What is a hospitalist?

Hospitalists are physicians who specialize in the practice of hospital medicine.

Following medical school, hospitalists typically undergo residency training in general internal medicine, general pediatrics or family practice.

Some hospitalists undergo additional post-residency training specifically focused on hospital medicine.

Hospitalists typically only see patients admitted to the hospital, leaving primary care physicians to focus on seeing patients in their clinics.

The use of hospitalists also facilitates quality-improvement and patient-safety efforts at a hospital, eliminating the need to train hundreds of community physicians on hospital protocols.

With widespread employment of hospitalists, most primary care physicians have given up their hospital-admitting privileges.

Doctors at Bend’s High Lakes Health Care will be unable to admit their patients to St. Charles Bend after Sept. 1, unless they can hammer out an agreement with the hospital in the coming weeks.

High Lakes had largely relied on Bend Memorial Clinic hospitalists — the doctors who take care of patients while they are in the hospital — to admit and care for their patients. But three BMC hospitalists will move to St. Charles this fall, leaving the clinic barely enough doctors to cover its own hospitalized patients.

“At that point, we will not have enough capacity to manage High Lakes patients,” BMC CEO Dr. David Holloway said. “That’s what precipitated the current crisis.”

If High Lakes and its management group, Adaugeo Healthcare Solutions, cannot make other arrangements with the hospital, the High Lakes patients would have to go to the emergency room to be admitted, likely increasing their costs and delaying their care.

Adaugeo officials declined to comment for the story but indicated they were working to resolve the issue for their patients.

Changing jobs

The game of musical chairs among Bend hospitalists began when St. Charles decided to add two new hospitalist positions to further its quality-improvement efforts, and had to replace two hospitalists who planned to retire.

Three BMC hospitalists applied for those jobs and were hired by the hospital to start Sept. 1. All three hospitalists informed BMC of their departure on the same day.

That will leave BMC with the equivalent of 4.5 full-time hospitalists, which is sufficient only to cover its own patients.

Representatives from BMC, High Lakes and St. Charles have been meeting to try to reach an arrangement that would allow St. Charles hospitalists to admit and care for High Lakes patients.

According to John Weinsheim, CEO of St. Charles Medical Group, the hospital signs hospitalist agreements with primary care physicians in the community, spelling out how the primary care physicians will be notified about their patients and how referrals will be made to specialists.

BMC and High Lakes opted against using St. Charles hospitalists initially, in part due to the competitive and often contentious relationship between the clinics and the hospital system. Many physicians were uncomfortable turning over their patients to St. Charles hospitalists, fearing the hospital-employed physicians would then steer those patients to specialists affiliated with the hospital system instead of those aligned with the clinics.

“Any time you have that situation, it’s going to take time to ensure that we are meeting any agreement we put in place,” Weinsheim said. “I can’t conceive of any other barrier. We don’t have any reason why we would say no to anybody.”

St. Charles employs 22 hospitalists as well as seven advance practice providers, such as physician assistants or nurse practitioners, who work variable hours depending on the demand for inpatient care. Holloway said BMC will soon add another hospitalist and, with time, may be able to expand its services to outside patients.

“That will be enough to cover (our patients) and maybe begin to cover High Lakes, but not immediately,” he said.

New trend

Hospitalists are a new specialty of physicians that has grown rapidly over the past two decades. Traditionally, primary care physicians had admitting privileges at local hospitals and often spent the first part of their day visiting their patients at the hospital before taking appointments in their clinic offices. But as pressures on primary care medicine began to mount and hospital medicine became increasingly complex, doctors were happy to turn over inpatient care to the newly emerging specialty.

That allows primary care physicians to see more patients in their offices and avoid having to keep patients waiting if they have to return to the hospital to deal with a patient crisis.

Hospitalists are primarily doctors trained in internal medicine, who work solely in the hospital, can keep up to speed with the rapidly changing hospital medicine world and oversee the transition of patients to follow-up care in the community.

St. Charles launched its hospitalist program in 2006, contracting with Sound Inpatient Physicians, to provide and manage 11 hospitalists in Bend. In 2011, St. Charles ended the contract with SIP and hired some of the SIP hospitalists directly.

BMC also hired some of the SIP physicians and preferred to maintain its own hospitalist program. With time, they expanded to cover High Lakes patients as well. High Lakes recently hired its own hospitalist who had been working as part of the BMC hospitalist group.

In some communities, hospitals work with primary care providers to develop a communitywide hospitalist program with preset rules on how doctors will be notified when their patients are admitted and how referrals to specialists after discharge are made.

That’s the model used for the pediatric hospitalist program in Bend, where Central Oregon Independent Physicians Association manages the program, with representatives from St. Charles, BMC and Central Oregon Pediatric Associates serving on the program’s board.

High Lakes officials have proposed a similar arrangement for the adult hospitalist program.

“I think what’s evolved here is the three organizations have never really sat down and decided what would be best for patients here,” Holloway said. “They can say, here’s what the ground rules are, here is how referrals work, get all that stuff out on the table.”

Weinsheim said the hospital and BMC have been able to meet the demand for hospitalist care so far. But as the population in Central Oregon grows, particularly with a large group of aging retirees, demands for inpatient care and hospitalists is expected to rise.

Holloway added, “We definitely need to bring in more to the community.”

—Reporter: 541-633-2162, mhawryluk@bendbulletin.com