In a 1996 article in The New England Journal of Medicine, Robert M. Wachter, MD, and Lee Goldman, MD, predicted that the ascendance of managed care and its demands for efficiency would spur a “new breed” of physicians called “hospitalists,” who would transform the American health care landscape.
They were right. The hospitalist model quickly delivered high-value care by reducing costs and lengths of stay, and maintaining or improving care quality and patient satisfaction. By 2016, hospital medicine had become the third-largest medical specialty in the United States, with more than 50,000 hospitalists practicing at about 75% of hospitals.
Most hospitalists are generalists in internal medicine, pediatrics, obstetrics and gynecology. As inpatient medicine specialists, they function as primary care providers in the hospital setting by coordinating patient care from admission through discharge. Subspecialty hospitalists remain rare, especially those with full-time positions, but gastroenterologists increasingly are forging careers exclusively in inpatient care.
“This is a relatively new, distinct branch of gastroenterologists who are developing a niche that is expected to grow in the future given its attributes,” said Vivek Kaul, MD, FACG, AGAF, FASGE, a professor of medicine at the University of Rochester Medical Center, in New York.
Dr. Kaul and others, including GI hospitalist Michelle Hughes, MD, from Yale School of Medicine, in New Haven, Conn., argue that more awareness and incorporation of the hospital-based gastroenterology practice model would benefit health care systems, patients and the entire GI community.
“The GI hospitalist is an evolving role, but we’re basically specialists who live in the inpatient world and focus on acute GI care,” Dr. Hughes said in a recent interview. “As practices continue to get busier and patients become more comorbid, dedicated inpatient physicians are going to become more prevalent, and fellows should consider these positions or consider starting a program at a hospital, if they have the right personality type.”
Because the day-to-day practice in a hospital can be unpredictable, Dr. Hughes said the optimal candidates for a GI hospitalist career are creative, motivated and adaptable.
“On the inpatient side, you never know how many consults or urgent procedures will come up,” Dr. Hughes said. “Every day is different, so you should be the kind of a person who enjoys a dynamic work environment and be able to adapt quickly.”
Meeting the COVID-19 Challenge
GI Hospitalists have played a key role to their hospitals and health care systems throughout the pandemic, Dr. Hughes said. “Given our familiarity with inpatient care and continuous presence in the hospital, we were uniquely positioned to provide insight and guidance to ICUs, endoscopy units and hospital leadership to develop processes for things like urgent and emergent endoscopy for COVID positive and negative patients, peri-procedural COVID testing, workplace social distancing practices, development of electronic consultation services, and alternate staffing models including restructuring of GI consult teams,” she said. “From the very first days through surges and now shifts towards reopening, we have taken an active role to adapt to changing recommendations and adjust workflows so that we can continue to provide safe and effective care.”
In some of the hardest-hit areas like New York City, GI hospitalists were redeployed to work on medicine floors, while others continued to provide increased support by either in-person or electronic-based consults to inpatient providers less familiar with their new role, she added. “As we move forward, GI hospitalists will continue to be active members of the hospital community and play an essential role in shaping the practice of inpatient GI care locally and on a larger scale as we all establish a new normal following the COVID-19 pandemic,” she said.
Getting Comfortable With Discontinuity
A gastroenterologist who finds excitement in treating challenging and urgent cases—like GI bleeds, perforations and food impactions—may be the type of physician who would thrive in an inpatient setting, according to Edward Sun, MD, MBA, a GI hospitalist and the assistant chief medical officer at Stony Brook University Hospital, in New York. “As a GI hospitalist, you’re constantly challenged and seeing very exciting cases,” he said. “You’re treating urgent medical conditions and literally saving lives.”
An important trade-off of the hospitalist model, and a major point of criticism since it emerged, is what Drs. Wachter and Goldman called the “purposeful discontinuity of care” that results from the absence of longitudinal relationships between hospitalists and patients. Although handoff protocols and other post-discharge systems can help mitigate this discontinuity, a full-time GI hospitalist must be comfortable with this aspect of inpatient medicine, Dr. Hughes said.
“You don’t get those longitudinal relationships some physicians really enjoy, but the benefit is that when I’m done with work, I’m done,” she said. “I don’t have that inbox hangover to tackle on the weekends, or the extra strain of prior authorizations and returning patient phone calls. But it’s certainly a trade-off, because I don’t get to follow up on my patients when they get discharged.”
Some GI hospitalists do continue to provide outpatient care, as more conventional subspecialty hospitalist programs involve groups of attendings who rotate their time in the inpatient setting. However, having a full-time GI hospitalist take on the majority of inpatient care is becoming more the norm, according to Dr. Kaul.
“GI hospitalists can be part of a rotating group with an outpatient component as part of their practice, but increasingly we are seeing dedicated full-time, hospital-based GI providers who have minimal to no outpatient activity,” Dr. Kaul said.
Part of the reason this tide is turning, according to Dr. Sun, goes back to the rationale for the hospitalist: efficiency. A quality improvement project that Dr. Kaul performed as a fellow, for example, showed that the outpatient productivity of a group of 10 rotating GI attendings in a 600-bed tertiary care hospital fell following each inpatient GI rotation.
“Each attending would rotate, taking one week at a time for inpatient service,” Dr. Sun said. “I found that every time one of our attendings was on GI rotation service, there was a dip in the number of procedures scheduled and performed during the following one to two weeks when they returned to the outpatient office. At the same time, there was a backlog of patients needing procedures as the inpatient service took away from a practitioner’s outpatient procedure availability.”
The findings illustrate how demanding the inpatient GI rotation model can be on attendings, and how a dedicated GI hospitalist can in effect improve outpatient care, Dr. Sun said.
“Being on inpatient service makes it challenging for a GI attending to answer their outpatient calls and messages,” Dr. Sun said. “As a full-time GI hospitalist, I work every other week, and my role decreases the number of inpatient weeks for everyone else in our practice. This model increases the efficiency of the outpatient practice as a whole because the outpatient GIs can continue seeing patients, performing procedures, and being available for their outpatients with less of an interruption.”
Dr. Sun said he hopes that raising awareness and continuing to grow the field of GI hospitalists can foster a standard model, as has occurred with internal medicine hospitalists.
“Hopefully, we can start to shift the conversation to creating a definitive standard,” he said. “Internal medicine hospitalists typically work seven days on, seven days off, and are paid a salary with a bonus determined by meeting certain quality metrics. GI hospitalists are still being compensated by a relative value unit (RVU) model with bonuses influenced by net earnings when there is little control over case volume or payor mix on the inpatient service. It’s still a real blue ocean in terms of defining the role and the job description.”
Dr. Hughes agreed that a more standardized model would be a boon for the field. In the meantime, GI hospitalists often shape their own roles and programs from the ground up, so it’s important that they know how to navigate the system, she said.
“There are probably as many compensation models as there are GI hospitalists right now, so they have to know what they’re getting into,” Dr. Hughes said. “Being an inpatient hospitalist is a value added for your practice, whether it’s private or academic. But while these tend to be salary positions, it can vary depending on the volume of the hospital, and you may or may not benefit from an RVU bonus package in the same way that an outpatient physician would since the metrics are very different.”
For GI fellows considering a career in inpatient GI care, Dr. Kaul said the most desirable benefits lie in the multidisciplinary collaboration and leadership opportunities within the hospital system.
“Hospital-based practice generates expertise and confidence quickly because you’re dealing with very sick patients, so within a short period it affords the young GI a very significant jump-start on his or her experience, expertise and confidence levels,” Dr. Kaul said. “But more importantly, there are also teaching opportunities and important administrative roles available.”
For Dr. Sun, the hospitalist’s focus on quality improvement is key to its ongoing growth. “The GI hospitalist model is not only growing but will be critical to the success of any practice, because hospitalists can improve transition of care programs, and help integrate inpatient and outpatient practices so that discharged patients can benefit from more streamlined care and decreased hospital readmission rates,” he said. “There’s tremendous opportunity in the GI hospitalist model for the individual, their practice and their hospital system.”
—Adam Leitenberger