Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.
For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.
Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.
NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”
A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.
Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.
The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”
Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.
“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”
PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”
The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”
Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”
“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”
The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”
“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.”
Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.
“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.
NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.
“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.
Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”
That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?
“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”
Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.
“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.
Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”
Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”
The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.
As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.
“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.
“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”