By Dr. Carolyn Taylor-Olson
When I trained in internal medicine, the concept was that my profession was my vocation. An internist takes care of a patient from age 18 to his or her passing whether it’s an ingrown toenail or septic shock. You went the distance with the patient and their family.
Medical advances have helped us take care of certain conditions better and has created a new cohort of older patients taking a lot of medications and living a quality of life their organs could not have sustained twenty years ago. My daughter in-law is a fourth-year medical student and I can’t believe how much more she’s asked to know and learn than in my early days as a physician.
In 1988, Dr. Robert Wachter, a professor and associate chair of the department of medicine at the University of California, San Francisco published an article in the New England Journal of Medicine acknowledging this new patient group was creating a distinction between the care given an outpatient and the care that needed to happen for an acute medical problem. He proposed a separate specialty within internal medicine that focused only on acute medical care, and that it should be done by one person or a team of people. And so the discipline known as Hospitalist Medicine was born.
Hospitalist Medicine became the most popular specialty for internists from 1993 to 2003. Many mid-career physicians discovered they like the inpatient part because they have the time to spend with individual patients with less bureaucracy. Now our newly-minted internists typically choose whether to specialize as a Hospitalist or run a strictly outpatient practice.
When I agreed to chair the task force for developing a Hospitalist Program at Brattleboro Memorial Hospital, I was actually a non-believer. The concept of referring my care to someone else was just not a concept I could get my head around. Fortunately, one of our consultants was Dr. Winthrop Whitcomb from Baystate Medical Center in Springfield, Massachusetts. Dr. Whitcomb was a colleague of Dr. Wachter and helped establish the Society for Hospital Medicine in 1993. He had seen different models for Hospitalist programs in hospitals of all sizes across the country. Through discussions with Dr. Whitcomb and our interdisciplinary committee, I began to see the true benefit for the patient in having this kind of separation in their care.
A patient with an acute medical need probably comes to the emergency room first for evaluation by our very capable staff. When the decision is made that the patient requires a hospital stay, we are called in to write admission orders and, at the same time, communicate with the primary care physician if there is one.
There are patients who really want to see their primary doctor. On the other hand, they become very quickly converted to the fact that if they have a question, you’re right there. When we started the night program, I would say to patients “I’m Dr. Taylor-Olson. I’m here all night.” and they would visibly relax. Knowing the doctor who was admitting them was going to be there was a great comfort and reassurance. Should there be an acute status-change, you don’t have to call up a doctor and wait. There is a rapid response team. We’re also available to talk with the nurses and family members. Whether they have immediate questions or think of something two hours later, there’s a doctor here who can talk to them instead of trying to track down someone the next morning.
For primary care physicians who choose to participate in BMH’s Hospitalist program, their patient now has a team of doctors providing care. They may still come to the hospital to see the patient but they now have a schedule in their outpatient setting that’s reliable and predictable so they can see more patients.
The communication piece is really important. The Hospitalist staff at BMH consists of Dr. Christopher Meyer, Dr. David Albright, Dr. John Silkensen, Dr. Amy Gadowski and myself, with a sixth doctor currently contracted through an agency. Between us we have more than 150 years of experience. We do face-to-face reporting at the end of each shift and continue to work with Information Systems to develop better reporting tools. We recently built a web page that enables primary care physicians to monitor a patient’s progress through narrative reports. Our care managers call, fax or email the primary doctor to notify them when a patient is discharged and give them the follow-up plan, including meds. The patient is also given information for their next visit to the primary care physician as well as a final report.
The Hospitalist program is voluntary but most of the physicians in the area have embraced it and I think other specialties are finding it to their benefit. After my own initial skepticism, being a Hospitalist is professional bliss because I’ve come back to the part I loved the most, which is hearing the patient’s story, putting it into medical language and solving the medical mystery. I think my colleagues who have done outpatient service would agree. From a patient standpoint, the quality of the care and accessibility to both outpatient and inpatient doctors has increased tremendously.
Dr. Carolyn Taylor-Olson is a doctor of internal medicine and the medical director for the BMH 24/7 Hospitalist Service.