Hospitalists treat acutely ill hospitalized patients

MD Anderson Cancer Center
Date: 03-18-2013

 

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Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas: MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention, providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today, we're talking with two guests. We've got Dr. Josiah Halm and Dr. Maria-Claudia Campagna who are both assistant professors in MD Anderson's General Internal Medicine Department. Our subject today is hospitalist which is a fairly new term. Dr. Halm, what is a hospitalist? Is it someone who loves hospitals?

Dr. Josiah Halm: Thank you very much and I think that's a question that I think we need to clarify and let everybody understand what we do. So pretty much, hospitalist is an internal medicine-trained physician who takes care of the acutely ill patient whilst they are hospitalized in the hospital. So this is a new concept or a new practice line in the field of internal medicine and it started about 15 years ago. And pretty much, what happened was those internal medicine-trained physicians originally took care of both inpatients and outpatients in the clinic. Over time, things related to healthcare cost, efficiency, dissatisfaction led to a natural concordance of all these factors where now a set of physicians devoted the attention to taking care of these acutely ill patients. And pretty much, what has happened over time is this specialty as well call as hospitalist is similar to patients--or physicians who were, I would say, trained and became eventually emergency room physicians and same concept as to the specialty that eventually became critical care medicine. So we are site-defined specialty, hospital-trained or hospital-specialty medicine physicians. I came to emergency room physicians. I came to critical care or ICU intensivist. So this is a sort of natural history of the people that call themselves hospitalist.

Lisa Garvin: So Dr. Campagna, we're not really talking about treating their cancer, per se, it's really about diseases that they may have come in with or maybe acute problems. What sorts of things are you covering as a hospitalist?

Dr. Maria-Claudia Campagna: Basically, we take care of the comorbidities of these patients. A lot of these patients are already undergoing chemotherapy and they have a lot of complications either from their disease or from the treatment that is provided to them. So we do take care of that. If the patient comes, for example, with pneumonia that might not be related to the cancer or might be like in case of lung cancer, we take care of that. So it's basically the comorbidities for individual, hypertension, diabetes, heart failure, what have you, whatever happens in the community and whatever it is exclusive to our cancer patients related to either, again, the disease or the complication of therapy.

Lisa Garvin: And because cancer tends to hit in aging population, do we see a lot of comorbidities in patients that come in to MD Anderson for example?

Dr. Josiah Halm: Absolutely. So most of these patients will certainly have the regular bread and butter internal medicine conditions, hypertension, diabetes as Dr. Campagna said, COPD exacerbation, underlying renal insufficiency. Unless--again, the other thing is some of these patients, because of the diseases have a lot of medications, polypharmacy we call it, so that we have to reconcile and make sure we get right, and basically adjust as the acutely hospitalized.

Lisa Garvin: But MD Anderson has had a General Internal Medicine Department and an Internal Medicine Center for many years, what is the difference between what you were doing ten years ago and what hospitalists are doing now? What's the shift there?

Dr. Josiah Halm: Right. So when hospitalist medicine as a movement started in the United Stated about 15 years ago, what has happened over time is it's become the most rapidly growing subspecialty, number one. Almost all hospitals in the United States right now have hospitalist. And now, that specialty is moving into this specialty hospitalist like cancer medicine, orthopedic hospitalist. And for us, Dr. Campagna, myself and our team of hospitalist, we pride ourselves on providing this inpatient care for the exclusive cancer hospitalized patient. So in the past, our general internal medicine colleagues used to do this and they did tried to do both like I talked about, the outpatient and the inpatient. And now, here comes these internists who are solely devoted to just doing the inpatient care and what I did was free up our colleagues to concentrate on doing the outpatient piece. So we joined a group of faculty who were doing both initially, not the exclusive, they're doing the outpatients while we focus on the inpatient aspects of the hospitalized cancer patient who is ill.

Lisa Garvin: And where does the hospitalist come in the whole cancer journey? Do they meet you after they're diagnosed or, you know, when exactly does the hospitalist get inserted into the care process?

Dr. Maria-Claudia Campagna: We do it from the very beginning when the patient start--let's--there are two different type of patients, the ones who come--the ones who are admitted from the emergency center and the ones who are admitted from the clinics. So the patients who are admitted from the emergency center again are two different categories. The ones who have never seen MD Anderson before, brand new, they decide to come through our emergency center for many reasons. One of them is because they are too sick to wait for an outpatient appointment. So those patients are admitted to our service because they don't have--and a lot of cases, they do not have a cancer diagnosis that we could prove. They come, they tell us they had been diagnosed with cancer in a different facility and they do come without any collaboration of this, without any pathology report, without any reports, whatsoever. And now, we do have different areas. As you probably know in MD Anderson, the clinical oncologist, they do work in different areas. You have the GI medical oncologist. You have the GU oncology. You have thoracic oncology. You have head and neck oncology. So there are different little silos and we need to locate this patient whether they belong. So this patient come to--these patients come to us, the hospitalist, and we work them out. Whenever we have all the documentation, all the pathology, all the biopsies, then they go to the corresponding services. The other category are the ones who are already diagnosed with cancer who have been at MD Anderson before but come with a medical problem like the pneumonia, sudden MI, myocardial infarctions, and heart failures, we do take care of those patients even though they already have another service.

Lisa Garvin: And for what I understand from what I've studied is that you kind of are like ER doctors or paramedics. You work like a seven-day shift and then you're off seven days. And so basically, you have to get up the speed every time you come back to work, it sounds like.

Dr. Josiah Halm: Right.

Lisa Garvin: Explain how that works.

Dr. Josiah Halm: So, it's--and I'll use a terminology that I'll probably--it's like systole and diastole, the way your heart beats. So we come in and put an acute inpatients shift of about seven days where we take care of patients, develop some relationship with them over the course of time that we're here, and then, you know, attend to their, you know, acute medical comorbidities if--so admit patients, discharge patients, and then at the end of our rotation or a week's work, we'll hand over the existing patients to one of our colleagues who come and assume--take over the patient care. So as you said, ours is a longer shift. I came to ER where they do maybe 12-hour shifts, some days off. Also, I came again to our intensive care unit colleagues who maybe do a two to three-day shift, or again 12-hour shift and then be off. So there's a shift system as you described where it's again you come in, put an acute workload and then take some time off to decongest or to deescalate the intensity of work and then come back and do some more.

Lisa Garvin: And we have a half of dozen hospitalists and a team, a support team of pharmacists and midlevel providers. How many patients do you guys handle on a typical shift?

Dr. Maria-Claudia Campagna: Now, really, we are supposed to be handling about 15 to--15 patients on our shift, 15, 16. But recently, the census has increased so fast and so--almost unexpectedly. We are seeing about 18 to 20 at the last three weeks, that's how as you say? So it could be a big burden. It could be very difficult to manage, but we--fortunately, we have a very good group of nurse practitioners who are of great support and we do have a fabulous pharmacist and they do take care--they do take turns. So we have--without them, it would be impossible, really.

Lisa Garvin: And--so you're not really developing an ongoing patient relationship, I guess. So basically, you handle who you handle on those seven days and then when you come back in your next shift, you may have a whole new cast of characters?

Dr. Josiah Halm: Correct. That's certainly correct. But what the little bit of--when I came to MD Anderson, some of these patients, you develop relationship because they sometimes come in and out of their chemotherapy treatments. So I don't want to use a word, what we say, frequent fliers. But again, we do develop a relationship like that with some of these patients that typically come in and out, for me, but not say the same problem, but you're right. We do develop relationship with the course with our patients over a period of seven days, and then hand off, come back and as you may a whole new team care with a new--whole new patient set. So we tend to that more than the other.

Lisa Garvin: How is it? I mean, you know, because that--like I said, again, I'm comparing you to ER technicians and paramedics. So how is that as a medical professional when you kind of, you know, are seeing new people every week, is it jarring? Is it exciting? How--

Dr. Maria-Claudia Campagna: It could be both. It is exciting. Whenever you have new patients, new cases, it is challenging. The old cases, the old case, and usually they come up with the same constellation of problems. So we know them already and we have established a relationship with those patients, a handful, the ones who frequently come to the hospital. And they are basically--they have no family, not quite a family, but they sometime ask for ourselves, you know, by name, "Oh can I see Dr. X? I would like to see Dr. Y to see me this time," because they already have established a relationship with us. But then the others are the challenging ones. The cases that everybody talks about the--"Wow, do you here this?" So that the cases that, you know, challenge our intellect, I would say, and our knowledge, those are very interesting and we can both like both cases.

Dr. Josiah Halm: The other thing to that makes it worthwhile, I would say, is that these patients have established a relationship with the oncologist and we tend to manage these patients in a collaborative way with the oncologist. So when we introduced ourselves about--to the patients when we see them for the first time, "I'm Dr. Halm and this is what I do, and I work with your attending oncologist, and I'm here to address this and we're going to be working together," and then we're certainly going to keep them updated on how you're doing and when you get discharged, you go back and see him. So that also helps the patient be, you know, satisfied with, you know, seeing this strange person 'cause sometimes they do expect to see their oncologist to take care of them in the hospital too. You know, but then, you know, with the new concept, that's one thing that we have to certainly navigate and navigate quickly to reassure the patients that that is what we trained for, we're here to work and get them feeling better so they can go back and see the oncologist who we have a relationship with to get back to treatment or get back to what the treatment plans maybe.

Lisa Garvin: And you say that the hospitalists are becoming common, but how common are they? I mean, is it still kind of a growing field?

Dr. Josiah Halm: Right. And I'll probably say that right now is the highest--most rapidly growing internal medicines as a specialty and we actually surpass the specialty of cardiology as in terms of the number of trainees in the United States. It's a young field. We do have our own journal. We do have our own board exam now by the ABIM. And certainly, we--in most hospitals, hospitalist much as they've seen patients have assumed leadership in hospital management and see suites and stuff like that, just by--back to the fact that we understand how hospitals work. We understand how patients come through the emergency room. We understand what takes to get a patient through, get a patient discharged. So we do understand the economics of the stay, you know. So what it takes to do a good quality job in an efficient manner to help reduce cost and that's where hospital executives has find us valuable. So much as we do care take care of patients in the medical aspects with our knowledge, we also have to understand how the healthcare system works and that's why we've also been able to prove our worth, you know.

Lisa Garvin: How do medical professionals internists like yourself arrive at this, admittedly, nontraditional career decision? I mean, what drove you to become a hospitalist, Dr. Halm?

Dr. Josiah Halm: My little secret is I did my residency internal medicine in Chicago's Cook County Hospital and when I was doing my residency, one thing that I find very difficult or challenging was doing the outpatient clinics. These were patients that were, again, difficult to manage in the clinic. So I realized that of the two kinds of practices, the inpatient piece was what I really enjoyed, the fast pace, you get a patient who's acutely ill with heart failure, pneumonia, or has an acute medical problematic at a course of a two to three day stay, they get better and then you're able to discharge them to go back home safely. So you see your results quickly. In contrast to your clinic patient who may not be taking his diabetic pills, may not be taking his blood pressure pills, and you pull your teeth because of insurance reasons, and things like that. So personally, that's what drove me to this specialty. And it was about the time when I was graduating from internal--my residency program that it took off. So that's my little secret. And I know Dr. Campagna has, so she has actually has some oncologic background here. She would tell you about it, yeah.

Dr. Maria-Claudia Campagna: Yes. Actually, it was quite by chance. I have been working for five years in the outpatient setting and I know, you know, I live the pains that Josiah is referring to, but when I was trying to look for something different to do because I was getting a little bit tired of doing outpatient, they were needing--they were looking for an internist who could help the oncologist, the only oncologist that we had, I was working within county, in Fort Worth. And they asked me, "Would you like to do this? You're going to have to do the inpatient oncology aspect of the practice, of the hospital, of the county hospital." It was very challenging and I said, "Sure, absolutely." So I started. My very first job as a hospitalist was working in oncology. So I became de facto, an oncology hospitalist from the very beginning.

Lisa Garvin: Do you find that hospitalists are young doctors on the way up or doctors like yourself that are--that have matured in your profession and maybe want to step to in different level? Or is it just a mix of different people?

Dr. Maria-Claudia Campagna: It is a mix of different people, absolutely. And you cannot be a hospitalist--the life of the hospitalist is not assured as it is for the intensivist or as it is for the emergency center physician. But, I would say, it's not as long as it is for the traditional or the physician doing outpatient practice because it could be very intense.

Dr. Josiah Halm: Right. And along those lines too with the fact that it's known to be the young or the resident, the freshly-minted resident who goes into internal medicine because, number one, they have the energy for the fast pace shift, 12-hour shift that you put in week on, week off. And for them, they tend to also want to use this as a transition to maybe do something else in the future. But increasingly over time, we've been able to--like I talked about, it's a both certified subspecialty in internal medicine right now. We have a whole in journal that's widely respected. And professionally, Dr. Campagna, myself and my team of doctors do have enough years on our belt that we've seen it more as a career and a profession and are trying to grow. And--so after that, initial [inaudible] where a residence will come out of it and make good money because when they come out like that, they do make good money and the one who do that for a couple of years wants to make up their mind and a bit chunk of them end up staying. And then, you know, so their career paths, like in patient safety and quality improvements, the electronic IT records that, you know, they tend to use the young talent and skills as residence to go into. And then certainly, it offers a lot of leadership potential and career paths in the administrative leadership. So that's sort of the natural trajectory as we grow older and we can put in the heavy shifts or hours that we do, [laughter] we tend to want to look at [inaudible] administrative rules that we can perform as--of a time we tend to understand how hospital systems works and how we get patients through, you know, through--we'll call through, you know, get them in and out and safely, efficiently at a lower healthcare cost, particularly in this time of healthcare reform and uncertainty. [Inaudible Remark]

Dr. Maria-Claudia Campagna: And acclamations are also the other spectrum. So there are programs with a clear academic hospitalist who are working to train either residence or other physicians, physicians who have finished internal medicine and who want to do additional training in the hospital as medicine.

Lisa Garvin: Have there been any metrics done to show the effects of hospitalist and how it improves, you know, efficiency and other factors? How do they measure your work?

Dr. Josiah Halm: Right. So some of the converging factors that led to this had to do initially with healthcare cost, length of stay, 'cause if you think about it, in the past, is you'll see in primary care physician, they will put you in the hospital, finish his clinic at about 5, 6 to 8 p.m. and they have to come back and take care of your pneumonia and heart failure. Obviously, this led to increase in hospital stay, dissatisfaction. This is what calling you at home, stuff like that. Now, you have to move from one hospital to another, taking care of [inaudible] your individual patients. So the key metrics initially was length of stay, especially for the DRG hospitals where you get paid a defined amount of money for how long your patient stays in the hospital. But I think we as hospitals move more beyond that. Now, we want to be measured by the quality of care that we produce. Are we safely discharging our patients so they don't have a 30-day readmission? Are we providing DVT prophylaxis for our hospitalized patients so they don't develop these clots? Are we controlling their blood sugars better? So there are these clinical metrics. There are also financial metrics. You know, are we officially using consults? Are we using less, you know, labs, [inaudible] consults less? You know, all of these are financial metrics and medical knowledge questions that we're being measured by. And certainly, with us, we know performance. Certainly, the new healthcare acts that turns to reward or reimburse base on quality, patient satisfaction, provider satisfaction, readmission rates, and how well we treat our pneumonia, heart failure patients. We are hospitalists who really understand theses metrics, big boom to the hospitals and CEOs. So I think that's what we're being measured right now and that's where our value really is.

Lisa Garvin: And it sounds like you're providing efficient yet compassionate care. Is that fair to say?

Dr. Maria-Claudia Campagna: Yes, I hope so.

Dr. Josiah Halm: Yeah.

Lisa Garvin:Thank you both. A very interesting topic and it sounds like a promising career field in healthcare. If you have questions about anything you've heard today on Cancer Newsline, contact ask MD Anderson at 1-877-MDA-6789, [background music] or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune-in for the next podcast in our series.