A new kind of physician> St. Joseph hospitalists take load off family doctors

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Articles in the Wall Street Journal and Modern Healthcare this spring hailed a rare occurrence, the appearance of a new medical specialty, one not yet added to dictionaries between hematologist and immunologist.

Chances are you haven’t heard the word “hospitalist,” but St. Joseph Hospital in Bangor, on the cutting edge of a national trend, has had the newfangled doctors roaming its halls for more than a year.

They’re not emergency room docs, surgeons, anesthesiologists, or any of the other kinds of physicians traditionally found in hospitals. They’re doctors who would have been found in private family practices in the past, who have traded occasional hospital rounds for full-time hospital work.

Now when their patients grow sick enough to enter St. Joseph Hospital, about 20 general practitioners from the Bangor area turn the leadership role over to four resident hospitalists, who call themselves by a simpler title: inpatient physicians. They handle roughly one-third of the hospital’s patients, 15 to 20 at once.

Longtime Bangor doctor Donald Krause was the first to take the plunge into inpatient services at St. Joseph, beginning Jan. 1, 1996. In spite of his satisfaction with private practice and close ties to his patients, the affable Connecticut native knew “it was an idea whose time had come,” for many reasons.

One reason, for better or worse, is managed care, and the HMO industry’s efforts to shorten hospital stays. Patients get well faster when a doctor is close at hand to guide their care. And with HMOs dictating terms — five days for a heart attack, two days for a gall bladder, etc. — it seemed easier to standardize stays with a few doctors running the show.

“It’s much easier to change five physicians’ behavior than 25,” said Dr. Ken Simone, an energetic young Brewer family doctor who helped design the new inpatient system.

In the first quarter of 1997, the average stay at St. Joseph Hospital decreased by about a day, he said. Reductions vary by diagnosis, from 1.7 fewer days for pneumonia to 2.7 days for a heart attack. The average heart attack patient was in the hospital 8.1 days before; 5.4 days is the latest standard.

In the past, Simone explained, hospital care ran in 24-hour cycles, the typical length of time between a doctor’s hospital rounds. “But patients don’t get better in 24-hour terms,” he said. “A patient might be better at 1 p.m., not the next morning.”

Discharges are processed more rapidly when the dismissing physician is right down the hall — not 15 miles away seeing patients in East Corinth. Krause said his constant presence at St. Joseph makes for better patient care.

“Most doctors would either make morning or evening rounds,” he said. “Here, we can make rounds two times, three times, four times, whatever. We see ICU [intensive care] patients four, five or six times a day. You can act on the information that comes to you quicker.”

At the same time, office-based doctors whose schedules are already hectic are no longer interrupted by phone calls from the hospital. With more and more health care going on in an outpatient setting — another managed care byproduct — the primary care physician’s time is increasingly valuable.

Because his time in the hospital has been cut back, Simone said he will soon be able to extend his morning and evening hours at Brewer Family Medicine, adding convenience for patients who work.

The hospitalist system was initiated by Northeast MSO, a group of 28 doctors and 13 physician assistants who now refer patients to the four resident specialists. The group has an official relationship with St. Joseph, but also sends patients to Eastern Maine Medical Center when needed.

The organization is somewhat unique, a fact that complicated the early search for models. Local leaders talked with doctors from New Orleans to Springfield, Mass., and didn’t find a set-up that matched their proposal.

“Coming in, I had no job description, no clue how to do the job,” said Krause. “Most hospitalist systems have been set up by hospitals. There are very few models for physician-led systems.”

Krause and Simone are already active in the fledgling National Association of Inpatient Physicians, and they hope to bring colleagues around the country to Bangor to share what they’ve learned.

Dr. Win Whitcomb, one of the association’s founders, is a hospitalist at Mercy Hospital in Springfield. He said Maine’s limited involvement in managed care makes the Bangor hospitalists atypical.

“I’m a little surprised it’s happening in areas where there’s not a lot of managed care,” he said. “In areas where there is a lot, there’s such a premium placed on efficiency that it’s not that surprising. … There are other reasons in places like Bangor.”

One reason is the more predictable schedule and improved quality of life for doctors who don’t mix office hours with trips to the hospital. Meanwhile, demands inside the hospital are greater, as HMOs make sure beds are filled with only the sickest patients.

“It’s harder and harder to be a jack-of-all-trades,” said Whitcomb. “It’s hard to be an expert in both inpatient and outpatient care.”

Far from operating in isolation, the primary doctors and hospitalists work closely together, Krause said. Under guidelines established early on, family doctors fax patient histories to the hospitalists within an hour of an admission. In return, the hospitalists make sure records of the hospital stay are on the family doctor’s desk within three hours of discharge.

A new voice mail system eases play-by-play consultation, and most primary physicians have not given up hospital visits altogether. The collaborative arrangement is explained to patients so they don’t feel abandoned.

“The first thing I say is that we’re on the same team,” Krause said. “I’ll sit on the patient’s bed, call his doctor and hand him the phone, so he knows his doctor is part of this.”

Patient satisfaction with the hospitalists has been better than expected. Warden Buck of Brewer spent a night at St. Joseph Hospital several weeks ago, and was cared for by inpatient physician Michael Coyne. Dr. Coyne also cared for Buck in the hospital last year, shortly after Coyne’s recruitment to Bangor.

“I think it’s a terrific idea,” said Buck, 71, who suspected a heart attack on his most recent hospital trip. “He certainly knows his business. He’s a very keen doctor.”

“We thought patients would be really disappointed,” intensive care nurse Michelle Markie said. “Once they see the time these physicians are able to spend with them and their families, I don’t think they mind.”

Nurses throughout the facility seem pleased with the arrangement. It’s nurses, after all, who spend the most time on the phone relaying symptoms to distant doctors.

“It’s a lot of stress for us when there’s something going wrong and we can’t get someone,” said Nancy Laqualia, a nurse who often works on the cardiac floor. “It’s wonderful for us because these doctors are always available. They’re there so much they get to know you, and you get to know them.”

They’re also there enough to see how the hospital works, how efficiently X-rays are produced and tests are performed. Watching the system up close, St. Joseph hospitalists have had a hand in quality control. They say systemwide improvements will continue.

All of the hospitalists are board-certified internists, specialists in diseases that don’t require surgery. Coyne was the first to join Krause a year ago. Jason Gramling has been at St. Joseph 10 months, and Lucy Kirshner arrived this summer. Three mid-level staff, including a physician’s assistant and a nurse practitioner, work with them in the hospital.

Each hospitalist is on call every fourth day and night, taking all new admissions in that period. Each patient sees only one of the four while in the hospital.

On a recent weekday Krause was juggling six cases: an elderly woman with weakness, a diabetic having surgery, someone with warning signs of stroke, someone else with chest pain that turned out to be cancer of the esophagus, an emphysemic having trouble breathing, and someone with gall bladder disease.

For the first time last month, one of the hospitalists was assigned to Eastern Maine Medical Center for a four-week stint. EMMC duty will continue on a rotating basis. While there, hospitalists will treat the handful of patients whose primary care physicians are part of Northeast MSO.

St. Joseph’s program remains “a work in progress,” said Krause. Potential remains for the hospitalists to take on more cases, but Simone said they will move ahead slowly to avoid burnout.

“It hasn’t been an easy thing to do,” Krause acknowledged. “Mistakes have been made. Systems have been developed so the mistakes don’t happen again. And the energy around the table hasn’t diminished.”

One change made early on, after some negative patient response, was to increase family involvement in planning care after discharge.

All in all, Krause is glad he took a chance.

“It was satisfying seeing patients over time, knowing them over years, seeing them in the grocery store,” he said. “To give that up was very difficult. But I did the right thing.”