By Samuel H. Steinberg, Ph.D.
If you are admitting patients to the hospital and intend to follow them while they are there, you are likely to share responsibility for their care as hospitals expand the ranks of employed physicians. While there are many professionals that you will interact with, particularly nurses; these individuals will have some degree of clinical decision-making authority regarding the care of your patients. It is also important to note that there may be an impact upon your income as the hospital bills and collects for the services of both hospitalists and intensivists, and this prevents the attending from billing.
There are a few common themes regarding the needs of these three categories of physicians, even though they play very different roles in the hospital setting. Residents are there for postgraduate medical education in a specialty and are technically hospital employees. Hospitalists and Intensivists are hospital employees fulfilling a particular function. Hospitalists are generally focused exclusively on managing inpatient care and are supposed to be expert in that. Intensivists are often in place in the various intensive care units and are knowledgeable in the critical care provided in that unit. In all cases, these individuals are expected to know more about how care is provided in their areas of responsibility, both in terms of the staff working there and the equipment and supplies available to them. They may also be expert in managing care through specific clinical pathways designed to provide optimal care and to move the patient through the system quickly and efficiently.
I think this is a particularly important discussion as these people are physician colleagues, but play very specific roles in the hospital setting, often exercising authority over your patients, while controlling assets and resources you may want access to. Physicians wanting privileges to work in the intensive care units are not pleased to learn that this is not allowed in some hospitals that utilize intensivists. Residents and hospitalists will often exercise some level of authority and control over your patients also. It is essential to understand the roles of these people and develop useful and collegial relationships with them.
First, and most important, is that you be available to them and provide them the information you have gathered regarding your patient. The absolute worst thing you can do is not return a call. Nothing upsets everyone more then the physician who is unreachable for some period of time. No one, of course, is always available immediately, but you must make a good faith effort to be in communication when needed.
Second, you must acknowledge the mutuality of responsibility regarding your patient. By definition, you have admitted your patient to this hospital because you believe it is in their best interest. Therefore, it is incumbent upon you to work cooperatively with the physicians the hospital has employed to oversee your patient. It is essential that the attending physician work willingly with these clinicians in the delivery of the best possible care for their patients. It may also be a requirement in order for you to have privileges at the hospital.
Lastly, remember that discharge planning begins at admission and have a plan for the care of your patient after their hospital stay is over. The most frustrating situation in the hospital, and, unfortunately very common, is for the patient to be unprepared to go home or to another institution. We all know this is something faced every day in every hospital, but to the extent possible, it is the responsibility of the attending physician to assist in the eventual placement of their patients. It is understood that many patients’ post-hospital placement is often difficult, but at least try to help. Ignoring the situation does not make it go away and your reputation can only benefit from the perception that you will try to be helpful.
The rules of the game for residency programs have changed with the number of work hours constrained and shorter length of stays for patients. Program directors must make certain that the educational component of the residency outweigh the service component and that the resident workload be managed according to the relevant guidelines of that specialty. Anything that adds to the service requirement of the program must be carefully scrutinized. So while we have all figured out that one of the things that brings your patients to our hospital is the 24 hour coverage we provide, we must make certain that the resident’s educational needs are foremost in our minds. Nurses provide much of that coverage, but the housestaff play a critical role in allowing you to sleep through the night knowing that your patient is well cared for. All they want in return is for you to provide them some teaching in return for their service, particularly if there is something of interest in the patient’s illness. They will also take care of your routine patients without complaint if you make yourself available to them for their education whenever you are there. Be sensitive to the idea of teachable moments and provide them to the residents whenever possible. Simple and straightforward, but you cannot imagine how often this does not happen.
As a good friend of mine says, if you have seen one hospitalist program, you have seen one program. They are all different and each hospital that has this program in place defines their roles and responsibilities differently. It is also the fastest growing physician specialty and has attracted for-profit companies to provide these services.
Your first challenge is to find out how your particular hospital defines the position. Is the hospitalist fully in charge of your patient or is the hospitalist a co-manager along with the attending physician? Are you asked to consider the recommendations of the hospitalist or are you expected to follow them? In some institutions hospitalists are involved with the care of just general medicine patients and in others they are overseeing all inpatients. Take the time to sit with the hospitalist chief and work through how they will take care of your patient and what they need from you. This advice applies to everyone discussed in this article. Most commonly, they will be your advisers and not have the final say on a patient’s plan of care, but some hospitals do give them the authority to make decisions and implement them. If that is how it is done there, and you object to it, admit your patients elsewhere. For some physicians, this is also a financial matter as they are interested in the income that derives from consulting on their patients in the hospital. For that reason, as well as the quality of care perspective, it is imperative that the hospital clearly define the responsibilities of the hospitalists and involve the medical staff organization in that process.
There is an increasing body of evidence that skilled, mature hospitalists can have some incremental benefit towards reducing length of stay and improving patient movement through the care process. Due to this, it is increasingly likely that you will see more of these programs starting up, particularly as hospitals see the benefits from their work. You will be ahead of things to determine how to work with these people.
The Leapfrog Group for Patient Safety has taken a leadership role in advancing the suggestion that quality of care in critical care units improves when the unit is closed to “outside physicians” and managed by unit intensivists. These physicians are highly trained experts who are in place at the most sophisticated hospitals, readily available to the critically ill patients they are responsible for. These hospitals have determined that the complex and expensive resources available in the critical care unit can best be managed by individuals who specialize in that activity. This not surprising as we know that most health care services are best performed by people who do lots of them and this applies to both hospitalists and intensivists. This is particularly true for the complex level of care provided by all critical care units. In addition, this is also the most expensive care delivered in the hospital and it is in everyone’s interest to utilize these resources as efficiently as possible. To work successfully with the intensivists, be available, communicate what you know about the patient, and be aware of what authority the intensivist has in caring for your patient.
To summarize, each of the parties to the transaction of patient care has differing needs, responsibilities and skills. It is the blending together of each of these skill sets that makes our health care system the envy of the entire world. When the blending is done correctly and with support from all the professionals involved, the patient and the system all benefit. The referring physician gets the best care for their patients as well as the 24 hour supervision that is needed. Each of the professionals receives the benefits from their chosen role in the system and, lastly, the hospital and the health care system strive to manage resources optimally.
Samuel H. Steinberg, Ph.D., FACHE, is Deputy Chair, Department of Medicine, Temple University School of Medicine. This article is adapted from his book, The Physicians Survival Guide for the Hospital.