07/15/11 Portland, Ore.
They existed before they had a name. Their proliferation can be traced to many factors – hospital economics, increasingly complex patient care, lifestyle benefits – but may also be considered a natural progression in the field of medicine. Finally, in the mid-1990s, the group had a common moniker.
"Hospitalists" are general internists who take care of hospitalized patients and, in The New England Journal of Medicine article where the term was originally coined, are defined as "specialists in inpatient medicine," similar to primary care providers who manage the overall care of a group of patients in the ambulatory setting. In an academic health center like OHSU, the term encompasses a scope of work that touches not just the clinical mission, but the education, outreach and research missions as well.
The OHSU Division of Hospital Medicine branched off from the Division of General Internal Medicine and Geriatrics, and was established within the Department of Medicine in 2005, under the leadership of Alan J. Hunter, MD, FACP, Associate Professor, Department of Medicine. Dr. Hunter was working since 1995 as one of the "original" hospitalists at OHSU, along with Drs. Greg Magarian (1996), Sima Desai, Rebecca Harrison, Scott Sallay and Peter Sullivan, who were all instrumental in forming the Medicine Teaching Service (MTS) in 1998.
"With the coining of the term and the published economic benefits and the theoretical safety benefits, I think it just took off like wildfire," said Dr. Hunter, architect and founder of the program as well as the current Head, Division of Hospital Medicine. Dr. Hunter said the hospitalist model is now the norm in most urban hospital settings; the Society of Hospital Medicine estimates that the number of hospitalists in North America has grown in the last decade from just a few hundred to over 30,000 and anticipates there will be more than 40,000 in the next few years.
OHSU embraces national trend
The development of the hospitalist as a standard for inpatient care may have been inevitable. Although the care model surfaced during the era of managed care, it has persisted beyond that relatively short-lived (and contentious) period of American health care. Patient care has become increasingly complex, and the need for high quality care with consistent, positive outcomes has not lessened. Similar to intensivists in the ICU, the hospitalist provides the skill and experience wrought by working solely in the hospital setting, while facilitating efficiency and coordinating care transitions.
"[The Clinical Hospitalist Service] is going to grow in ways I can't even anticipate yet, but this program will be integral to the operation of all OHSU inpatient activities." - Alan Hunter, MD, Head, Division of Hospital Medicine
"It’s a terrific job if you give them a chance to build an academic career around it," said Lynn Loriaux, MD, Chair, Department of Medicine. This career-building focus informed the programmatic emphases within the Division of Hospital Medicine – namely, the MTS, Clinical Hospitalist Service (CHS) and Peri-Operative Medicine Clinic (PMC). OHSU hospitalists work closely with the Portland Veterans Affairs Medical Center (VAMC) Hospitalist Service, most of whom have joint appointments with the School of Medicine and, often, trained at OHSU before going to the VAMC.
Faculty members in the MTS program are integral to the education of medical students and training of house officers. Rebecca Harrison, MD, FACP, Associate Professor, Department of Medicine, is Section Chief of the University Section in the Division of Hospital Medicine. MTS hospitalists oversee patient care but are also "managers" of a care team, providing residents a certain degree of autonomy while giving feedback and serving as mentors to trainees.
The CHS program is newer, and growing. "There’s no doubt to me the growth and significance of the Clinical Hospitalist Service," said Dr. Hunter. "Their scope is going to grow in ways I can’t even anticipate yet, but this program will be integral to the operation of all OHSU inpatient activities." Faculty members in the CHS are the sole providers for their patients – often seriously ill patients whose care involves frequent communication with other specialty providers and a working knowledge of multiple disciplines. Their academic pursuits are ambitious – process improvement, quality initiatives, outcomes measurement – and have implications for the university as a whole.
The Division of Hospital Medicine assumed operation of OHSU’s peri-operative medicine program several years ago, with the development of the PMC, under the direction of Cornelia Taylor, MD, Assistant Professor, Department of Medicine. She, Avital O’Glasser, MD, Assistant Professor, Department of Medicine, and newcomer Katherine Kasik, MD, Instructor, Department of Medicine, provide pre-operative services and work closely with the Departments of Anesthesiology & Perioperative Medicine and Surgery.
A career in motion
The Division of Hospital Medicine leaders are interested in promoting a culture that fosters productive academic careers while being cognizant of the importance of a healthy work-life balance, not only to keep turnover low (hiring and departure is costly to the institution), but to position faculty members for leadership roles and maximize the division’s contributions to the community – both here and abroad. Scott Sallay, MD, Clinical Associate Professor, Department of Medicine, is known for his volunteerism at Wallace Medical Concern. Honora Englander, MD, Assistant Professor, Department of Medicine, is developing and leading quality improvement for underserved patients as they transition from hospital to home with the Care Transitions Innovation (C-TraIn) project. She also has an appointment at Central City Concern’s Old Town Clinic.
"It’s a career in motion," said Dr. Harrison. "We have a real opportunity to study the profession and its impact on patient care, education and research." The Division of Hospital Medicine is a leader in such self-study. Dr. Harrison, a founding member of the Society of General Internal Medicine Academic Hospitalist Task Force, contributed to a paper entitled "Satisfaction and Burnout in Academic Hospital Medicine," published in the April 2011 edition of Archives of Internal Medicine. In it, they explored career promotion, job satisfaction, stress and rates of burnout in academic hospital medicine in order to contribute to a relatively small body of literature about hospitalists. Drs. Hunter and Harrison explored mentoring and career development programs in academic hospital medicine groups in a survey published earlier this year in the Journal of Hospital Medicine. In 2004, Drs. Hunter, Desai and Harrison evaluated the impact of academic hospitalists on third-year medical students during inpatient medicine rotations with a study published in Academic Medicine.
The CHS program is expanding this year, adding two additional physicians and two nurse practitioners to its ranks.
A list of OHSU and VA Hospitalists is available on the Department of Medicine website; Heather Crowell heads up the administrative office for the Division. Below are highlights of the Division’s educational contributions:
- Sima Desai, MD, FACP, Associate Professor, Department of Medicine, is the new Director, Internal Medicine Residency Program
- Dr. Harrison is the fourth year Clerkship Director as well as the Director of the third and fourth year Internal Medicine Interest Group
- Stephanie Halvorson, MD, FACP, Assistant Professor, Department of Medicine, is the newest Associate Program Director for the Internal Medicine Residency Program
- Dr. Hunter has been an Associate Residency Program Director for 16 years
- Shalini Jacob, MD, MRCP, FACP, Assistant Professor, Department of Medicine, is the new Director of the Hospital Medicine Immersion CME Program
- Greg Magarian, MD, FACP, Professor, Department of Medicine, has been the third Year Clerkship Program Director for over 23 years
- Drs. O’Glasser and Taylor are site preceptors for residents and students in the peri-operative clinic
- Dr. Sallay is the Co-Course Director of the Principles of Clinical Medicine Course
- Peter Sullivan, MD, Assistant Professor, Department of Medicine, is the Course Director of the first and second year History of Medicine Elective and Director of a Physical Diagnosis elective
Pictured (from top): Dr. Sullivan attending a patient; Dr. Taylor at work