Inpatient specialty program helps UF College of Medicine provide better care

Since the late 1990s, a discipline called hospital medicine has taken the idea of health-care specialization in a new direction, focusing exclusively on the treatment of acutely ill, hospitalized patients. Studies show hospital medicine offers benefits to both patients and providers, and it’s finding a home at institutions across the country, including the University of Florida’s College of Medicine.

Hospital medicine programs can shorten patients’ hospital stays an average of almost 17 percent and reduce hospitals’ costs an average of 13 percent, according to a review published in the Jan. 23, 2002, issue of the Journal of the American Medical Association.

Physicians in the field are known as hospitalists, and they often work in tandem with nurses, physician assistants and other professionals who also specialize in the care of hospitalized patients, said Rebecca R. Pauly, M.D., chief of UF’s division of internal medicine and supervisor of a nine-person hospital medicine team based in the division that serves Shands at the University of Florida.

“Technology changes so quickly,” said Pauly, who also is an associate professor in UF’s department of medicine. “If someone is spending 80 percent of his or her time working in the outpatient clinic, that person is not going to be as up-to-date (as someone who works only with inpatients).”

For academic medical institutions such as UF’s College of Medicine, the use of hospital medicine teams has provided a way to cope with restrictions on the number of hours worked by residents and fellows, said Caridad Hernandez, M.D., a UF assistant professor of medicine and chief of the internal medicine division’s hospitalist section.

The section employs a team of five physicians, two nurse practitioners and two physician assistants that cares for about 40 percent of the general-medicine patients admitted to Shands at UF, Hernandez said. General medicine involves treatment of most conditions that do not require surgery.

“The number of patients that are cared for at Shands exceeds the number that can be taken care of by the number of house staff that we have in the department of medicine, and the role of the hospitalist service is to take care of that overflow,” said Hernandez, who has been a hospitalist for four years. “After the house staff gets a certain number of admissions at night, we get the rest.”

Each night, the hospital medicine team provides care for 60 to 80 Shands at UF patients who are otherwise treated by physicians who work during the day, Pauly said. The team also provides preoperative consultation for surgeons and admits specific patients such as post-operative kidney transplant patients and former pediatric cardiology patients who now are adults.

“We have a little bit of a different hospitalist practice here because we’re a tertiary referral hospital,” Pauly said. Shands at UF is the state’s major referral hospital and often treats patients with highly complex health-care issues.

Hospital medicine is the fastest-growing health-care specialty in America, with an estimated 7,000 to 8,000 practitioners working today, according to the Society of Hospital Medicine, the largest professional organization for hospitalists. The society was founded by a former medicine resident, John Nelson, M.D., currently an internist in Bellevue, Wash. The society, which has approximately 3,200 members, estimates that the number of U.S. hospitalists will reach 20,000 by the end of the decade.

Ninety-five percent of hospitalists have completed a categorical internal medicine residency, Pauly said. The remaining five percent have completed residencies in other disciplines such as family medicine, pediatrics or emergency medicine. Fellowship programs providing further training for hospitalists are beginning to arise throughout the country.

“If one anticipated becoming a hospitalist, he or she would take extra electives during the categorical internal medicine residency in areas such as critical care medicine and cardiology,” Pauly said.

The Shands at UF program has been well-received by the College of Medicine, Hernandez said. Approval and funding for the program were provided by UF College of Medicine Dean Craig Tisher, M.D., and Shands HealthCare Chief Executive Officer Timothy Goldfarb, M.H.A.

“Because this is sort of a new concept, I think people weren’t quite sure what to think of us at first,” Hernandez said. “As time has gone by, people have gotten to know us, I think the value of our role has come to be better appreciated.”

The current Shands at UF hospital medicine program originated about four years ago, with a single physician, Pauly said. Personnel were added gradually, and last fall the program reached what may be its ideal size, with the addition of a dedicated social worker and a patient care resource manager. These professionals arrange for follow-up care patients will need after discharge.

All members of the Shands at UF hospital medicine team typically work 12-hour shifts on a seven-day work week, followed by five to seven days off, said Dheeraj Kumar, M.D., one of the team’s hospitalists.

“Once you get used to the schedule, it’s great,” said Kumar, who worked as a hospitalist in Melbourne for almost a year before coming to UF in 2002. “We need a lot of energy to work those seven days and if you know at the end of those seven days you’ll have time off to relax and take it easy, you can work with that, because it’s a high-energy, high-pace work environment.”

Though the long shifts and emphasis on nighttime work may not appeal to everyone, the chance to make a difference in patients’ lives is a great attraction, said Matthew Obal, P.A.-C., a certified physician assistant who has been with the Shands at UF program since its inception.

“There are so many health-care diagnoses we see and we manage and it really keeps you on your toes,” Obal said. “It’s very rewarding when you get people over their acute illness and get them on to the next stage of care. They’re very thankful and it gives you a lot of positive feedback.”