Hospitalist a glorified resident?

[mercaptovizadeh]

So, can a hospitalist actually do most of the management on his own or does he basically have to consult all the specialists for anything slightly complicated? I'm not talking about knowledge base, but rather certain unsaid "rules" that if you don't follow you are a "bad doctor" and will get ruined by a malpractice suit some day.

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[mackie]

I think this will depend on the hospital--ie, different practice cultures, etc. I learned within a few short months that some specialists get annoyed when you consult them later in a case, for example patient in the hospital a week or more with you doing what you know to do and then consulting them when it doesn't work, there are complications, etc. Some of them would rather be on board from the start. It can actually save you time anyway, but it leads to over consulting IMO.

 

[angel80]

I agree. It depend on the hospital. In my hospital, I feel that hospitalists are just there to babysit and do all the paperwork. None of the pulmonologists, endocrinologists, gastroenterologists, rhuematologists, ID docs, or neurologists admit their own patients. They all want the patients admitted to medicine, but they want to be consulted and call all the shots. Even the cardiologists, nephrologists, and hemotologist/oncologists are admitting a lot of their patients to medicine. Some of the hospitalists are supersmart and could easily be managing these patients on their own, but either don't want to step on the specialists' toes, or are afraid of the litigation if they make a mistake. I have absolutely no desire to be a hospitalist or practice this type of medicine. At other hospitals though, I think the hospitalists are actually able to manage patients on their own.

 

[radslooking]

I agree. It depend on the hospital. In my hospital, I feel that hospitalists are just there to babysit and do all the paperwork. None of the pulmonologists, endocrinologists, gastroenterologists, rhuematologists, ID docs, or neurologists admit their own patients. They all want the patients admitted to medicine, but they want to be consulted and call all the shots. Even the cardiologists, nephrologists, and hemotologist/oncologists are admitting a lot of their patients to medicine. Some of the hospitalists are supersmart and could easily be managing these patients on their own, but either don't want to step on the specialists' toes, or are afraid of the litigation if they make a mistake. I have absolutely no desire to be a hospitalist or practice this type of medicine. At other hospitals though, I think the hospitalists are actually able to manage patients on their own.

consulting is really up to the individual provider. I do not consult as much as my partners. If a patient has a creatinine up to 2.4 from a baseline of 1.5 I am not calling renal unless i can't figure it out on my own. Other people do. Likewise I don't call cardiology for chest pain unless I get an abnormal stress. Same thing for GI, others. Everybody has their own practice style. Apparently there are some places that encourage consultation, I have not seen them personally. But yes, they do like to admit to hospitalists because admits and discharges require the most work, namely paperwork. Plus pages during the day about routine management. But whatever, you control the work up. You don't have to do exactly what they request, although usually you try to work in their recommendations. Ultimately you say when the patient leaves or goes depending on their situation. I have never been told I 'need to consult more'. Also, a lot of consultation can happen over the phone. Sometimes you don't need a full consult, just a clinical question.

Frankly, I have a problem, both monetarily and philosophically with overconsultation. Use your training and only consult when necessary. But yes, I'd agree with an above poster that you don't want to flail away on a specialized problem for a week without consulting someone. Reasonableness is key.

 

[Trifling Jester]

So, can a hospitalist actually do most of the management on his own or does he basically have to consult all the specialists for anything slightly complicated? I'm not talking about knowledge base, but rather certain unsaid "rules" that if you don't follow you are a "bad doctor" and will get ruined by a malpractice suit some day.

Nobody else can tell you how to practice medicine. Once you have your own medical license you can treat patients however you see fit. Of course, since you are unlikely to get credentialed by the hospital committee to perform angiography unless you're a cardiologist, dialysis unless you're a nephrologist, etc., then you're forced to consult on certain patients... or else you'll be treating them in a substandard fashion.

That being said, there are some "cultures" of practice that vary by hospital:

At one hospital that I'm at, internists rarely consult anyone. ID does not get any consults for pneumonia, cellulitis, UTI, etc. They basically only get consulted for HIV or TB. Renal does not get consulted unless the patient needs dialysis. Cardiology does not get consulted unless there are positive troponins or a positive stress (i.e. the patient needs a cath).

At another hospital (a more private hospital) there is a much lower threshold for consulting other services. It's my opinion that this is probably because the patients are all insured and the other physicians can bill a reasonable amount for their services and will get paid to see them in clinic at a follow up appointment. This makes the decision-making easier for the hospitalist and lessens their workload (if they're covering 20-30 patients the nurses may be paging the endocrinologist about out-of-whack sugars despite a sliding scale... and the internist will probably appreciate that help). However, even at this facility, there still aren't any rules that say you have to consult.

-The Trifling Jester

 

[mercaptovizadeh]

Nobody else can tell you how to practice medicine. Once you have your own medical license you can treat patients however you see fit. Of course, since you are unlikely to get credentialed by the hospital committee to perform angiography unless you're a cardiologist, dialysis unless you're a nephrologist, etc., then you're forced to consult on certain patients... or else you'll be treating them in a substandard fashion.

That being said, there are some "cultures" of practice that vary by hospital:

At one hospital that I'm at, internists rarely consult anyone. ID does not get any consults for pneumonia, cellulitis, UTI, etc. They basically only get consulted for HIV or TB. Renal does not get consulted unless the patient needs dialysis. Cardiology does not get consulted unless there are positive troponins or a positive stress (i.e. the patient needs a cath).

At another hospital (a more private hospital) there is a much lower threshold for consulting other services. It's my opinion that this is probably because the patients are all insured and the other physicians can bill a reasonable amount for their services and will get paid to see them in clinic at a follow up appointment. This makes the decision-making easier for the hospitalist and lessens their workload (if they're covering 20-30 patients the nurses may be paging the endocrinologist about out-of-whack sugars despite a sliding scale... and the internist will probably appreciate that help). However, even at this facility, there still aren't any rules that say you have to consult.

-The Trifling Jester

Thanks, this is very informative. Does the employer take into account solely patient load or how far you (i.e. yourself, not the consults) have worked up the patient?

 

[radslooking]

Thanks, this is very informative. Does the employer take into account solely patient load or how far you (i.e. yourself, not the consults) have worked up the patient?

the employer has nothing to do with it. you decide when and who to consult. the consulted physician may say...."well, I don't think that needs to be seen as an inpatient, or do X, Y, Z, and if you need me to see him, call back"
Some physicians will consult a neurologist for vertigo. Others won't. Neither is allowed, or disallowed, it's a personal preference. Now, if the neurologist says "I don't need to be consulted on everyone with vertigo" that's one thing. But it's between the physicians.
the administration has little to do with it, other than encouraging a certain culture or whatever. but its up to you.
For instance, I think i was told something about DKA always needing an endocrine consult. Well, I did talk with the endocrinologist, but only to figure out what regimen they wanted him on. It took a few minutes over the phone. There was no "official" consult.

 

[Trifling Jester]

Thanks, this is very informative. Does the employer take into account solely patient load or how far you (i.e. yourself, not the consults) have worked up the patient?

I am not sure what you mean by employer.

If you are an individually practicing private physician you don't work for anyone else and you don't have an employer. You get privileges to admit to a hospital but you aren't really working for the hospital. You may have to admit "x number of patients per month" or something like that in order to maintain admitting privileges but I've never heard of them including "x number of consults" into that agreement. If you are an individual physician then you bill the patient's insurer and your payment isn't affected by whether or not you've consulted a specialist.

Alternatively, you could work as part of a larger practice that contracts with a hospitalist group. Most hospitalist groups that I am aware of have some MD assigned as the hospitalist director. They would sign you to a contract, and in turn, contract with the hospital for that group. In this case the hospitalist director is acting as your boss (still not the hospital itself). Depending on your contract you would be paid based on either a straight salary or on how many patients you see. Either way your salary would not change regardless of whether or not you consulted a lot, or not much at all.

The hospitals themselves get paid based on whatever diagnosis you give the patient. They get X number of dollars for heart failure, x number of dollars for DKA etc. It's all based on how many DRGs each diagnosis is worth. It doesn't matter how many tests you order or how long the patient stays (generally speaking). So if you order fewer tests and have a shorter length of stay then the hospital will make more money. Therefore, the hospital itself may peripherally care about the number of consults because it's been my experience (admittedly anecdotal) that consults tend to increase the number of tests ordered and increase the length of stay for the patient.

-The Trifling Jester

 

[radslooking]

I am not sure what you mean by employer.

If you are an individually practicing private physician you don't work for anyone else and you don't have an employer. You get privileges to admit to a hospital but you aren't really working for the hospital. You may have to admit "x number of patients per month" or something like that in order to maintain admitting privileges but I've never heard of them including "x number of consults" into that agreement. If you are an individual physician then you bill the patient's insurer and your payment isn't affected by whether or not you've consulted a specialist.

Alternatively, you could work as part of a larger practice that contracts with a hospitalist group. Most hospitalist groups that I am aware of have some MD assigned as the hospitalist director. They would sign you to a contract, and in turn, contract with the hospital for that group. In this case the hospitalist director is acting as your boss (still not the hospital itself). Depending on your contract you would be paid based on either a straight salary or on how many patients you see. Either way your salary would not change regardless of whether or not you consulted a lot, or not much at all.

The hospitals themselves get paid based on whatever diagnosis you give the patient. They get X number of dollars for heart failure, x number of dollars for DKA etc. It's all based on how many DRGs each diagnosis is worth. It doesn't matter how many tests you order or how long the patient stays (generally speaking). So if you order fewer tests and have a shorter length of stay then the hospital will make more money. Therefore, the hospital itself may peripherally care about the number of consults because it's been my experience (admittedly anecdotal) that consults tend to increase the number of tests ordered and increase the length of stay for the patient.

-The Trifling Jester

It most certainly increases the number of tests and length of stay for me personally. Whether that's a good thing or a bad thing is up for debate.

 

[Febrifuge]

Ditto what others have said about this being institution-dependent. Yes, it's important to "play nice" with the other services, particularly when by definition you're stuck with them, and them with you. I've been in places where it even varied by MD within a service; one specialist liked to keep the threshhold low for frequent, brief curbside consults from our team, just so he had a sense of who the patients were, because he learned that he'd rather get a call on hospital day five for a patient he sort of remembered hearing about when they came in. Another preferred to forget there were any patients aside from the ones on her list, and it didn't matter when you consulted, the patient popped into existence then. And they were partners.

So the best approach seems to be, just practice the best medicine you can. Consult when you need to. For the sake of smooth and harmonious working relationships, the hospitalists should have a sense of what the specialist consultants like, while keeping in mind what works best for actually managing all those patients admitted to Medicine. If that's a non-answer, it's because that balancing act is as imprecise as it is central to hospital medicine.

One thing that stuck with me from one of my rotation sites was the idea that it might have been Dr. Cards who admitted the patient to Medicine, but blast it all, they were admitted to Medicine. In other words, there's a benefit to the specialists in being "just" the consultant and not having to manage everything; the tradeoff should be for them not to create too much drama about being asked to consult.