More physicians turning to hospital-based practice

NEW BRITAIN–Dr. Neeraj Kalra’s first job after residency was in a primary care practice. In the mornings, he’d visit any of his patients who were hospitalized, then go to the office for his appointments.  He liked the mix of inpatient medicine and forming relationships with the patients he saw regularly in his office.

But he came to realize it wouldn’t last. “You could see the trend,” he said.

Neeraj Kalra

Dr. Neeraj Kalra

Like many in primary care, Kalra’s practice began exploring having hospital-based doctors handle its hospitalized patients, allowing the practice doctors to devote their time to outpatients. And when the practice made the change, Kalra made a change of his own, becoming a hospitalist at The Hospital of Central Connecticut.

Hospital medicine is a fast-growing field, attracting many of the young doctors who pursue general internal medicine. It evolved as pressures on primary care doctors mounted, making it harder to take time to see hospitalized patients, and as the care of hospitalized patients grew more complex. At many Connecticut hospitals, most medical inpatients–those not there for surgery, urology, psychiatric care or childbirth–are now cared for by hospitalists.

Research suggests that hospitalists can provide care at a lower cost and reduce patients’ time in the hospital, without sacrificing quality.

But while primary care doctors can get to know a patient over years, hospitalists must get to know them quickly, usually during acute illnesses. And having a separate doctor in the hospital can add to the challenge of smoothly transitioning a patient from a hospital to the community, sometimes leading patients to be readmitted to the hospital. Hospitals have increased their efforts to improve patients’ transitions out of the hospital, especially as Medicare is expected to begin cutting payments next year to hospitals that have high rates of preventable readmissions.

A study published this month raised new questions about hospitalists and what happens to patients after discharge. Using data from Medicare patients from 2001 to 2006, researchers Yong-Fang Kuo and Dr. James S. Goodwin found that hospital charges for patients treated by hospitalists was less than for patients treated by primary care doctors. But they were higher in the 30 days after patients left the hospital, offsetting the earlier savings. Those cared for by hospitalists also had fewer visits to their primary care doctor after discharge.

Dr. Joseph Ming Wah Li, president of the Society of Hospital Medicine, which represents hospitalists, praised the authors but said the study has limitations. The years covered predate the focus on reducing readmissions. And Li, a hospitalist at Boston’s Beth Israel Deaconess Medical Center, said the study did not address care quality.

“Regardless of what studies come out,” he said, “the truth of the matter is that hospital medicine is not going away.”

Complexity, pressure, standardization

Since the term “hospitalist” was coined in 1996, the field has grown from one or two thousand doctors to close to 35,000 nationwide, and many hospital officials say they’re indispensible.

“Hospitalists have become an invaluable part of the care of patients in this day and age, and they improve the quality immensely,” said Dr. Rolf Knoll, chief medical officer at St. Francis Hospital and Medical Center in Hartford. In 2005, St. Francis had a couple hospitalists who mainly focused on teaching and treating patients who didn’t have primary care doctors. Now St. Francis has 20 hospitalists who care for about 85 percent of medical inpatients. The hospital expects to add four more.

Dr. Rolf Knoll

Dr. Rolf Knoll

“I believe that hospitalists and hospital medicine, in essence, is absolutely essential to the quality and safety and the advancements that are occurring and will continue to occur within hospitals as we work to more effectively coordinate care and eliminate the variations which historically existed in how care is delivered,” said Jeffrey Flaks, president and CEO of Hartford Hospital, which has 17 hospitalists and expects to add five more. Nearly all medical inpatients there are cared for by hospitalists.

Dr. Bud McDowell, vice president for clinical affairs at Middlesex Hospital, where hospitalists take care of at least 95 percent of medical inpatients, likened the growth of hospitalists to the development of emergency medicine in the 1960s and ’70s, filling the need for after-hours sources of care after house calls became uncommon, then becoming more specialized as complexity increased.

As primary care doctors faced pressure to see more patients, it became harder to spend time in the hospital. Fewer patients were being hospitalized, and those that were had more complex or acute conditions. Having a hospitalist available at all times can mean more timely care than if a patient had to wait for a primary care doctor to come in. More recently, cutbacks in the hours residents work left hospitals with a gap to fill in inpatient care.

Doctors in primary care and hospital medicine say the knowledge base required for each has diverged enough that it’s difficult to specialize in both.

Many hospitalists now are involved in quality improvement initiatives and on hospital committees. Having a team of doctors who treat inpatients, rather than hundreds of private physicians who visit their own patients, can make it easier to standardize care. And when hospitalists are employed, hospitals have more leverage in getting doctors to make adjustments, such using a therapy that is equivalent to others but less costly, said Dr. Adam Silverman, chief of the UConn Health Center’s Division of General Internal Medicine and one of its hospitalists.

The vast majority of medical school graduates considering general internal medicine–a minority of all students–now choose hospital medicine, Silverman said. Primary care is a harder sell–not because of the medicine, he said, but because of the challenges of running a practice. And new doctors are familiar with inpatient medicine from their training.

“A lot of us, coming out of residency, that’s what we knew best,” said Dr. Elizabeth Tillman, medical director of IPC New England, a practice that includes Bristol Hospital’s hospitalists, who care for about 60 percent of the hospital’s inpatients.

Kalra is now the associate director of his hospitalist program, which takes care of between 60 to 70 percent of the hospital’s medical inpatients. He likes the unpredictability of inpatient medicine. He’s often learning new things and likes working as part of a team. He also likes the chaos. “I thrive in it,” he said. “I enjoy it.”

Dr. Rupal Panchal

Dr. Rupal Panchal

His colleague, Dr. Rupal Panchal, considered cardiology or gastroenterology before choosing hospital medicine. Part of the appeal was working with different specialties. Now she works frequently with staff including social workers to address patients’ needs that go beyond medicine, like those of a patient with cancer who is homeless.

Dr. Michael R. Grey, The Hospital of Central Connecticut’s chief of medicine, described hospitalists as the generalists of the hospital. They do what primary care doctors do, including working with patients’ families, addressing the social factors affecting patients and coordinating with other care providers, but it’s compressed into a matter of days, not years. There’s a lot to be said for the long-term relationship between a primary care doctor and a patient, Grey said. But he noted that hospitalists can quickly get to know patients and their families.

Ideally, he said, hospitalists would handle the day-to-day patient care and their primary care doctors would visit and let patients know he or she talked to the hospitalists and has confidence in them. Grey, a primary care doctor, does so for his patients, and said it’s possible for him because doesn’t see outpatients full time and already spends time in the hospital.

But, he added, “Nobody pays for that extra time.”

Keeping track of patients

The use of hospitalists makes sense to Dr. Claudia Gruss, a gastroenterologist and primary care physician who practices in Fairfield County. She goes to the hospital for hospitalized gastroenterology patients, but relies on hospitalists for her primary care patients.

The downside, she said, is some loss of the continuity of care. A doctor who has been taking care of a patient for 20 years knows the patient much better than the hospitalist, “who has to start to know the patient from scratch,” she said, although she noted that there should be communication between the hospitalist and primary care doctor.

Many hospitals have procedures for notifying primary care physicians when a patient is admitted and discharged, and if there are significant changes in a patient’s status. Electronic medical records, and a way to exchange them, will help, but Grey said there’s likely to always be a need for doctors to talk to each other.

As the focus on preventing readmissions intensifies, and payment systems evolve toward paying to keep patients healthy across care settings, rather for each procedure or visit, hospitalists and hospital officials said they expect hospitalists to play a central role in coordinating care. Tillman’s practice goes further; she now sees patients from the hospital when they go to nursing homes, assisted living and rehabilitation facilities.

“The make or break of this readmission thing will be the communication between the primary care physician, the hospital, the patients,” and nursing homes, visiting nurses or any other type of caregivers a patient sees, said Dr. Surendra Khera, chief of St. Francis’ department of hospital medicine.

Gruss said transitions can be improved by having the hospital staff schedule a follow-up visit with the patient’s primary care doctor, reconciling the patient’s medications before discharge, and having the hospitalist call to update the primary care doctor after the patient leaves.

“I think hospitals are working on all of these issues and trying to get it done for every patient, but it is very labor intensive. It takes a lot of time, both on the doctor level and the hospital level,” she said. “But it really does have to be done.”