Hospitalists: The next generation

Tara Schulz, MD, a third-year internal medicine resident, has experience under her belt that hospitalist Win Whitcomb, MD, would have been grateful to have the first time he faced a grieving family.

Dr. Schulz already has been called in to talk with terminally ill patients and their families. Most recently she spoke with an end-stage cancer patient about his options and discussed home hospice care with his family. Those experiences at the University of Colorado Health Sciences Center have made her confident that she'll be able to handle tough situations when she begins her first hospitalist job this summer.

For Dr. Whitcomb -- now 13 years into his career -- those are areas where he found himself stumbling as a new hospitalist. The first time he was confronted with the death of a patient he had not been treating, the patient's family was deeply upset with how he handled the situation.

"I felt uncomfortable, went into the room and didn't make eye contact with the family," he said. "I listened for heart tones, checked the pupils and left the death note in the chart."

Dr. Schulz is one of the University of Colorado's first internal medicine residents to participate in a hospitalist track that started in July 2004. Palliative and perioperative care are among the skills that the new specialty track focuses on to ensure that hospitalists are prepared when they start their first jobs.

Understanding hospital systems and learning how to partner with pharmacists, nurses, hospital administrators and other physicians as a team is also part of the training. Dr. Schulz knows that teamwork will be key as she starts her first job at Denver Health.

Leaders of the Society of Hospital Medicine are trying to establish their field as a specialty, similar to what emergency physicians did for their discipline in the 1970s. They hope Dr. Schulz will be the first of a new generation of doctors given the chance to learn hospitalist-specific skills during residency instead of coping with on-the-job training as her predecessors did. That's especially important as the field of roughly 12,000 is expected to explode to 30,000 by 2010, said Larry Wellikson, MD, the Society of Hospital Medicine's chief executive officer.

William Atchley Jr., MD, director of hospitalist services for Sentara Careplex Hospital in Hampton, Va., sees the need firsthand.

"I find with residents coming out of residency programs, there's a lack of understanding of what goes on outside of the hospital walls in terms of patient treatment," he said. "They need to understand what goes on at home, if the patient can afford the medicine and take the meds as prescribed. Is the environment safe so the patient will continue to get better or will they get re-admitted for the same condition?"

Hospitalists coming into their own

The push for training is particularly important not only because the number of hospitalists are growing, but also because the roles that hospitalists play are expanding.

According to a Center for Studying Health System Change study in the February Journal of General Internal Medicine, hospitalists are increasingly substituting for intensivists in intensive care units, teaming with subspecialists to care for complicated patients, functioning as primary attending physicians in skilled-nursing facilities and caring for hospitalized nursing home patients.

"At one point, we defined a hospitalist as someone to catch everything the other doctors didn't want to do," Dr. Wellikson said. "Now the scope of practice for hospitalists involves being a partner with just about every doctor who brings in patients to the hospital."

They work with surgeons to do perioperative care, managing patients' chronic conditions such as diabetes or hypertension and taking care of complications including infections such as pneumonia. They're also being asked to partner with nursing and pharmacy staff and hospital administrators, he said, to help measure quality and redesign hospital systems.

As recently as 10 years ago, some physicians feared that hospitalists would steal their patients. But those fears are gone, and hospitals and physicians alike have seen that hospitalists can shorten patient stays and can fill in the gaps created when the new resident hour restrictions went into effect two years ago.

Training tomorrow's hospitalists

With the new growth in numbers and respect for the field, internal medicine faculty at the University of Colorado saw the need to better train those who wanted to embark on a career as a hospitalist. Jeffrey Glasheen, MD, a hospitalist and a faculty member, took the opportunity to create a track geared toward his specialty.

Now director of the hospitalist track at Colorado, he hopes to provide his trainees with the skills they need to treat patients and to make them leaders in the profession.

"There aren't many [palliative care] experts in most communities, and I want them to have excellent palliative care skills," Dr. Glasheen said.

His residents, including Dr. Schulz, participate in a two-day retreat where they receive intensive training on palliative care. Throughout their residency, the doctors focus on a number of areas pertinent to their field, including strokes, hip fractures and orthopedics, pneumonia, pain management, geriatrics, and quality improvement. They study how the hospital functions as a system. For example, they learn how patients flow from the emergency department to intensive care and into the wards.

Understanding quality improvement and the hospital system is particularly important because hospitalists are often asked to lead quality improvement efforts at their institutions. That requires a different thought process than most physicians are accustomed to.

"The role of the hospitalist in the future is not to treat one patient with pneumonia but how to treat 2,000 with pneumonia," Dr. Glasheen said. "That's different than the way we're trained -- to treat one patient at a time. Hospitalists want to improve care for everyone with that condition."

Interns at the University of Colorado complete their first year of training before deciding which path to take. Those choosing the hospitalist track then follow a two-year curriculum geared toward their chosen field. Of the university's 130 internal medicine residents, 11 are on the hospitalist track. The school's goal is to have 12 students total in the program, six new students each year.

Trial and error

Society of Hospital Medicine leaders see the newly formed hospitalist track in Colorado as a model for other internal medicine residency programs, and they want to encourage more schools to set up programs like it.

To do that, the society plans to formally announce a core hospitalist curriculum in January 2006. At the same time it will launch a peer-reviewed medical journal, The Journal of Hospital Medicine.

It has been a long road to this point.

Developing a successful residency model has not been without setbacks. Scott Flanders, MD, headed up an effort at the University of California, San Francisco, School of Medicine in the late 1990s. But it ultimately didn't work, he said, because it was too hard to sustain a hospitalist option without revamping the entire residency program.

UCSF offered intensive training during the residents' elective month. Those who chose a hospitalist elective had a month packed with lectures on medical economics, medical consultations, quality improvement and end-of-life care. The residents followed patients from the hospital to acute facilities to learn what type of care was available outside the hospital, and they completed a quality improvement project.

"A lot of what we felt was critical for hospitalists the other residents wanted. Ultimately, a good chunk of what we'd provided to our group became available to many residents," Dr. Flanders said, so the medical school folded the learning opportunities into the general training, rather than keeping them as a hospitalist elective.

Now at the University of Michigan Medical School, Dr. Flanders is wrestling with whether to try creating a hospitalist option again. "We need to fundamentally rethink internal medicine education," he said. "Our current system is archaic. We have the same three years of training for someone who will go off and be a cardiologist, a primary care outpatient doctor or a hospitalist."

Back in Colorado, Dr. Schulz believes she is getting the specialized training she needs to succeed as a hospitalist. She's spending a month handling perioperative care of surgical patients, where she's managing patients' diabetes, hypertension or other medical problems outside the surgeons' expertise.

"We're working with surgeons who we don't usually see," she said. "You learn where their knowledge base is and where yours is. I don't know much about surgical procedures, but I'm learning rapidly. ... I wish that I was 10 years younger and starting with hospitalist training [10 years in the future]. Everyone is still figuring out where it's going and how best to design it."

Yet her training is far more tailored than it would have been 10 years ago.

"Understanding the role for empathy, understanding the role for appropriate hand-holding and physical contact ... using the right words to make people feel at ease and cared for. That's a whole skill set I didn't learn in residency that I had to develop," Dr. Whitcomb said.