Written by: Stacy Goldsholl, MD – Executive VP, Chief Medical Officer
For those of us “dinosaurs” in hospital medicine, it is not uncommon to hear the term “back when we were hospitalists…” being exclaimed, sometimes with resonations of artificial bravado. Twenty years ago, hospital medicine was just learning how to walk, and graduate medical education had no work-hour restrictions.
In the Beginning
I can vividly (or perhaps through the fog) recall the six weeks of q2 critical care call as a second-year internal medicine resident in the intensive care unit (ICU). When I finished residency in 1995 at the University of North Carolina at Chapel Hill, I started my first job as an inpatient physician, a full year before the term “hospitalist” was coined in the New England Journal of Medicine by Dr. Bob Wachtner.
In those early days, the as-yet-to-be-labeled “Hospitalist” was frequently all things to all stakeholders. Is there an unassigned admission? That’s my job. Is there a denial of care that needs be negotiated with the payer? That’s also my job. Is there a Code Blue? Mine. Does the patient require ICU admission, ventilator management, line insertion, or a Swan floated? All of this was the job of the hospitalist.
In the late 90s, there were big questions surrounding the hospital medicine movement. Will patients accept someone other than their primary care physician (PCP) caring for them when they were at their sickest? Will the PCPs allow hospitalists to manage their patients? Will 24/7 hospital medicine programs, designed akin to its emergency medicine counterparts, ever be financially sustainable? Over and over the question of continued affordability of an in-house night physician was posed.
Fast forward twenty years and hospital medicine has quite literally transformed the delivery of inpatient care. Despite being subsidy driven, hospital medicine is now the standard of care in hospitals throughout the country. We now have Hospital Medicine Fellowships, an ABIM subspecialty board credential, and even a National Hospitalist Day!
Hospital Medicine & Critical Care
Just as hospital medicine evolved as its own specialty following emergency medicine, so has the rise of critical care medicine. Leap Frog, and other consumer driven external factors, have created the increasing need for dedicated critical care physicians.
Hospitalists were then, and with increasing frequency even now, shut out of the ICU. With the clinical shift away from ICU, and with new demand placed on inpatient utilization and throughput, the hospitalist’s clinical practice shifted. Increasingly, the hospitalist role has evolved away from critical care while being the champion of inpatient efficiency, quality, utilization, patient satisfaction, and throughput management.
The reality of COVID-19 and the crises of 2020 and 2021 brought increased recognition to de-evolution of the hospitalists’ practice of critical care in many facilities around the country. The drastic increase in inpatient acuity and volume, with its subsequent need for ventilator, inpatient Code Blue management, and procedures, has brought increased scrutiny to the critical care clinical gap. Needless to say, the current supply of critical care physicians is unable to fulfill the present need.
Over the course of the past year, an increasing number of hospitals have raised concern around hospitalist critical care competency. Many have voiced a desire for hospitalists to be up-tooled for Code Blue management (perhaps where the EM physicians have traditionally facilitated), inpatient intubations and expanded competency in critical care procedures. The COVID world has now not only demanded a return of hospitalist competency in some practices of critical care, but also continued the laser focus on inpatient throughput management.
Additionally, there has been the concurrent exodus of other physicians from the hospital as a result of COVID. Today with increasing frequency, the hospitalist is being asked to expand their role into the inpatient rehab unit, behavioral health, SNF management, as well as serve as primary attending for subspecialist patients, including obstetrics.
Growth and increased demand are good problems to have, but what is the solution?
What if there was a way for hospitalists (and EM physicians for that matter) to have a tele-intensivist “in their pocket” every day? This is not a total solution for all proceduralist demand, but for non-procedural management – such as ventilator management, IV drips, etc., this would provide instantaneous critical care expertise at the push of a button.
Where patient volume does not support an in-house intensivist solution, a hospitalist could potentially be a virtual consult away from their critical care colleagues. Hospitals would therefore be able to retain more patients currently lost to external transfers and hospitalists would be able to expand their critical care reach. For the patient and family, it keeps them closer to home.
No doubt, as hospital medicine has evolved (or de-evolved) from critical care, technology and innovation can make what was once old, new.