The Hospitalist Movement, 2004The Hospitalist Movement, 2004

Eric M. Siegal, M.D.Eric M. Siegal, M.D.Assistant Professor of Medicine (CHS)Assistant Professor of Medicine (CHS)

Director, Hospitalist ProgramDirector, Hospitalist Program

University of WisconsinUniversity of Wisconsin

es2@medicine.wisc.edues2@medicine.wisc.edu

Objectives

Recent history of the Recent history of the hospitalist movementhospitalist movement

Impact of hospitalists on Impact of hospitalists on health care: what we health care: what we do, don’t and should do, don’t and should knowknow

Where the hospitalist Where the hospitalist movement is goingmovement is going

Hospitalists at the Hospitalists at the University of WisconsinUniversity of Wisconsin

Disclosure

This talk has not been sponsored by any organization.This talk has not been sponsored by any organization.

No pharmaceutical representatives were harmed in the No pharmaceutical representatives were harmed in the making of this presentation.making of this presentation.

What is a Hospitalist?What is a Hospitalist?

““Hospitalist” first coined in 1996 by Wachter Hospitalist” first coined in 1996 by Wachter and Goldmanand Goldman

Hospitalists are physicians whose primary Hospitalists are physicians whose primary professional focus is the general medical professional focus is the general medical care of hospitalized patients. They may care of hospitalized patients. They may engage in clinical care, teaching, research engage in clinical care, teaching, research or leadership in the field of general hospital or leadership in the field of general hospital medicine.medicine.

Wachter, Goldman: NEJM, 1996; 335:514-7

Workforce CompositionWorkforce Composition

88% Medicine trained88% Medicine trained 83% GIM83% GIM 5% medical subspecialists5% medical subspecialists

12% Peds and Family Medicine12% Peds and Family Medicine

SHM Hospitalist Productivity and Compensation Survey, 2002

Is This Really a New Idea?

Not entirely:Not entirely:Canada, Britain, Australia and NZ have Canada, Britain, Australia and NZ have maintained hospitalist-like models for maintained hospitalist-like models for decades.decades.

 

Redelmeier. A Canadian Perspective on the American Hospitalist Movement. Arch Intern Med. 1999;159:1665-1668

Bindman, Majeed. Organisation of primary care in the United States. BMJ. 2002; 326: 631-634

Explosive GrowthExplosive Growth

NAIP/SHM founded in 1997 at a breakout NAIP/SHM founded in 1997 at a breakout session of the ACP meetingsession of the ACP meeting

1997: 23 members1997: 23 members 2003: 3,900 members2003: 3,900 members Currently 7-8,000 hospitalistsCurrently 7-8,000 hospitalists Potential size: 20,000 – 30,000Potential size: 20,000 – 30,000 There are about 20,000 cardiologists in the There are about 20,000 cardiologists in the

United StatesUnited States

Lurie et al. The Potential Size of the Hospitalist Workforce in the United States. Am J Med. 1999; 106:441-5

Inpatient Services, PCInpatient Services, PC

Denver, CO hospitalist practiceDenver, CO hospitalist practice Founded in 1998 by 4 physicians at 2 Founded in 1998 by 4 physicians at 2

hospitals seeing 35 encounters per dayhospitals seeing 35 encounters per day As of 12/03: 22 physicians at 4 As of 12/03: 22 physicians at 4

hospitals seeing 190 encounters per hospitals seeing 190 encounters per dayday

This is happening across the countryThis is happening across the country

Why is the Hospitalist Why is the Hospitalist Movement Growing so Fast?Movement Growing so Fast?

DemandDemand::Physicians (PCPs & specialists)Physicians (PCPs & specialists)HospitalsHospitalsThird party payersThird party payers

SupplySupply: : Increasing numbers of physicians perceive Increasing numbers of physicians perceive hospital medicine as a viable long-term hospital medicine as a viable long-term career.career.

New Hospitals in Denver

Three new hospitals opening across metro Three new hospitals opening across metro Denver in 2004Denver in 2004

All three hospitals plan to contract hospitalist All three hospitals plan to contract hospitalist groups to provide inpatient coverage from groups to provide inpatient coverage from day oneday one

Why: Many community physicians (PCPs Why: Many community physicians (PCPs and specialists) made patient referrals and specialists) made patient referrals contingent upon having pre-existing contingent upon having pre-existing hospitalist groups on sitehospitalist groups on site

What’s Fueling Physician Demand for Hospitalists?

Inpatient medicine is becoming more Inpatient medicine is becoming more demanding and difficultdemanding and difficult

Physicians are increasingly concerned about Physicians are increasingly concerned about lifestyle issueslifestyle issues

Unassigned / ER callUnassigned / ER call Financial pressures are driving physicians to Financial pressures are driving physicians to

look for more efficient ways to deliver health look for more efficient ways to deliver health carecare

Is Inpatient Medicine Becoming More Difficult?

Aging populationAging population

++ Increasing co-morbidities Increasing co-morbidities

+ Care shifting to ambulatory setting+ Care shifting to ambulatory setting

Sicker patients in the hospitalSicker patients in the hospital

Sicker patients inevitably demand more Sicker patients inevitably demand more physician time and expertisephysician time and expertise

Sicker Patients at UWHC

Case Mix IndexCase Mix Index: : A numerical score of A numerical score of blended patient acuity:blended patient acuity:1: minor 2: moderate 3: major 4: extreme1: minor 2: moderate 3: major 4: extreme

From 7/97 – 9/03, CMI at UWHC increased From 7/97 – 9/03, CMI at UWHC increased from 1.65 to 1.79 (p <.0001)from 1.65 to 1.79 (p <.0001)

CMI has been increasing by .01 every four CMI has been increasing by .01 every four months for the past six yearsmonths for the past six years

UWHC Case Mix Index 07/97 – 09/03

1.40

1.45

1.50

1.55

1.60

1.65

1.70

1.75

1.80

1.85

1.90

Month

CMI

Sicker Patients NationallySicker Patients Nationally

18.2 million CA inpatients (1993-97)18.2 million CA inpatients (1993-97)

Acuity index: 1.69 Acuity index: 1.69 1.79 1.79 By 2025: A.I. 2.50 (40% increase)By 2025: A.I. 2.50 (40% increase)

Institute for Health and Socio-economic Policy: California Healthcare: Institute for Health and Socio-economic Policy: California Healthcare: Sicker Patients, Fewer Nurses, Fewer Staffed Beds; 1999Sicker Patients, Fewer Nurses, Fewer Staffed Beds; 1999

Physician Lifestyle

Physicians are increasingly concerned about Physicians are increasingly concerned about balancing lifestyle and practicebalancing lifestyle and practice

Juggling inpatient and outpatient medical Juggling inpatient and outpatient medical practice is stressful and time-consumingpractice is stressful and time-consuming

The more primary care physicians practice The more primary care physicians practice inpatient medicine, the more they are likely to inpatient medicine, the more they are likely to express job dissatisfaction and burnout.express job dissatisfaction and burnout.

Saint et al. What Effect Does Increasing Inpatient Time Have on Outpatient-oriented Internist Satisfaction? JGIM. 2003; 18: 725-729

The Unassigned Call Crisis

Management of unassigned patients is reaching crisis Management of unassigned patients is reaching crisis levels across the nationlevels across the nation

Unassigned patients are typically difficult: No access to Unassigned patients are typically difficult: No access to pre-hospital primary care, difficult follow-up, higher pre-hospital primary care, difficult follow-up, higher rates of substance abuse, noncompliance…rates of substance abuse, noncompliance…

Reimbursement is generally poorReimbursement is generally poor Unassigned patients have become problematic for all Unassigned patients have become problematic for all

parties: Internists, ERs, hospitals and patientsparties: Internists, ERs, hospitals and patients Hospitalists are increasingly perceived as the solutionHospitalists are increasingly perceived as the solution

Edlich et al. A National Epidemic of Unassigned Patients: Is the Hospitalist the Solution? J. Emerg Med. 2002; 23: 297-300

Financial PressuresFinancial Pressures

Inpatient/outpatient medical practices are Inpatient/outpatient medical practices are generally inefficientgenerally inefficient Travel timeTravel time Divided attention interrupts efficiency in the Divided attention interrupts efficiency in the

clinicclinic Some large practices rotate inpatient call Some large practices rotate inpatient call

One physician manages everyone’s One physician manages everyone’s inpatientsinpatients

This is really a quasi-hospitalist modelThis is really a quasi-hospitalist model

Financial Bottom Line

Hospitalists may improve generalists’ Hospitalists may improve generalists’ bottom line by $40,000 by allowing bottom line by $40,000 by allowing increased outpatient productivityincreased outpatient productivity

Falk CT, Miller C. Hospitalist Programs: Towards a New Practice of Inpatient Care. Washington, DC: Advisory

Board Company; 1998:1-59.

Why Do Why Do SpecialistsSpecialists Like Like Hospitalists?Hospitalists?

““I think, therefore I am ---undercompensated”I think, therefore I am ---undercompensated”

DoingDoing pays pays wayway better than better than thinkingthinking 30-74 min. critical care = 4.00 RVUs30-74 min. critical care = 4.00 RVUs single-vessel PTCA = 14.84 RVUssingle-vessel PTCA = 14.84 RVUs

In areas with shortages of specialists, hospitalists can In areas with shortages of specialists, hospitalists can fill some of the voids, allowing specialists to fill some of the voids, allowing specialists to concentrate on the most complicated patientsconcentrate on the most complicated patients

Specialists would rather practice their specialitesSpecialists would rather practice their specialites

Hospitalists Can:

Make PCPs and specialists more Make PCPs and specialists more productiveproductive

Allow specialists to concentrate on their Allow specialists to concentrate on their specialtiesspecialties

Help their colleagues enjoy their careers Help their colleagues enjoy their careers

Why Do Why Do HospitalsHospitals Want Want Hospitalists?Hospitalists?

Do more with less:Do more with less: Sicker patientsSicker patients Worsening staffing shortagesWorsening staffing shortages Decreasing reimbursementDecreasing reimbursement

Prospective paymentProspective payment Unassigned patientsUnassigned patients 24:7 in-hospital attending coverage may 24:7 in-hospital attending coverage may

become mandatorybecome mandatory

Quality / Safety CrisisQuality / Safety Crisis

44,000-98,000 inpatient deaths per year 44,000-98,000 inpatient deaths per year attributed to medical errorsattributed to medical errors 88thth leading cause of death, exceeding MVA, leading cause of death, exceeding MVA,

breast cancer and AIDSbreast cancer and AIDS Cost: $17-29 billion per yearCost: $17-29 billion per year

Major system flaws and failures are endemic Major system flaws and failures are endemic to hospitalsto hospitals

“To Err is Human: Building a Safer Health System”: Institute of Medicine, 2000

Hospitalists are Uniquely Positioned to Champion Patient Safety and Quality Improvement Initiatives

Nobody knows the hospital better than a Nobody knows the hospital better than a hospitalisthospitalist

Hospitalists are uniquely invested: the Hospitalists are uniquely invested: the hospital is our homehospital is our home

Why Are Physicians Attracted to Why Are Physicians Attracted to Hospital Medicine?Hospital Medicine?

Why is a career that offers unpredictable Why is a career that offers unpredictable days, weird hours and perpetual days, weird hours and perpetual treatment as a house officer becoming treatment as a house officer becoming so popular?so popular?

Because…Because…

Logical transition from I.M. residencyLogical transition from I.M. residency Fast-paceFast-pace High-acuity, interesting casesHigh-acuity, interesting cases Daily interaction with subspecialistsDaily interaction with subspecialists Alternative to primary care for people Alternative to primary care for people

who don’t want to subspecializewho don’t want to subspecialize ““It’s why I became an internist”It’s why I became an internist”

Is the Proliferation of Is the Proliferation of Hospitalists a Good Thing?Hospitalists a Good Thing?

Why it Could be Bad

Discontinuous care Discontinuous care of hospitalized of hospitalized patients:patients: Misinformed Misinformed

caregiverscaregivers Nobody knows Nobody knows

patients’ wishes or patients’ wishes or social situationsocial situation

Fumbled handoffsFumbled handoffs

Why it Could be Bad - II

Could increase the sense of Could increase the sense of marginalization already felt by many marginalization already felt by many primary care physiciansprimary care physicians

Could precipitate a schism in Internal Could precipitate a schism in Internal Medicine by creating discrete Medicine by creating discrete specialties in outpatient and inpatient specialties in outpatient and inpatient practicepractice

Why it Could be GoodWhy it Could be Good

Discontinuity of care isn’t always badDiscontinuity of care isn’t always bad Internal Medicine might actually benefit from Internal Medicine might actually benefit from

differentiating outpatient and inpatient tracksdifferentiating outpatient and inpatient tracks Physicians who focus solely on hospital care Physicians who focus solely on hospital care

might do it better than physicians who don’tmight do it better than physicians who don’t Hospitals might function betterHospitals might function better Could actually increase the allure and Could actually increase the allure and

prestige of a generalist careerprestige of a generalist career

Christakis, Wachter. Does Continuity of Care Matter? West Med. 2001; 175: 174-75

How Do We Decide?How Do We Decide?

User satisfaction:User satisfaction:PCP/specialistsPCP/specialistsPatientsPatientsHospitals and staffHospitals and staff

Resource utilization and outcomesResource utilization and outcomes Impact upon General Internal MedicineImpact upon General Internal Medicine Impact upon Medicine as a wholeImpact upon Medicine as a whole

Do We Have Enough Data to Do We Have Enough Data to Decide?Decide?

No – Studies to date are small and No – Studies to date are small and limited in scope and powerlimited in scope and power

Ongoing areas of research:Ongoing areas of research: User satisfactionUser satisfaction Resource utilizationResource utilization OutcomesOutcomes

Do Hospitalists Improve Do Hospitalists Improve Patient Satisfaction?Patient Satisfaction?

No large, well-designed studies to dateNo large, well-designed studies to date My impression:My impression:

Patient concern about abandonment by their PCP Patient concern about abandonment by their PCP when they’re sick may be offset by greater when they’re sick may be offset by greater availability and attentiveness from hospitalistsavailability and attentiveness from hospitalists

Patients are deeply concerned that their PCPs are Patients are deeply concerned that their PCPs are informed and involved in their care. They are less informed and involved in their care. They are less concerned whether or not the PCP is making the concerned whether or not the PCP is making the day to day decisionsday to day decisions

Do Hospitalists Improve Nurses’ Job Satisfaction?

Again, no published studiesAgain, no published studies Anecdotally, nurses love hospitalists.Anecdotally, nurses love hospitalists. Hospitalists:Hospitalists:

Are readily availableAre readily available Understand hospital protocols and systemsUnderstand hospital protocols and systems Probably know the RNs on a first-name basisProbably know the RNs on a first-name basis Attuned to the team-based care model that is Attuned to the team-based care model that is

central to nursing carecentral to nursing care

“ “ From a nursing perspective, it is hard From a nursing perspective, it is hard to imagine the Hospitalist role as to imagine the Hospitalist role as anything but a dream come true. ”anything but a dream come true. ”

Elizabeth Henneman, PhD, RN.Elizabeth Henneman, PhD, RN.

Clinical Specialist, MICU, UCLAClinical Specialist, MICU, UCLA

Do Hospitalists Improve PCP Job Satisfaction? 708 PCPs surveyed: 524 responded (74%)708 PCPs surveyed: 524 responded (74%) 62% of physicians surveyed had hospitalists available 62% of physicians surveyed had hospitalists available

to themto them PCPs with experience with hospitalists believed that PCPs with experience with hospitalists believed that

hospitalists:hospitalists: Had no effect on their income (69%)Had no effect on their income (69%) Decreased their workload (53%)Decreased their workload (53%) Increased their practice satisfaction (50%)Increased their practice satisfaction (50%) Decreased the quality of their relationships with their Decreased the quality of their relationships with their

patients (28%)patients (28%)

Fernandez et al. Friend or Foe? How Primary Care Physicians Perceive Hospitalists. Arch Int Med. 2000; 160: 2902-2908

Are Hospitalists Better Than General Internists at Inpatient Care?

High volume and subspecialization High volume and subspecialization improve outcomes and efficiency improve outcomes and efficiency (surgery, cardiology, critical care)(surgery, cardiology, critical care)

It makes intuitive sense that this should It makes intuitive sense that this should apply to hospital medicine as wellapply to hospital medicine as well

Do Hospitalists Improve Do Hospitalists Improve Resource Utilization?Resource Utilization? 19 studies comparing hospitalists and 19 studies comparing hospitalists and

generalistsgeneralists 15 studies: Hospitalists significantly 15 studies: Hospitalists significantly

decreased costs (average: 13.4%) and decreased costs (average: 13.4%) and lengths of stay (average: 16.6%)lengths of stay (average: 16.6%)

Outcomes were at least neutralOutcomes were at least neutral Limitations: Many of these studies were Limitations: Many of these studies were

small and retrospectivesmall and retrospective

Wachter, Goldman. The Hospitalist Movement 5 Years Later. JAMA. 2002;287:487-494.

How About Quality of Care?

Two recent studies: One at a community Two recent studies: One at a community hospital, the other at an academic centerhospital, the other at an academic center

Short-term relative risk of death for patients Short-term relative risk of death for patients admitted to hospitalist services was about admitted to hospitalist services was about 0.70.7

Auerbach et al. Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes. Ann Intern Med. 2002; 137: 859-865

Meltzer et al. Effects of Physician Experience on Costs and Outcomes on an Academic General Medicine Service: Results of a Trial of Hospitalists. Ann Intern Med. 2002; 137: 866-874

Intriguing Results, but Intriguing Results, but HardlyHardly DefinitiveDefinitive

RetrospectiveRetrospective VeryVery limited scope: 7 hospitalists at 2 limited scope: 7 hospitalists at 2

hospitals – Difficult to generalize this to the hospitals – Difficult to generalize this to the entire medical communityentire medical community

Stay tuned – more data are comingStay tuned – more data are coming

What Can We Say About Hospitalists in 2004?

Probably utilize inpatient resources more Probably utilize inpatient resources more efficiently than generalistsefficiently than generalists

Probably do not adversely affect outcomes Probably do not adversely affect outcomes and and mightmight improve them improve them

May improve hospital staff satisfactionMay improve hospital staff satisfaction Should improve physician satisfaction in a Should improve physician satisfaction in a

voluntary systemvoluntary system Effect on patient satisfaction unclearEffect on patient satisfaction unclear

Could “Hospitalism” be a Could “Hospitalism” be a Distinct Medical Subspecialty?Distinct Medical Subspecialty?

Not until we come up with a better Not until we come up with a better name than “Hospitalism”name than “Hospitalism”

(Hospitalism(Hospitalism first coined in 1869 to describe first coined in 1869 to describe unhygienic conditions in old, overcrowded unhygienic conditions in old, overcrowded hospitals)hospitals)

““Hospital Medicine”?Hospital Medicine”? ““Hospitology”?Hospitology”? ““Hospiturgery”?Hospiturgery”? ““Overgrown interns”Overgrown interns”

What Defines a Specialty?What Defines a Specialty?

Physicians who self-identify and Physicians who self-identify and organize as a distinct grouporganize as a distinct group

Distinct scholarly activityDistinct scholarly activity Distinct body of knowledgeDistinct body of knowledge Demonstrable value in specializationDemonstrable value in specialization

Physicians Who Self-Identify and Physicians Who Self-Identify and Organize as a Distinct GroupOrganize as a Distinct Group

Growing number of pure hospitalist Growing number of pure hospitalist practicespractices

Society of Hospital MedicineSociety of Hospital Medicine National and regional hospitalist National and regional hospitalist

meetings that are rapidly increasing in meetings that are rapidly increasing in size, scope and sophisticationsize, scope and sophistication

Growing Number of Pure Growing Number of Pure Hospitalist PracticesHospitalist Practices Lawrence Wellikson, MD, SHM Hospitalist Productivity and Compensation Survey, 2002

20022002 20002000 19971997

Hospital ownedHospital owned 38%38% 33%33% 23%23%

Multispecialty groupMultispecialty group 17 %17 % 24%24% 35%35%

University facultyUniversity faculty 9%9% 10%10% 5%5%

Hospitalist onlyHospitalist only 19%19% 12%12% 12%12%

Insurance companyInsurance company 9%9% 10%10% 14%14%

Distinct Scholarly ActivityDistinct Scholarly Activity

National journal: “The Hospitalist”National journal: “The Hospitalist” Hospital medicine textbookHospital medicine textbook Fellowships in Hospital MedicineFellowships in Hospital Medicine Novel research in patient safety, quality, Novel research in patient safety, quality,

hospital systems and best practiceshospital systems and best practices

Distinct Body of Knowledge?Distinct Body of Knowledge?(Isn’t this what categorical Medicine residents have been learning for decades?)

New skills:New skills: QA/QIQA/QI OperationsOperations Systems improvementSystems improvement Team-based medicineTeam-based medicine

Established skills: Established skills: Medical consultationMedical consultation Palliative / end of life Palliative / end of life

carecare Medical ethicsMedical ethics Critical careCritical care Rehabilitation / sub-Rehabilitation / sub-

acute careacute care

PrecedentsPrecedents

Quasi-specialties:Quasi-specialties:Geriatric MedicineGeriatric MedicineGIMGIM

Site-specific specialties:Site-specific specialties:Critical CareCritical CareEmergency MedicineEmergency Medicine

Demonstrable Value?

Is medicine better due to the presence Is medicine better due to the presence of hospitalists?of hospitalists?

Controversies and Problems

Moving target phenomenonMoving target phenomenon IncomeIncome Hospitalists in the ICUHospitalists in the ICU Longevity and BurnoutLongevity and Burnout Impact on General Internal MedicineImpact on General Internal Medicine

Moving Target: As Hospitalists Make Everyone Else Better, They Make Themselves Look Worse

Hospitalists improve hospital quality, Hospitalists improve hospital quality, systems and efficiencies: This affects systems and efficiencies: This affects everyone who practiceseveryone who practices

The generalists who choose to remain The generalists who choose to remain in the hospital are usually the ones who in the hospital are usually the ones who are most motivated to do it wellare most motivated to do it well

Hospitalists Can’t Generate Their Own Incomes 80-85% of all hospitalist practices receive 80-85% of all hospitalist practices receive

financial supportfinancial support Poor reimbursement for cognitive specialtiesPoor reimbursement for cognitive specialties Adverse payer mixesAdverse payer mixes ““Unbillable” time spent coordinating careUnbillable” time spent coordinating care

ROI for hospitals that support hospitalists ROI for hospitals that support hospitalists groups is 3-5:1groups is 3-5:1

Hospitalists Don’t Belong in Hospitalists Don’t Belong in the ICUthe ICU When compared to generalists, intensivists When compared to generalists, intensivists

lower ICU mortalitylower ICU mortality Unfortunately, there aren’t enough of them:Unfortunately, there aren’t enough of them:

22% shortfall by 202022% shortfall by 2020 35% by 203035% by 2030

Not every ICU patient needs an intensivistNot every ICU patient needs an intensivist We need to decide how to share the burden of We need to decide how to share the burden of

caring for patients in the ICUcaring for patients in the ICU

Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease. Can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.

Longevity and Burnout

How many 55 year old cardiologists, How many 55 year old cardiologists, surgeons or intensivists do you regularly see surgeons or intensivists do you regularly see rounding in the hospital?rounding in the hospital?

Inpatient physicians tend to work weird hours, Inpatient physicians tend to work weird hours, weekends and holidaysweekends and holidays

Lack of control over dayLack of control over day Most specialists can shift to outpatient Most specialists can shift to outpatient

practices as they get older—hospitalists can’tpractices as they get older—hospitalists can’t

Longevity and Burnout

Recognize that this is a high-stress job and Recognize that this is a high-stress job and plan accordinglyplan accordingly

Limit workloadsLimit workloads Embrace shift work as a necessary Embrace shift work as a necessary

component and build systems to make it work component and build systems to make it work wellwell

Respect circadian rhythmsRespect circadian rhythms Emergency Medicine may provide a templateEmergency Medicine may provide a template

Hospitalists are Bad for GIM

Hospitalists are overwhelmingly Hospitalists are overwhelmingly generalistsgeneralists

Generalist (primary care) careers are Generalist (primary care) careers are losing appeallosing appeal

Hospital medicine is the only generalist Hospital medicine is the only generalist specialty that is growing (briskly!)specialty that is growing (briskly!)

Hospital medicine is breathing new life Hospital medicine is breathing new life into general medicineinto general medicine

Can We (Should We?) Train Internists to Become Expert in Both Inpatient and Outpatient Medicine in 3 Years?

One Potential Model

All Medicine residents train identically in PG-1 All Medicine residents train identically in PG-1 and PG-2 yearsand PG-2 years

PG-3: Either Inpatient or Outpatient Medicine PG-3: Either Inpatient or Outpatient Medicine / Primary Care track/ Primary Care track

If practice environment demands both skill If practice environment demands both skill sets, can take both tracks and do a four year sets, can take both tracks and do a four year residencyresidency

If subspecializing, can pick track most If subspecializing, can pick track most appropriate to the specialtyappropriate to the specialty

What Issues Have Hospitalists Been Asked to Tackle at UW?UWHCUWHC Improve integration of Improve integration of

care across disciplinescare across disciplines Fill voids left by a Fill voids left by a

contracting housestaff contracting housestaff programprogram

Improve resource Improve resource utilization and LOSutilization and LOS

More effective More effective deployment of deployment of specialistsspecialists

MeriterMeriter Unattached patients!!!Unattached patients!!! 24/7 & emergency 24/7 & emergency

coveragecoverage Referrals from outlying Referrals from outlying

areasareas Improve qualityImprove quality Support those PCPs Support those PCPs

who no longer want to who no longer want to do inpatient medicinedo inpatient medicine

The Future of Hospitalists at UW Internists are tightly woven into the fabric of inpatient Internists are tightly woven into the fabric of inpatient

health carehealth care Hospitalists bring a new level of service and Hospitalists bring a new level of service and

responsiveness to the medical staffresponsiveness to the medical staff Hospitalists drive progressive systemic improvements Hospitalists drive progressive systemic improvements

in efficiency, quality, safety and outcomesin efficiency, quality, safety and outcomes The hospital becomes a “living laboratory” for novel The hospital becomes a “living laboratory” for novel

healthcare outcomes researchhealthcare outcomes research Develop a unique educational curriculum Develop a unique educational curriculum

(fellowship?) in hospital medicine(fellowship?) in hospital medicine Become role models for housestaff and studentsBecome role models for housestaff and students