists must reconcile conflicting goals between patients and their families. The same day Syed hunts for his patient’s mystery illness, BMC hospitalist Jennifer Hughes, a MED assistant professor, who works on palliative (pain and other symptom relief) care, takes a pharmacist and a nurse practitioner to the bedside of a man with lung cancer. He only wants to go home, but he’s resisting hospice care, which would give him the in-home services he needs. He thinks it would preclude his right to call 911 in an emergency.
“Hospice becomes your 911, so there’s a nurse you can call 24/7,” Hughes patiently explains. “You always have the option of calling 911 if you have to.” The man’s adamant: “I don’t think so, right now.”
“That’s a very different approach than the traditional doctor would take,” Hughes says later. “We always say the same line: When you think about the future — knowing you have cancer — what’s important to you? And that question brings out so much. He told me, ‘I just want to go home.’ Then we do the translating — ‘From what your goals are, this is what we recommend as the best option.’ Once he sits down with his wife and talks about maybe the best way to keep him at home is with hospice, usually it’s an easy conversation. You have to start with what they want.”
Radhakrishan believes that doctors who go into medicine to save lives and prefer to leave the systems-management stuff to others would benefit if they embraced the evolving medical model. “Everybody needs to get an aspirin if they had a heart attack,” she says. “But that doesn’t matter if they don’t actually get the aspirin. When I take care of patients one-on-one, I enjoy it. But when I work on systems of care, I know that what input I’ve had is going to affect many patients.”
Rich Barlow may be reached at firstname.lastname@example.org.