It’s been 21 years since Drs. Robert Wachter and Lee Goldman, in an article in the New England Journal of Medicine, first described a new delivery model called “hospitalists” – clinicians whose primary professional focus is the care of hospitalized patients. Since that time the healthcare system has seen rapid growth of hospitalist programs across a variety of specialties.
In the OB world, I have had the opportunity to observe the entire transition from both sides. In my opinion, the addition of a unit (OB emergency department, or OBED) where every patient presenting to labor and delivery for unscheduled care is seen by a provider capable of doing a medical screening exam and handling the worst emergency as a first responder is a critical supplement to patient safety.
It should also be acknowledged that changing the status quo can be disruptive. For better or worse, disruption breeds resistance. A well-known primary care physician recently criticized “hospital-based doctors who know nothing about the patients for whom they care” – which suggests that there is residual suspicion, or perhaps professional competition, regarding what hospitalists actually do. This opinion does not account for the fact that the two roles are different and complementary.
The unfortunate myth of hospitalists as interfering “stand-ins” degrades the role of these clinicians. It also does little to advance the potential for hospitalists and community physicians to partner on healthcare delivery. That relationship has to be respected and nurtured by the hospitalist for the model to work to enhance patient safety. Attention to patient safety issues such as SBAR (situation, background, assessment, recommendation) communication, good documentation, availability of medical records and provider to provider communication provide a safety net that enhances patient care across the spectrum of care.
After 34 years in a private community OB/GYN practice, I now work to provide local hospitals with hospitalist focused on the care of women in labor and delivery. It is a different job than our internal medicine or pediatric colleagues perform. Our hospitalist team evaluates and triages patients, acts as an emergency first responder on the labor and delivery, provides care to unassigned emergent obstetric and gynecologic patients, and supports the patients and practices of community OB/GYNs.
Far from being competitors, we are first responders who optimize the safety net by providing emergent care until the primary provider is in place and knows the story. Most OB/GYN providers still provide hospital care for their own patients. At other times, they check out their entire practice. The secret is respecting the doctor-patient relationship that attendants have with their patients and only serving when asked. When caring for a patient whose provider is not present at that hospital, we provide seamless care then pass the patient to their community physician or designee with appropriate communication to ensure continuity.
Because they are at the hospital 24/7, an OB hospitalist can relieve some of the pressure and urgency on a community provider. A private OB/GYN practice requires being available to deliver a baby or handle an obstetrical emergency at any point during the day or night, which hampers the ability to smoothly run a private practice and often leads to OB/GYN burnout, the rate of which is among the highest of all physician specialties. Having an OB hospitalist available to handle routine care and rapidly evolving emergencies lessens time out of office, away from practice and patients, and promotes a healthy life balance to increase the length of a professional practice. Hospitalists help optimize the community provider’s practice and life style.
When a hospital contracts with the right hospitalist team, the hospitalists can leverage best practice protocols with community physicians to ensure a rapid assessment and care in emergency situations, direct communication and a seamless transition of patient care. That can only benefit patients. In our experience, this model, with practices based on our large national database, has produced measureable improvements in care and safety, including significantly decreased rates of C-section and a 31 percent reduction in high severity incidents.
Finally, disparaging hospitalists minimizes their professional dedication and commitment to patient care. A few months ago, Hurricane Harvey slammed the U.S., causing catastrophic damage to the Gulf Coast. The hurricane also disrupted medical care for millions of Americans, including those who needed emergency care.
In those days before, during and after the hurricane, there were remarkable acts of courage among healthcare professionals serving individuals in need of care. Some physicians on my team of obstetric hospitalists worked three straight days in Labor and Delivery to cover for physicians who couldn’t physically get to the facility. Neither patients nor community clinicians drew a distinction between assigned physicians and hospitalist in this state of emergency when collaboration was the difference between life or death. So should it be in non-emergency times.
Last year, Dr. Wachter and Dr. Goldman revisited 20 years of hospitalist programs, noting that, “Today, hospital medicine is a respected field whose greatest legacies may be improvement of care and efficiency, injection of systems thinking into physician practice, and the vivid demonstration of our health care system’s capacity for massive change under the right conditions.” Healthcare stakeholders, including health systems, clinicians and patients, are best served when we are willing to disrupt the traditional model of care delivery and embrace improved evolutions that enhance organizations and outcomes. When OB hospitalist and community OBs communicate and collaborate, we can optimally achieve those most important goals.
Charles Jaynes is an obstetrical hospitalist and senior director of medical operations, Ob Hospitalist Group.
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