Barbara Dillard

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is almost universal agreement that conducting multidisciplinary rounds is a good idea. It’s putting them into practice that has some hospitalists scratching their heads and wondering if the payoff is worth the effort.

Multidisciplinary rounds, in a perfect world, would bring together all care providers every morning to discuss each patient’s condition and the occurrences of the past 24 hours while collaboratively planning for the day ahead. Physicians, nurses, case managers, social workers, respiratory, physical and occupational therapists, pharmacists, and the patient’s family would join in face-to-face communication and share decision-making.

In practice, many hospitals are redefining the term by bringing together only a core group of caregivers or rounding on a selected group of patients each day. Even this seems more likely to happen in hospitals that geographically segregate patients by condition, level of care, or attending physician.

“The term, multidisciplinary rounds, is vague and can even be used to refer to any two types of caregivers talking to each other on a regular basis, which almost all hospitalists regularly do,” says John Nelson, MD, medical director of the hospitalist group at Overlake Hospital Medical Center in Bellevue, Wash., and a consultant to hospitalist practices across the country. “But there are few places that bring together a larger group.”

Real-World Examples

At the minimum, multidisciplinary rounds should include physicians, bedside nurses and case managers, and ideally, everyone involved in a patient’s care, says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. Dr. Li, also a member of SHM’s Board of Directors, has been doing multidisciplinary rounds on his teaching service for more than seven years and on his non-teaching service for almost three years. “I am a huge advocate of multidisciplinary rounds, and I think that all hospitalists should do them,” Dr. Li says. “They are not an option for me because they are one of the ways hospitalists can improve patient care.”

Dr. Li’s rounds are done early in the day on weekdays, with hospitalists, nurses, and case managers always involved and other providers when they are available. His team discusses all patients on a 40-bed unit in a little more than half an hour by sticking to a clearly defined script with a checklist he developed. Bedside nurses attend only for the time it takes to discuss their patients. Each floor schedules rounds at different times in the morning so physicians can attend multiple rounds if they have patients on different floors. Dr. Li says the rounds are “a work in progress” because they are continually refined.

At the University of Colorado Hospital in Denver, multidisciplinary rounds are done within the acute care for the elderly service. They are conducted weekdays by all providers caring for patients on the service. This includes four physicians, four nurses plus a charge nurse, case manager, pharmacist, and physical or occupational therapist, with the addition of a pet therapist once a week. A typical meeting covers five to six patients and lasts about 15 minutes, according to Ethan Cumbler, MD, director of the service.

Dr. Cumbler calls the current incarnation of multidisciplinary rounds “2.0.” The previous version didn’t work because elderly patients were spread throughout the hospital. “We scrapped that version and worked on getting most of our patients assigned to the same floor and began again with more success.”

Scheduling staff seems to be the biggest stumbling block for hospitalists who would like to do multidisciplinary rounds but have given up. “Although our intensive care unit does multidisciplinary rounds, we can’t find a way to make it work on our medical floors,” says Matthew Szvetecz, MD, CPE, division of internal medicine director, Kadlec Medical Associates, Richland, Wash. “When you have five geographic units, four rounding physicians, and many nurses and ancillary service providers, you’ve added more levels of scheduling complexity. Try as we might, even in our relatively small hospital, we can’t figure out how to make it work.”

Tricky Logistics

Committing so much of a providers’ time to meetings makes Dr. Nelson skeptical of whether multidisciplinary rounds are worth the effort. “If you have 20 people sitting around in a room for an hour, you’re losing 20 hours of healthcare time. You could take those people and redirect their efforts and get a better result, I suspect,” he says.

Yet, Dr. Nelson agrees multidisciplinary rounds are a good idea and says they have tried to do them at Overlake Hospital. “We’ve done it in fits and starts, but we really don’t have a meaningful model.”

Dr. Li notes that multidisciplinary rounds can be a time-saver, not a time waster. “I view rounds as an investment, and as with any wise investment, it pays off in time savings,” he says. If rounds are effective, hospitalists don’t get as many pages, nor are nurses interrupted by physicians afterward. “Everyone leaves knowing the care plan and is ready to carry it out,” he concludes.

Dr. Nelson believes adapting rounds for patients with common issues may be more effective—for example, rounds on patients age 70 and older with the goal of reducing falls. “Set up multidisciplinary rounds to address the things you know improve care that may be missed during regular caregiver rounds,” he suggests.

Although Dr. Szvetecz believes “nothing is a substitute for face-to-face communication,” he is working on a technological “rounding” system he hopes will come close. He envisions an interactive digital document containing a communication checklist that could be accessed by all caregivers. Information that would have been discussed at multidisciplinary rounds would be entered into the database and each morning caregivers would take action on the items.

“You might still be losing 25% to 50% of the information transfer in face-to-face communication, but if it’s not feasible to do multidisciplinary rounds, this might be the next best thing,” he suggests.

Advocates note that studies have credited multidisciplinary rounds with improving patient care, reducing length of stay, minimizing unneeded services, reducing bounce-back rates, and preventing gaps and delays in care. Some hospitals report that multidisciplinary rounds are a key to developing a culture of collaboration and improvement.

For those considering implementing them, Dr. Cumbler says it’s important to have champions who embrace cultural change and value communication. “People in hospitals aren’t rewarded for communication, so sometimes it’s hard getting everyone to agree to give it a try.”

After his pilot program, nurses reported they were more satisfied with their jobs and saw patient care improve in a direct and immediate way. The hospital awarded a quality improvement grant to track their effect on outcomes such as reduced falls, restraint use, and length of stay. Dr. Cumbler hopes the results will encourage the hospital to implement multidisciplinary rounds hospitalwide.

Dr. Nelson says measurement is critical: “Start with a goal in mind, then go back and measure to make sure multidisciplinary rounds are moving the quality needle on those things.”

Dr. Li says people give up on multidisciplinary rounds when team members fail to show up on time, stray off the topic at hand, and are unprepared to speak. At first, rounds can be too physician-centered, discouraging others to participate.

Dr. Cumbler solves this problem by putting his hand on the shoulder of the presenting physician if he talks for more than 40 seconds. Dr. Li recommends doing rounds standing to encourage people to be quick and to the point.

Dr. Li says caregivers learn to be more effective if they are given a script and encouraged to role play. “We have a checklist of what we need to talk about for each patient,” he says. “It’s like a play. The best way to learn your part is to practice and have a script.” He points out that as staff members change, new ones have to be taught. “It’s always a work in progress,” he notes.

Dr. Li also has found bedside nurses are critical for effective multidisciplinary rounds. “There’s no way a charge nurse can bring the same information as a bedside nurse,” he asserts.

Advocates go on to say that multidisciplinary rounds are the future of hospital medical care because they reflect attitude changes toward more cooperation and teamwork. “Physicians writing orders in isolation breaks down in the light of how sick hospitalized patients are and how complex their treatment has become,” Dr. Cumbler points out.

Perhaps the best argument for multidisciplinary rounds comes with experience. “Once you pilot it, support builds and everyone sees patient care improving,” Dr. Cumbler says. “Then they become self-sustaining.” TH

Barbara Dillard is a medical journalist based in Chicago.

Hospital medicine often is regarded as a young person’s field. Because the specialty is so new, most hospitalists are young, bright-eyed, energetic, and seemingly invincible. But how will they feel after they have logged thousands of miles down hospital corridors, eaten hundreds of late-night fast-food dinners, and spent countless hours worrying about their patients?

How this generation of hospitalists takes care of itself may determine if the practice can be a healthy, sustaining career throughout a lifetime.

Michael Ruhlen, MD, MHCM, FAAP, who spent 18 years as a hospitalist before his declining health forced him into an administrative position, hopes young hospitalists don’t end up with the health problems he has experienced. Dr. Ruhlen, vice president of medical affairs at Toledo Children’s Hospital in Ohio, offers a cautionary tale illustrating the need for physicians to take care of themselves so they can have a long and fulfilling career in their chosen specialty.

A self-proclaimed stress eater, Dr. Ruhlen gradually gained weight over the years, mainly because of late dinners grabbed at fast-food restaurants—the only ones open when he finished night duties. The caffeine he consumed to keep up with his demanding schedule increased his blood pressure so much that he ended up in the cardiac cath lab with chest pains. The extra weight and miles of hospital halls he walked put additional stress on his joints, aggravated his arthritis, and led to sleep apnea.

“When you are young it’s easy to burn off the extra calories from stress eating,” he says. “But as you age, you find it harder and harder to keep your weight stable, especially when your cholesterol starts going up. Your joints get sore when you walk the halls for 24 hours straight, and shift work can produce sleep apnea and other stress-related sleep problems. Sleep apnea leads to hypertension. I pushed myself for the benefit of my practice and my patients. As an older hospitalist looking back, I can say that I didn’t stop enough to smell the roses.”

Stigma Persists

Dr. Ruhlen is courageous to openly discuss his health problems. An international study by the British Medical Association in 2007 found many doctors who are sick do not seek help because of the stigma of ill health or because of peer pressure. “This stigma attached to ill health reinforces the perception that ill health is akin to inadequate performance and unacceptable conduct,” according to the report. These beliefs lead many physicians to work through illness and self-treat.

Another danger as hospitalists take on more and more patient care and co-management is overwork. A case in point is the harrowing story from one hospitalist who shared his insights on condition of anonymity.

“I suffered from a multiyear bout of workaholism,” he says. “I used to laugh about it when initially diagnosed thinking, ‘How could this be a bad thing?’ As time went by I realized it follows the same stages of nearly every other addiction—and the consequences can be just as devastating. I lost 90% of my friends. At one point I was within days of losing my wife and family. My overall work performance significantly worsened despite increasing time devoted to work. My patient satisfaction scores dropped.”

The load also took a physical toll.

“My personal health deteriorated as I stopped making time for the gym and moved from a healthy diet to a quick-carb/junk-food diet. Work became my drug, and like all drug abusers—I suffered a great deal. During my second year as a hospitalist I developed hyperthyroidism. I’m embarrassed to admit how far it progressed before I made the diagnosis.”

Initially, the symptoms are positive ones, this hospitalist notes.

“I could get by on less sleep, always had bundles of energy, could dictate three times faster than anyone around me, and could eat anything and everything in sight and still lose weight,” he recalls. “My daily hospital rounds that typically take eight to 10 hours were often completed in four to six hours. Then came the sweating … followed by the tremors, which is not very conducive to performing delicate procedures such as inserting central venous catheters. The palpitations and eventual chest pains came next and prompted me to seek care.”

This hospitalist has since found a healthy balance—but it took hard work.

“Once I accepted that I had a work addiction, I began setting boundaries and had my wife remind me (which she needed to do often at first) when I was pushing the bounds,” he explains. “Over time I was able to resume a more balanced life.”

Having overcome his work addiction, he finds the signs easy to spot among his peers.

“Workaholics (unless you work under them) often look like super heroes,” he notes. “They say yes to every assignment. They always put 120% in. They are often the go-to person. On the rare occasion I do identify it in a colleague, I’ll let them know. I’ll tell them what it did to me and my family. Sometimes they listen—usually they’re too busy working to listen.”

A Hard Life

While hospitalists experience the same unhealthy stresses as other physicians, they may face unique demands caused by their chosen specialty.

“Hospitalists are at the forefront of an evolving new specialty,” Dr. Ruhlen says. “In order to create satisfaction with the specialty and help it evolve, you’re willing to extend yourself above and beyond what others in different fields might be doing. So you take the extra shifts when you don’t quite have enough people in your group. You get up early and go to meetings to promote your practice within the hospital. And maybe you stay up later at night than you ordinarily would have because you want to make sure you absolutely provide the best care.”

All this, of course, takes a toll at home.

“You slight personal relationships and outside interests, which adds to the stress in your life,” Dr. Ruhlen says. “Every time you miss a birthday party or a family activity you’re digging yourself deeper into an unsatisfying family life and giving up things that help you to relax and be healthy.”

Hospitalists also have more to juggle these days because they need to know a lot about both human beings and machines, says Richard Gunderman, MD, PhD, MPH, who speaks internationally on doctors’ health and its role in sustaining a medical career. Dr. Gunderman is associate professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy at Indiana University Medical School in Indianapolis.

He is passionate about the need for physicians to take care of themselves because “we spend so much time focused on the needs of our patients that we often don’t pay attention to our own health. We spend millions of dollars on the latest equipment but we spend almost no time thinking about our most important resource—our people.”

Another contributor to ill health among hospitalists is exposure to more infections and serious illnesses in the hospital setting. “At the same time they are asked to take care of the sickest people, which puts them under more stress,” Dr. Gunderman observes. “We have new information on the role high levels of stress hormones (catecholamines) play in metabolism and the breaking down and tearing of muscle tissue which can make hospitalists more prone to injuries.”

Dr. Gunderman believes getting to know patients is one of the most fulfilling aspects of being a physician and a stress reliever. Hospitalists may miss out on developing long-term relationships with their patients because of the nature of their jobs, he points out. They also are pressured by financial concerns to minimize the time patients spend in the hospital, which does not promote developing relationships with patients.

As for Dr. Ruhlen, he struggles to follow his own advice. He doesn’t stay up all night anymore. He’s trying to get back into a regular exercise routine and eat healthier. He has a strong relationship with his wife, which keeps him grounded. He also enjoys golfing, spends time with his granddaughter, has taken up photography, and is traveling a little.

Although he still works many hours at the hospital, he is convinced that making time to take care of himself is the answer to a long, healthy career. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospital medicine often is regarded as a young person’s field. Because the specialty is so new, most hospitalists are young, bright-eyed, energetic, and seemingly invincible. But how will they feel after they have logged thousands of miles down hospital corridors, eaten hundreds of late-night fast-food dinners, and spent countless hours worrying about their patients?

How this generation of hospitalists takes care of itself may determine if the practice can be a healthy, sustaining career throughout a lifetime.

Michael Ruhlen, MD, MHCM, FAAP, who spent 18 years as a hospitalist before his declining health forced him into an administrative position, hopes young hospitalists don’t end up with the health problems he has experienced. Dr. Ruhlen, vice president of medical affairs at Toledo Children’s Hospital in Ohio, offers a cautionary tale illustrating the need for physicians to take care of themselves so they can have a long and fulfilling career in their chosen specialty.

A self-proclaimed stress eater, Dr. Ruhlen gradually gained weight over the years, mainly because of late dinners grabbed at fast-food restaurants—the only ones open when he finished night duties. The caffeine he consumed to keep up with his demanding schedule increased his blood pressure so much that he ended up in the cardiac cath lab with chest pains. The extra weight and miles of hospital halls he walked put additional stress on his joints, aggravated his arthritis, and led to sleep apnea.

“When you are young it’s easy to burn off the extra calories from stress eating,” he says. “But as you age, you find it harder and harder to keep your weight stable, especially when your cholesterol starts going up. Your joints get sore when you walk the halls for 24 hours straight, and shift work can produce sleep apnea and other stress-related sleep problems. Sleep apnea leads to hypertension. I pushed myself for the benefit of my practice and my patients. As an older hospitalist looking back, I can say that I didn’t stop enough to smell the roses.”

Stigma Persists

Dr. Ruhlen is courageous to openly discuss his health problems. An international study by the British Medical Association in 2007 found many doctors who are sick do not seek help because of the stigma of ill health or because of peer pressure. “This stigma attached to ill health reinforces the perception that ill health is akin to inadequate performance and unacceptable conduct,” according to the report. These beliefs lead many physicians to work through illness and self-treat.

Another danger as hospitalists take on more and more patient care and co-management is overwork. A case in point is the harrowing story from one hospitalist who shared his insights on condition of anonymity.

“I suffered from a multiyear bout of workaholism,” he says. “I used to laugh about it when initially diagnosed thinking, ‘How could this be a bad thing?’ As time went by I realized it follows the same stages of nearly every other addiction—and the consequences can be just as devastating. I lost 90% of my friends. At one point I was within days of losing my wife and family. My overall work performance significantly worsened despite increasing time devoted to work. My patient satisfaction scores dropped.”

The load also took a physical toll.

“My personal health deteriorated as I stopped making time for the gym and moved from a healthy diet to a quick-carb/junk-food diet. Work became my drug, and like all drug abusers—I suffered a great deal. During my second year as a hospitalist I developed hyperthyroidism. I’m embarrassed to admit how far it progressed before I made the diagnosis.”

Initially, the symptoms are positive ones, this hospitalist notes.

“I could get by on less sleep, always had bundles of energy, could dictate three times faster than anyone around me, and could eat anything and everything in sight and still lose weight,” he recalls. “My daily hospital rounds that typically take eight to 10 hours were often completed in four to six hours. Then came the sweating … followed by the tremors, which is not very conducive to performing delicate procedures such as inserting central venous catheters. The palpitations and eventual chest pains came next and prompted me to seek care.”

This hospitalist has since found a healthy balance—but it took hard work.

“Once I accepted that I had a work addiction, I began setting boundaries and had my wife remind me (which she needed to do often at first) when I was pushing the bounds,” he explains. “Over time I was able to resume a more balanced life.”

Having overcome his work addiction, he finds the signs easy to spot among his peers.

“Workaholics (unless you work under them) often look like super heroes,” he notes. “They say yes to every assignment. They always put 120% in. They are often the go-to person. On the rare occasion I do identify it in a colleague, I’ll let them know. I’ll tell them what it did to me and my family. Sometimes they listen—usually they’re too busy working to listen.”

A Hard Life

While hospitalists experience the same unhealthy stresses as other physicians, they may face unique demands caused by their chosen specialty.

“Hospitalists are at the forefront of an evolving new specialty,” Dr. Ruhlen says. “In order to create satisfaction with the specialty and help it evolve, you’re willing to extend yourself above and beyond what others in different fields might be doing. So you take the extra shifts when you don’t quite have enough people in your group. You get up early and go to meetings to promote your practice within the hospital. And maybe you stay up later at night than you ordinarily would have because you want to make sure you absolutely provide the best care.”

All this, of course, takes a toll at home.

“You slight personal relationships and outside interests, which adds to the stress in your life,” Dr. Ruhlen says. “Every time you miss a birthday party or a family activity you’re digging yourself deeper into an unsatisfying family life and giving up things that help you to relax and be healthy.”

Hospitalists also have more to juggle these days because they need to know a lot about both human beings and machines, says Richard Gunderman, MD, PhD, MPH, who speaks internationally on doctors’ health and its role in sustaining a medical career. Dr. Gunderman is associate professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy at Indiana University Medical School in Indianapolis.

He is passionate about the need for physicians to take care of themselves because “we spend so much time focused on the needs of our patients that we often don’t pay attention to our own health. We spend millions of dollars on the latest equipment but we spend almost no time thinking about our most important resource—our people.”

Another contributor to ill health among hospitalists is exposure to more infections and serious illnesses in the hospital setting. “At the same time they are asked to take care of the sickest people, which puts them under more stress,” Dr. Gunderman observes. “We have new information on the role high levels of stress hormones (catecholamines) play in metabolism and the breaking down and tearing of muscle tissue which can make hospitalists more prone to injuries.”

Dr. Gunderman believes getting to know patients is one of the most fulfilling aspects of being a physician and a stress reliever. Hospitalists may miss out on developing long-term relationships with their patients because of the nature of their jobs, he points out. They also are pressured by financial concerns to minimize the time patients spend in the hospital, which does not promote developing relationships with patients.

As for Dr. Ruhlen, he struggles to follow his own advice. He doesn’t stay up all night anymore. He’s trying to get back into a regular exercise routine and eat healthier. He has a strong relationship with his wife, which keeps him grounded. He also enjoys golfing, spends time with his granddaughter, has taken up photography, and is traveling a little.

Although he still works many hours at the hospital, he is convinced that making time to take care of himself is the answer to a long, healthy career. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospital medicine often is regarded as a young person’s field. Because the specialty is so new, most hospitalists are young, bright-eyed, energetic, and seemingly invincible. But how will they feel after they have logged thousands of miles down hospital corridors, eaten hundreds of late-night fast-food dinners, and spent countless hours worrying about their patients?

How this generation of hospitalists takes care of itself may determine if the practice can be a healthy, sustaining career throughout a lifetime.

Michael Ruhlen, MD, MHCM, FAAP, who spent 18 years as a hospitalist before his declining health forced him into an administrative position, hopes young hospitalists don’t end up with the health problems he has experienced. Dr. Ruhlen, vice president of medical affairs at Toledo Children’s Hospital in Ohio, offers a cautionary tale illustrating the need for physicians to take care of themselves so they can have a long and fulfilling career in their chosen specialty.

A self-proclaimed stress eater, Dr. Ruhlen gradually gained weight over the years, mainly because of late dinners grabbed at fast-food restaurants—the only ones open when he finished night duties. The caffeine he consumed to keep up with his demanding schedule increased his blood pressure so much that he ended up in the cardiac cath lab with chest pains. The extra weight and miles of hospital halls he walked put additional stress on his joints, aggravated his arthritis, and led to sleep apnea.

“When you are young it’s easy to burn off the extra calories from stress eating,” he says. “But as you age, you find it harder and harder to keep your weight stable, especially when your cholesterol starts going up. Your joints get sore when you walk the halls for 24 hours straight, and shift work can produce sleep apnea and other stress-related sleep problems. Sleep apnea leads to hypertension. I pushed myself for the benefit of my practice and my patients. As an older hospitalist looking back, I can say that I didn’t stop enough to smell the roses.”

Stigma Persists

Dr. Ruhlen is courageous to openly discuss his health problems. An international study by the British Medical Association in 2007 found many doctors who are sick do not seek help because of the stigma of ill health or because of peer pressure. “This stigma attached to ill health reinforces the perception that ill health is akin to inadequate performance and unacceptable conduct,” according to the report. These beliefs lead many physicians to work through illness and self-treat.

Another danger as hospitalists take on more and more patient care and co-management is overwork. A case in point is the harrowing story from one hospitalist who shared his insights on condition of anonymity.

“I suffered from a multiyear bout of workaholism,” he says. “I used to laugh about it when initially diagnosed thinking, ‘How could this be a bad thing?’ As time went by I realized it follows the same stages of nearly every other addiction—and the consequences can be just as devastating. I lost 90% of my friends. At one point I was within days of losing my wife and family. My overall work performance significantly worsened despite increasing time devoted to work. My patient satisfaction scores dropped.”

The load also took a physical toll.

“My personal health deteriorated as I stopped making time for the gym and moved from a healthy diet to a quick-carb/junk-food diet. Work became my drug, and like all drug abusers—I suffered a great deal. During my second year as a hospitalist I developed hyperthyroidism. I’m embarrassed to admit how far it progressed before I made the diagnosis.”

Initially, the symptoms are positive ones, this hospitalist notes.

“I could get by on less sleep, always had bundles of energy, could dictate three times faster than anyone around me, and could eat anything and everything in sight and still lose weight,” he recalls. “My daily hospital rounds that typically take eight to 10 hours were often completed in four to six hours. Then came the sweating … followed by the tremors, which is not very conducive to performing delicate procedures such as inserting central venous catheters. The palpitations and eventual chest pains came next and prompted me to seek care.”

This hospitalist has since found a healthy balance—but it took hard work.

“Once I accepted that I had a work addiction, I began setting boundaries and had my wife remind me (which she needed to do often at first) when I was pushing the bounds,” he explains. “Over time I was able to resume a more balanced life.”

Having overcome his work addiction, he finds the signs easy to spot among his peers.

“Workaholics (unless you work under them) often look like super heroes,” he notes. “They say yes to every assignment. They always put 120% in. They are often the go-to person. On the rare occasion I do identify it in a colleague, I’ll let them know. I’ll tell them what it did to me and my family. Sometimes they listen—usually they’re too busy working to listen.”

A Hard Life

While hospitalists experience the same unhealthy stresses as other physicians, they may face unique demands caused by their chosen specialty.

“Hospitalists are at the forefront of an evolving new specialty,” Dr. Ruhlen says. “In order to create satisfaction with the specialty and help it evolve, you’re willing to extend yourself above and beyond what others in different fields might be doing. So you take the extra shifts when you don’t quite have enough people in your group. You get up early and go to meetings to promote your practice within the hospital. And maybe you stay up later at night than you ordinarily would have because you want to make sure you absolutely provide the best care.”

All this, of course, takes a toll at home.

“You slight personal relationships and outside interests, which adds to the stress in your life,” Dr. Ruhlen says. “Every time you miss a birthday party or a family activity you’re digging yourself deeper into an unsatisfying family life and giving up things that help you to relax and be healthy.”

Hospitalists also have more to juggle these days because they need to know a lot about both human beings and machines, says Richard Gunderman, MD, PhD, MPH, who speaks internationally on doctors’ health and its role in sustaining a medical career. Dr. Gunderman is associate professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy at Indiana University Medical School in Indianapolis.

He is passionate about the need for physicians to take care of themselves because “we spend so much time focused on the needs of our patients that we often don’t pay attention to our own health. We spend millions of dollars on the latest equipment but we spend almost no time thinking about our most important resource—our people.”

Another contributor to ill health among hospitalists is exposure to more infections and serious illnesses in the hospital setting. “At the same time they are asked to take care of the sickest people, which puts them under more stress,” Dr. Gunderman observes. “We have new information on the role high levels of stress hormones (catecholamines) play in metabolism and the breaking down and tearing of muscle tissue which can make hospitalists more prone to injuries.”

Dr. Gunderman believes getting to know patients is one of the most fulfilling aspects of being a physician and a stress reliever. Hospitalists may miss out on developing long-term relationships with their patients because of the nature of their jobs, he points out. They also are pressured by financial concerns to minimize the time patients spend in the hospital, which does not promote developing relationships with patients.

As for Dr. Ruhlen, he struggles to follow his own advice. He doesn’t stay up all night anymore. He’s trying to get back into a regular exercise routine and eat healthier. He has a strong relationship with his wife, which keeps him grounded. He also enjoys golfing, spends time with his granddaughter, has taken up photography, and is traveling a little.

Although he still works many hours at the hospital, he is convinced that making time to take care of himself is the answer to a long, healthy career. TH

Barbara Dillard is a medical journalist based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

There is an increasing debate in major academic medical centers across the county on where hospitalists fit in the organizational structure—and consequently what resources, prestige, and power they will have.

The movement of academic hospitalists toward autonomy may be inevitable. Community hospitalists are less affected by the separation issue, most agree, because a community hospital may have fewer hospitalists who relish remaining in general internal medicine divisions. Conversely, they may have their own division because they are not driven by research or teaching. Either structure seems to work well in a community setting.

Even those who want academic hospitalists to remain firmly ensconced in divisions of general internal medicine realize it may be a losing battle as hospitalist groups increase in size, depth, and importance. So they caution: “Not so fast.”

Hospitalists would be better off remaining in divisions of general internal medicine and “learning from the mistakes we’ve made over the last 25 years,” says Bob Centor, MD, professor and director of the division of general internal medicine at the University of Alabama at Birmingham and associate dean for the Huntsville Regional Medical campus.

While Dr. Centor acknowledges it’s not always wrong to have a separate division, he believes leadership in general medicine divisions can help hospitalists succeed in their careers and negotiate academic politics to better advance their interests.

Early Stirrings

The independence movement began about two years ago when some academic hospitalists formed separate divisions, frustrated by chairs of general internal medicine “who just didn’t get it,” says Dr. Centor.

Others have found support from division chiefs who worked to develop academic hospitalists and encouraged them to go out on their own.

Academic hospitalists at the University of California, San Francisco’s (UCSF) school of medicine became a separate division two years ago. The move was encouraged by its division of general internal medicine chief, according to Bob Wachter, MD, hospitalist division chief at UCSF who coined the term hospitalist. “After 10 years of growth, we had 38 academic hospitalists, 10 assistant professors, many faculty with impressive accomplishments, a robust research department and the support of the chief,” he says. “Clearly we were ready.”

Separation has become a hot topic as the numbers of hospitalist faculty reach critical mass in academic medical centers, with some hospitalists’ departments having larger faculties than any other specialty within the division.

While it may be time for hospitalists to separate in large medical centers, that may not be the case at smaller schools,” says Karen DeSalvo, MD, MPH, MSc, chief of general internal medicine and geriatrics, Tulane School of Medicine in New Orleans, and president-elect of the Association of Chiefs of General Internal Medicine. “For smaller medical schools, it just doesn’t make sense financially to have a separate division.”

A school’s culture also can be a barrier to separation, she points out. Tulane takes a multidisciplinary approach to teaching with faculty encouraged to work across traditional specialty areas. This is easier when hospitalists are in the same division, she says.

However, size is not the only requirement for divisions in medical schools. “The goals of divisions within the infrastructure of medical centers are clinical care, teaching, and research,” says SHM President-elect Scott A. Flanders, MD, associate professor of medicine at the University of Michigan, Ann Arbor. “While most hospitalist programs at major academic medical centers do a great job with clinical care and many have teaching success, very few have succeeded in developing robust research programs.” Until this happens, hospitalists should remain in divisions of general internal medicine and take advantage of their resources to develop research programs and faculty, he says.

Dr. Wachter agrees: “It’s not just size. It’s also scope and accomplishments and whether your leader is experienced enough and strong enough to go toe to toe with other division chiefs.”

Anticipate Demand

Dr. Flanders says the controversy has heated up as academic medical centers seek to recruit leaders for large hospitalist programs. “They dangle the division chief position as a tool to recruit from the small pool of experienced academic hospitalists who could head a program,” he says. Along with creating a division comes a package of incentives, such as tenure, investments in building the academic and research components, power, and prestige.

That was the case at Northwestern University’s Feinberg School of Medicine, which lured Mark Williams, MD, away from 18 years at Emory University to head a new division of hospital medicine. Dr. Williams, editor of the Journal of Hospital Medicine, believes it’s important for hospitalists to have a separate division so they are at the same level as the other academic specialties. “That’s why I came to Northwestern,” he says. “I think it’s essential that hospitalists have division status so they are present at the table when decisions are made about investments in research, coverage, teaching of residents, and particularly budgetary matters.”

However, Dr. DeSalvo points out that there are not enough experienced academic hospitalists to head divisions in all medical schools. “If we were to say tomorrow that all hospitalists should have their own divisions, there would not be enough experienced people to head all those divisions,” he stresses. “So if it’s going to happen, it will happen over time.” In the meantime, it’s important that schools mentor and train academic hospitalists who could be division chiefs, she says.

The issue has become a priority for SHM and the Society of General Internal Medicine (SGIM), which have created task forces to find ways to help academic hospitalists advance their careers without “isolating themselves as to site of care,” Dr. Centor says. “Hospitalists are complementary to outpatient physicians and vice versa. They have to talk to each other, and the general internal medicine division structure provides that.”

Fault Lines

Hospitalists and general internists have more in common and more reasons to stay together than to separate, according to Dr. Centor. “Internists and hospitalists both concentrate on taking care of the whole patient and see patients who have multiple diseases.” Their issues are the same: advancing their careers, creating knowledge, and developing better teaching methods, he says. “Exactly the same issues general internal medicine has been working on for the last 25 years,” he explains.

General internists worry hospitalists are dichotomizing internal medicine and their careers by separating. “If you have a division of inpatient medicine and a division of outpatient medicine, it becomes harder for hospitalists to switch to outpatient medicine when they burn out,” Dr. Centor says.

Dr. Williams says hospitalist burnout is a myth: “People keep bringing up hospitalist burnout as a threat. It’s not a problem. We have programs in which the original hospitalists have been practicing since 1988 and are still enjoying doing it.”

The question of where academic hospitalists, with so few older physicians in its ranks, will find mentors concerns those opposed to separate divisions. Dr. Williams says there is nothing preventing general internal medicine physicians from mentoring hospitalists whether or not they are in a separate division.

Dr. Wachter says strong division leaders help academic hospitalists find mentors among more experienced physicians in other divisions and even at other institutions.

Some general internists and hospitalists believe separation is an academic issue that doesn’t affect patient care. Dr. Williams disagrees. “Decisions on whether hospitalists are going to be the primary people delivering care to patients can affect budgetary, scheduling, and training issue, which ultimately affect patients,” he counters.

Academic turf wars, politics, and allocation of resources also play into the desire to keep hospitalists within divisions of general internal medicine. “Many chiefs don’t want them to separate because they see it as a reduction or fracturing of their division’s resources, both financial and human,” Dr. Flanders says.

Academic hospitalists who remain within divisions of general internal medicine need the support of those divisions. The SGIM task force recommended that divisions provide leadership to support hospitalists, build mentorships, create sustainable academic jobs, and value the education and quality improvement work of hospitalists, according to Dr. Flanders.

Many believe the independence of hospitalists is inevitable. “It’s where we are heading, and we will get there,” says Dr. Flanders.

Dr. Wachter says academic hospitalists are following the predictable “organizational rules of gravity. You start small and you build and you become more independent. Those who need parenting, over time, become adolescents and go to college and become independent. That’s just the nature of the beast,” he says. “It won’t happen at every place at the same minute, but I’ll be very surprised if 10 years from now, there aren’t very few academic hospitalists groups of any size that are not freestanding divisions.” TH

Barbara Dillard is a medical journalist based in Chicago.

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Hospitalist Bradley Rosen, MD, has become something of a celebrity lately. Dr. Rosen, assistant director of the Procedures Center at Cedars-Sinai Medical Center in Los Angeles, is making news as the prime example of physicians carving new turf by becoming experts in performing medical procedures.

But it’s his center’s eye-popping statistics that are generating interest from patient safety groups and hospitals around the country. Dr. Rosen has documented a complication rate of less than 1% for procedures performed at the center. Published data for similar procedures done elsewhere sets the rate at between 3% and 5%.

The statistics don’t surprise Dr. Rosen. “The more you do something, the better you are going to be at it, and the better you are able to deal with the unexpected,” he explains.

Stories on proceduralists have also generated interest from hospitalists, who wonder if becoming experts in procedures can make them a more valuable part of the healthcare team and make their jobs more varied.

Safety Advantages

The evolution of proceduralists is first and foremost a patient safety measure. Many internists have given up doing procedures, concerned that they don’t do enough of them to stay proficient. In a study published in The Annals of Internal Medicine, internists reported that they do 50% fewer procedures today than they did 18 years ago. And the American Board of Internal Medicine has reduced the number of procedures required for certification, saying internists should focus on core procedures they are likely to do frequently. Proceduralists are moving in to fill the void.

Also driving the proceduralist movement is concern that residents don’t get enough experience in doing today’s more complicated procedures and are being trained by other residents.

“Unfortunately, training in procedures hasn’t progressed much from when I was a resident,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston and assistant professor of medicine at the Harvard Medical School. “When I had to do a thoracentesis, for example, a junior resident was teaching me, and we would get three or four kits because I knew that I would screw up. We had no notion of cost, and although I felt bad sticking a patient a bunch of times, it was the way it worked in the teaching hospital. Unfortunately that is still the way it’s done in the overwhelming majority of medical schools today.”

The Trend Spreads

Simply put, proceduralists perform procedures. They may perform them all or part of the time and may teach others how to do them. Depending on where they work and how they’ve been trained, they perform thoracentesis, paracentesis, lumbar punctures, central line and arterial line placement, difficult IVs, percutaneous tracheostomy, chest tube insertion, skin biopsy, intubations, and conscious sedation.

Cedars-Sinai is the only hospital to establish a dedicated proceduralist center. Four proceduralists, with the help of a nurse practitioner and 14 nurses, perform about 24 medical procedures, according to Dr. Rosen.

The center was created in 1991 by Mark Ault, MD, FACEP, director of the division of general internal medicine at Cedars-Sinai, whom Dr. Rosen calls “the godfather of proceduralists.” Dr. Ault started the center after he found patients stayed in the hospital longer than necessary while waiting for procedures, Dr. Rosen says.

The early proceduralists came from critical and pulmonary care, and later from the academic hospitalists ranks. Proceduralists spend between 50% and 75% their time performing procedures and the rest on academic hospitalist duties such as supervising and teaching procedures to residents, working in clinics, rounding, and research.

In addition to working in the center, physicians perform procedures at the bedside using a mobile cart stocked with everything they need. “The advent of the portable ultrasound has really transformed vascular access and allows us to do procedures at the bedside, without having to move a patient,” Dr. Rosen says.

At Beth Israel Deaconess, 20 of the hospital’s 24 hospitalists have received advanced training and feel comfortable doing procedures. They also teach and supervise residents, according to Dr. Li.

“When a patient needs a procedure, the resident or physician pages 9-4-TAP, and we arrange a time to supervise the resident doing the procedure,” Dr. Li explains. “In about 80% of the cases, the resident does the procedure without my intervention. About 20% of the time I need to step in and do the procedure.”

The University of Chicago Pritzker School of Medicine started a procedures service five years ago, which is run by the critical care faculty and intensivists from 8 a.m. to 5 p.m. on weekdays. Hospitalists work as proceduralists to fill in the gaps at other times of the day and night and on weekends, according to Nilam Soni, MD, instructor of medicine in the school’s section of hospital medicine.

Dr. Soni received advanced training in procedures and says he enjoys doing procedures for the patients he sees as a hospitalist. “Being able to do procedures gives you a sense of confidence that you can take care of your patients without having to worry about finding someone to do a procedure,” Dr. Soni says.

Northwestern University Feinberg School of Medicine in Chicago is focusing on developing procedure-training programs for residents using advanced simulation, according to Jeffrey Barsuk, MD, FACP, assistant professor of medicine in the division of hospital medicine.

Small But Growing

The proceduralist movement makes up in enthusiasm what it lacks in numbers. There may be only 20 to 30 physicians in the country calling themselves proceduralists. However, countless physicians do procedures without the title. Interventional radiologists, intensivists, critical care physicians, pulmonologists, and surgeons to do procedures in larger hospitals. At small community hospitals, “Everyone does everything,” Dr. Soni says.

Fueled by patient safety concerns and the need for advanced training, there is a growing demand for experts to do procedures. Because hospitalists staff hospitals round the clock, they are the obvious physicians to move into the field. “Hospitalists are in the best position to take ownership of procedures because we are in the hospital 24/7,” Dr. Soni says. “We can zip down to the patients’ rooms and take care of a problem before it becomes serious.”

Another advantage is that a hospitalist is likely to have seen a patient before a procedure is needed. Dr. Soni believes it’s not as frightening for a patient to have a procedure done at bedside by someone they have met. “And we can educate patients about the procedure and answer follow-up questions because we are there,” he notes.

However, physicians doing procedures may not agree that hospitalists should take over the service. In some institutions the idea of establishing a proceduralist service or center has met roadblocks from physicians who see proceduralists an interlopers.

At Cedars-Sinai this hasn’t been a problem. “Our interventional radiologists and surgeons have been supportive because they have as much as they can handle,” Dr. Rosen explains. “They are content to focus on the more complicated procedures.”

Hospitalists specializing in procedures say it adds variety to their usual routines. “It takes a different mentality and different skills,” Dr. Rosen explains. “It’s much like surgery. You get a feeling of accomplishment when you’re done and then you go on to something else. It’s very satisfying,”

From a revenue standpoint, hospitalists can bill for the procedures they perform, although reimbursement for the typical procedure is not “jaw-dropping,” Dr. Rosen says.

For hospitalists, developing procedure skills may lead to career advancement. “The more you have to offer, the more valuable you are,” Dr. Soni advises. “By becoming a proceduralist you generate money for the hospital instead of being just an expense.”

Training and Standards

Whether hospitalists or other physicians do procedures, most of them agree there is a need for training and certifying of proceduralists. “Currently there are no standards for mastery in performing procedures,” Dr. Li says. “We measure mastery by personal belief. You ask me if I feel comfortable doing a certain procedure, and I say ‘Yes’ or ‘No.’ ”

SHM has identified performing procedures as one of the skills all hospitalists should be able to demonstrate, according to Dr. Li. To that end, an advanced procedures training course will be held at Hospital Medicine 2008, SHM’s Annual Meeting in April. For the first time, procedure experts will train hospitalists using different simulators, portable ultrasound, and other equipment.

“The future growth of proceduralist services and centers will come from being closely associated with and staffed by hospitalists,” Dr. Rosen says. He believes it’s an opportunity for hospitalists to supply another value-added service and have more variety in their work. TH

Barbara Dillard is a medical journalist based in Chicago.

Everyone has been there. You’re making rounds in the hospital and another physician taps you on the shoulder and says, “Can I ask you something?” He then gives the details and diagnosis of a patient’s condition and asks, “What would you suggest?”

Or maybe you stop the cardiologist in the hall to run your planned treatment of a particularly perplexing case by him.

These encounters—called curbside consultations—happen everywhere: hallways, cocktail parties, weddings, parking lots, and, increasingly, on the Internet.

As hospitalists increase their presence, they expose themselves to more curbside consultations—and the risks they entail. The practice is fraught with minefields that can turn the best of intentions into a potential medical and legal nightmare.

The term curbside consults implies opportunity—and hospitalists are most available to other hospitalists as they work in the hospital. In return, hospitalists have a greater opportunity to ask questions of other specialists without even picking up a telephone. A combination of geography and opportunity puts hospitalists at increasingly greater risk.

“We’re so accessible to other doctors in the hospital,” says Janet Nagamine, MD, chair of SHM’s Hospital Quality and Patient Safety committee and a hospitalist at Kaiser Permanente Santa Clara Medical Center in California. “I think we get more requests for informal consultations because we are there. It’s so easy for another physician to tap you on the shoulder and ask what you think about a patient’s condition or treatment. I am more frequently the giver of information than the receiver because it is so easy for a physician to tap me on the shoulder and ask my opinion.”

Proximity also presents an increased opportunity for hospitalists to seek a curbside consult from another physician in the hall. “I think hospitalists are more likely to ask for help from specialists they see in the hospital because hospitalists are generalists and can see a wide variety of conditions in the hospital,” says Clifford Zwillich, MD, professor of medicine at the University of Colorado and a hospitalist at the Denver Veterans Affairs Medical Center.

Widespread Practice

In an April 2006 study in the Journal of the Medical Library Association, hospitalists reported that they seek a curbside consultation for a variety of reasons. These include:

• Confirm what they already know;
• Get quick answers to a question;
• Continue their medical education;
• Determine if a formal consultation is called for;
• Negotiate an appropriate course of treatment for a particular patient;
• Spread the emotional risk during a difficult case;
• Create or sustain camaraderie with physician colleges;
• Find like thinkers among their physician colleagues;
• Monitor their own knowledge; and
• Obtain help to get out of a difficult situation.

Hospitalists who provide curbside consultations reported doing so to provide good patient care, fulfill professional obligations, serve doctors, and encourage formal referrals.

Another study reported that 70% of primary care hospitalists and 68% of subspecialists surveyed participated in at least one informal consult in the previous week.

Critics say an enormous number of hospitalists put themselves at risk and potentially jeopardize patient care by taking part in these consultations. These dangers seem to increase when the consultation veers from the general educational question to advice on treating a specific patient.

“Medical errors are potentially a lot higher in curbside consultations because much is lost in translation,” Dr. Zwillich explains. “When a curbside is used as a substitute for the physician seeing the patient, it can result in an incorrect diagnosis and medical errors.”

Dr. Zwillich is concerned because a physician can give the best treatment advice, but if the underlying diagnosis is wrong patients can be harmed. Because curbsides are quick, one physician doesn’t know if the other physician is leaving out something critical or even if the underlying diagnosis is correct. “By taking a curbside consult, you are giving up your opportunity to make an alternative diagnosis,” Dr. Zwillich says.

When giving advice on a specific patient nothing beats a formal consultation in which the patient is seen and a complete history is taken, he says: “The best care is given at the bedside.”

Legal Liability

Dr. Nagamine also fears the risk hospitalists take for a medical malpractice lawsuit. “My biggest concern is when hospitalists don’t recognize the risk they take on,” she says. “We shouldn’t take a curbside consult without knowing the risks.”

Traditionally, medical malpractice liability for curbside consultations has hinged on an established physician-patient relationship, generally limited to hospitalists seeing a patient. “Courts have been reluctant to extend liability to specialists consulted informally by the patient’s primary physician,” writes Kim Baker, JD, a healthcare attorney with Williams Kastner, in Seattle, Wash., in an analysis of court rulings.

However, courts are allowing suits to proceed against the consulting hospitalist, trying to decide whether a physician-patient relationship existed—and if so whether the [consulting] physician’s advice led to the alleged malpractice. Particularly relevant to hospitalists is the legal question of whether a pre-existing contract between the consulting physician and the hospital creates a physician-patient relationship with patients in that hospital. On this question courts have been mixed. In other cases, liability turned on whether the consultant physician went beyond giving general advice to participating in the patient’s care.

Courts are continually revising their rulings and may change the way they interpret a physician-patient relationship. Baker cautions that this may be a trend with curbside consults. She says trial attorneys are continually trying to find ways to bring more hospitalists into a suit. Baker sees a “discernible shift away from the longstanding policy that favors physician’s expectations over those of patients when determining whether a particular physician owed a duty of care to a particular patient.” She warns that hospitalists who engage in informal consults “may be at greater risk for medical malpractice liability.”

Can’t Stop Lawsuits

The reality of a litigious society is that even if you aren’t liable for malpractice you can still be sued. Attorneys routinely “paper the hospital,” naming in a suit everyone who came in contact with a patient or gave advice on his treatment, says Robin Diamond, MSN, JD, vice president of patient safety at The Doctors Company, Napa, Calif., a professional liability insurer of hospitalists and other hospitalists.

“Even if you have no responsibility, you still have to go through all the pain, expense, and heartache of getting yourself dismissed from the suit,” she explains. “What makes the curbside consultation easy and convenient for the consulting physician is what turns it into a legal nightmare for both of them.” Because the consult is on the run, the consulting physician may not give all the information that reveals the whole clinical picture.

So far The Doctors Company hasn’t seen a significant number of lawsuits against hospitalists—but this could increase as the subspecialty grows, Diamond says. The closest example she knows of is a pending case in which a hospitalist is being sued for advice he gave in a consult in an emergency department.

Two things concern Diamond most about curbside consults. The first is that because there is no documentation in a curbside consult, the physician giving advice cannot prove later what was said. Insurers worry that because there is no documentation of curbside consults it can be one physician’s word against the other’s if the case goes to court. There can be disagreements about what was said, when, and the advice given—and no way to prove who is right, she says.

Her second area of concern is when the conversation goes from general to specific. A physician is easier to defend if it can be proved that the question asked was general and didn’t have a specific application or sharing of clinical expertise. If a specific patient and a specific history is discussed, courts could establish that this constituted a formal consultation and established a patient-physician relationship. They could also establish that the consulting physician relied on the recommendation, which harmed the patient, Diamond says.

Despite the dangers, are hospitalists likely to stop doing curbside consultations? Even the critics answer with a resounding “no.” They say such consults are a fact of life.

“Curbsides are a part of our professional community of care,” Dr. Zwillich says. “It’s good to ask advice of other hospitalists. The danger comes when a curbside is used as a substitute for a needed full consultation.”

Dr. Nagamine thinks curbside consultations are a good way for hospitalists to continue their medical education. “In the hospital setting, many knowledgeable hospitalists are nearby, and you can learn a lot from them. I don’t think that’s bad or wrong,” she says. “The biggest problem we have is not asking for help when you’re not sure. I’m all for making it easy for hospitalists to ask for advice when they are not sure. But I’m in favor of full consultations when appropriate.”

Safer Consults

If hospitalists are going to participate in curbside consults they can make them safer by following this advice: Tread carefully, keep it general, think before you speak, and consider documenting what you say. And never hesitate to ask to see the patient.

Keep the curbside consultation general and brief: Curbside consultations may be safer when they are more general and used for the physician’s general education, experts agree. It’s when the discussion gets complex or about a specific patient that it’s time to think before you speak and be cautious.

Diamond says it is probably safe to say to another physician: “This is what I just saw. Have you ever seen it before?” But once the question goes from there to asking the physician what he or she did in such a case, “That’s when you’ve got to say, ‘Wait a minute, this is becoming so complex that it would be better if we did a formal consult.’ ”

Consider the risk of being wrong: “You have to ask yourself what is the downside—or the risk—of the question you’re asking,” Dr. Nagamine says. “If you know you’re going to order some tests and want to know which one to do first, this is far less risky than [deciding] if … we admit someone to the hospital or send him home.” In the first case there’s probably not much risk because you can order other tests if the first ones don’t give you the results you need. But in the second, if you send someone home and you are wrong, you can cause harm, she explains.

Dr. Nagamine also recommends considering the seriousness of the patient’s condition. Patients rarely die from a rash but can if you’re wrong about chest pain, for example.

“You need to ask yourself, ‘What’s the complexity of the case and the downside of being wrong and what, exactly [is my colleague] asking me?’ ” she says.

Ask specific questions: “Think very carefully about whether the situation is appropriate for a curbside consultation,” Dr. Nagamine cautions. “Ask probing questions that assure you that the correct and complete information was gathered. What is the quality of the information you’re being given?” If you don’t have complete faith in the ability of the physician asking you for a consult, it’s best to see the patient, she says.

Consider facts not given: Diamond recommends the hospitalists consider the facts not given before deciding to give advice in a curbside consultation. The physician asking for the consult is going to give the information he feels is important at the time. He may have left out or discounted important facts about the patient’s history. Ask “What am I not getting here?” she recommends.

Don’t hesitate to ask to see the patient: Dr. Nagamine urges hospitalists not to refrain from asking to see the patient involved. “Many times I feel like the other physician really wants me to see the patient but doesn’t want to bother me. I find they are relieved when I suggest that I see the patient,” she says. “Other times hospitalists don’t like to admit they are in over their heads and ask for help. In many cases when I see the patient I’m glad I did.”

Document the conversation: The Doctors Company recommends hospitalists document curbside consultations. “Keep a brief record of it in a memo to yourself, “ Diamond says. However, that can be a Catch-22. “If you end up in court you have to supply all the information you have. So we say that if it gets to the point that you feel like you need to document a curbside consult, you need to bump it up to a formal consultation.”

Know your responsibilities to the hospital: For those hospitalists who work at more than one hospital, Diamond recommends you make sure you are following hospital protocol and not doing more than the hospital expects from you. Some hospitalists think it’s their responsibility to take a curbside consult from a facility’s hospitalists, and it may not be the case. All hospitals don’t have the same expectations of hospitalists, she says.

Dr. Nagamine thinks the stakes are higher for hospitalists taking curbside consultations because hospitalized patients are usually sicker than in an office setting. So the hospitalist may need to be even more cautious. TH

Barbara Dillard is a medical journalist based in Chicago.

Resources

1. Manian FA. Curbside consultations: a closer look at a common practice. JAMA. 1996;275(22):145-147.
2. Perley CM. Physician use of the curbside consultation to address information needs. J Med Libr Assoc. 2006 April;94(2);137-144.
3. Pearson SD, Moreno R, Trnka Y. Informal consultations provided to general internists by the gastroenterology department of an HMO. J Gen Intern Med. 1998 July;13(7):435-438.

Everyone has been there. You’re making rounds in the hospital and another physician taps you on the shoulder and says, “Can I ask you something?” He then gives the details and diagnosis of a patient’s condition and asks, “What would you suggest?”

Or maybe you stop the cardiologist in the hall to run your planned treatment of a particularly perplexing case by him.

These encounters—called curbside consultations—happen everywhere: hallways, cocktail parties, weddings, parking lots, and, increasingly, on the Internet.

As hospitalists increase their presence, they expose themselves to more curbside consultations—and the risks they entail. The practice is fraught with minefields that can turn the best of intentions into a potential medical and legal nightmare.

The term curbside consults implies opportunity—and hospitalists are most available to other hospitalists as they work in the hospital. In return, hospitalists have a greater opportunity to ask questions of other specialists without even picking up a telephone. A combination of geography and opportunity puts hospitalists at increasingly greater risk.

“We’re so accessible to other doctors in the hospital,” says Janet Nagamine, MD, chair of SHM’s Hospital Quality and Patient Safety committee and a hospitalist at Kaiser Permanente Santa Clara Medical Center in California. “I think we get more requests for informal consultations because we are there. It’s so easy for another physician to tap you on the shoulder and ask what you think about a patient’s condition or treatment. I am more frequently the giver of information than the receiver because it is so easy for a physician to tap me on the shoulder and ask my opinion.”

Proximity also presents an increased opportunity for hospitalists to seek a curbside consult from another physician in the hall. “I think hospitalists are more likely to ask for help from specialists they see in the hospital because hospitalists are generalists and can see a wide variety of conditions in the hospital,” says Clifford Zwillich, MD, professor of medicine at the University of Colorado and a hospitalist at the Denver Veterans Affairs Medical Center.

Widespread Practice

In an April 2006 study in the Journal of the Medical Library Association, hospitalists reported that they seek a curbside consultation for a variety of reasons. These include:

• Confirm what they already know;
• Get quick answers to a question;
• Continue their medical education;
• Determine if a formal consultation is called for;
• Negotiate an appropriate course of treatment for a particular patient;
• Spread the emotional risk during a difficult case;
• Create or sustain camaraderie with physician colleges;
• Find like thinkers among their physician colleagues;
• Monitor their own knowledge; and
• Obtain help to get out of a difficult situation.

Hospitalists who provide curbside consultations reported doing so to provide good patient care, fulfill professional obligations, serve doctors, and encourage formal referrals.

Another study reported that 70% of primary care hospitalists and 68% of subspecialists surveyed participated in at least one informal consult in the previous week.

Critics say an enormous number of hospitalists put themselves at risk and potentially jeopardize patient care by taking part in these consultations. These dangers seem to increase when the consultation veers from the general educational question to advice on treating a specific patient.

“Medical errors are potentially a lot higher in curbside consultations because much is lost in translation,” Dr. Zwillich explains. “When a curbside is used as a substitute for the physician seeing the patient, it can result in an incorrect diagnosis and medical errors.”

Dr. Zwillich is concerned because a physician can give the best treatment advice, but if the underlying diagnosis is wrong patients can be harmed. Because curbsides are quick, one physician doesn’t know if the other physician is leaving out something critical or even if the underlying diagnosis is correct. “By taking a curbside consult, you are giving up your opportunity to make an alternative diagnosis,” Dr. Zwillich says.

When giving advice on a specific patient nothing beats a formal consultation in which the patient is seen and a complete history is taken, he says: “The best care is given at the bedside.”

Legal Liability

Dr. Nagamine also fears the risk hospitalists take for a medical malpractice lawsuit. “My biggest concern is when hospitalists don’t recognize the risk they take on,” she says. “We shouldn’t take a curbside consult without knowing the risks.”

Traditionally, medical malpractice liability for curbside consultations has hinged on an established physician-patient relationship, generally limited to hospitalists seeing a patient. “Courts have been reluctant to extend liability to specialists consulted informally by the patient’s primary physician,” writes Kim Baker, JD, a healthcare attorney with Williams Kastner, in Seattle, Wash., in an analysis of court rulings.

However, courts are allowing suits to proceed against the consulting hospitalist, trying to decide whether a physician-patient relationship existed—and if so whether the [consulting] physician’s advice led to the alleged malpractice. Particularly relevant to hospitalists is the legal question of whether a pre-existing contract between the consulting physician and the hospital creates a physician-patient relationship with patients in that hospital. On this question courts have been mixed. In other cases, liability turned on whether the consultant physician went beyond giving general advice to participating in the patient’s care.

Courts are continually revising their rulings and may change the way they interpret a physician-patient relationship. Baker cautions that this may be a trend with curbside consults. She says trial attorneys are continually trying to find ways to bring more hospitalists into a suit. Baker sees a “discernible shift away from the longstanding policy that favors physician’s expectations over those of patients when determining whether a particular physician owed a duty of care to a particular patient.” She warns that hospitalists who engage in informal consults “may be at greater risk for medical malpractice liability.”

Can’t Stop Lawsuits

The reality of a litigious society is that even if you aren’t liable for malpractice you can still be sued. Attorneys routinely “paper the hospital,” naming in a suit everyone who came in contact with a patient or gave advice on his treatment, says Robin Diamond, MSN, JD, vice president of patient safety at The Doctors Company, Napa, Calif., a professional liability insurer of hospitalists and other hospitalists.

“Even if you have no responsibility, you still have to go through all the pain, expense, and heartache of getting yourself dismissed from the suit,” she explains. “What makes the curbside consultation easy and convenient for the consulting physician is what turns it into a legal nightmare for both of them.” Because the consult is on the run, the consulting physician may not give all the information that reveals the whole clinical picture.

So far The Doctors Company hasn’t seen a significant number of lawsuits against hospitalists—but this could increase as the subspecialty grows, Diamond says. The closest example she knows of is a pending case in which a hospitalist is being sued for advice he gave in a consult in an emergency department.

Two things concern Diamond most about curbside consults. The first is that because there is no documentation in a curbside consult, the physician giving advice cannot prove later what was said. Insurers worry that because there is no documentation of curbside consults it can be one physician’s word against the other’s if the case goes to court. There can be disagreements about what was said, when, and the advice given—and no way to prove who is right, she says.

Her second area of concern is when the conversation goes from general to specific. A physician is easier to defend if it can be proved that the question asked was general and didn’t have a specific application or sharing of clinical expertise. If a specific patient and a specific history is discussed, courts could establish that this constituted a formal consultation and established a patient-physician relationship. They could also establish that the consulting physician relied on the recommendation, which harmed the patient, Diamond says.

Despite the dangers, are hospitalists likely to stop doing curbside consultations? Even the critics answer with a resounding “no.” They say such consults are a fact of life.

“Curbsides are a part of our professional community of care,” Dr. Zwillich says. “It’s good to ask advice of other hospitalists. The danger comes when a curbside is used as a substitute for a needed full consultation.”

Dr. Nagamine thinks curbside consultations are a good way for hospitalists to continue their medical education. “In the hospital setting, many knowledgeable hospitalists are nearby, and you can learn a lot from them. I don’t think that’s bad or wrong,” she says. “The biggest problem we have is not asking for help when you’re not sure. I’m all for making it easy for hospitalists to ask for advice when they are not sure. But I’m in favor of full consultations when appropriate.”

Safer Consults

If hospitalists are going to participate in curbside consults they can make them safer by following this advice: Tread carefully, keep it general, think before you speak, and consider documenting what you say. And never hesitate to ask to see the patient.

Keep the curbside consultation general and brief: Curbside consultations may be safer when they are more general and used for the physician’s general education, experts agree. It’s when the discussion gets complex or about a specific patient that it’s time to think before you speak and be cautious.

Diamond says it is probably safe to say to another physician: “This is what I just saw. Have you ever seen it before?” But once the question goes from there to asking the physician what he or she did in such a case, “That’s when you’ve got to say, ‘Wait a minute, this is becoming so complex that it would be better if we did a formal consult.’ ”

Consider the risk of being wrong: “You have to ask yourself what is the downside—or the risk—of the question you’re asking,” Dr. Nagamine says. “If you know you’re going to order some tests and want to know which one to do first, this is far less risky than [deciding] if … we admit someone to the hospital or send him home.” In the first case there’s probably not much risk because you can order other tests if the first ones don’t give you the results you need. But in the second, if you send someone home and you are wrong, you can cause harm, she explains.

Dr. Nagamine also recommends considering the seriousness of the patient’s condition. Patients rarely die from a rash but can if you’re wrong about chest pain, for example.

“You need to ask yourself, ‘What’s the complexity of the case and the downside of being wrong and what, exactly [is my colleague] asking me?’ ” she says.

Ask specific questions: “Think very carefully about whether the situation is appropriate for a curbside consultation,” Dr. Nagamine cautions. “Ask probing questions that assure you that the correct and complete information was gathered. What is the quality of the information you’re being given?” If you don’t have complete faith in the ability of the physician asking you for a consult, it’s best to see the patient, she says.

Consider facts not given: Diamond recommends the hospitalists consider the facts not given before deciding to give advice in a curbside consultation. The physician asking for the consult is going to give the information he feels is important at the time. He may have left out or discounted important facts about the patient’s history. Ask “What am I not getting here?” she recommends.

Don’t hesitate to ask to see the patient: Dr. Nagamine urges hospitalists not to refrain from asking to see the patient involved. “Many times I feel like the other physician really wants me to see the patient but doesn’t want to bother me. I find they are relieved when I suggest that I see the patient,” she says. “Other times hospitalists don’t like to admit they are in over their heads and ask for help. In many cases when I see the patient I’m glad I did.”

Document the conversation: The Doctors Company recommends hospitalists document curbside consultations. “Keep a brief record of it in a memo to yourself, “ Diamond says. However, that can be a Catch-22. “If you end up in court you have to supply all the information you have. So we say that if it gets to the point that you feel like you need to document a curbside consult, you need to bump it up to a formal consultation.”

Know your responsibilities to the hospital: For those hospitalists who work at more than one hospital, Diamond recommends you make sure you are following hospital protocol and not doing more than the hospital expects from you. Some hospitalists think it’s their responsibility to take a curbside consult from a facility’s hospitalists, and it may not be the case. All hospitals don’t have the same expectations of hospitalists, she says.

Dr. Nagamine thinks the stakes are higher for hospitalists taking curbside consultations because hospitalized patients are usually sicker than in an office setting. So the hospitalist may need to be even more cautious. TH

Barbara Dillard is a medical journalist based in Chicago.

Resources

1. Manian FA. Curbside consultations: a closer look at a common practice. JAMA. 1996;275(22):145-147.
2. Perley CM. Physician use of the curbside consultation to address information needs. J Med Libr Assoc. 2006 April;94(2);137-144.
3. Pearson SD, Moreno R, Trnka Y. Informal consultations provided to general internists by the gastroenterology department of an HMO. J Gen Intern Med. 1998 July;13(7):435-438.

Everyone has been there. You’re making rounds in the hospital and another physician taps you on the shoulder and says, “Can I ask you something?” He then gives the details and diagnosis of a patient’s condition and asks, “What would you suggest?”

Or maybe you stop the cardiologist in the hall to run your planned treatment of a particularly perplexing case by him.

These encounters—called curbside consultations—happen everywhere: hallways, cocktail parties, weddings, parking lots, and, increasingly, on the Internet.

As hospitalists increase their presence, they expose themselves to more curbside consultations—and the risks they entail. The practice is fraught with minefields that can turn the best of intentions into a potential medical and legal nightmare.

The term curbside consults implies opportunity—and hospitalists are most available to other hospitalists as they work in the hospital. In return, hospitalists have a greater opportunity to ask questions of other specialists without even picking up a telephone. A combination of geography and opportunity puts hospitalists at increasingly greater risk.

“We’re so accessible to other doctors in the hospital,” says Janet Nagamine, MD, chair of SHM’s Hospital Quality and Patient Safety committee and a hospitalist at Kaiser Permanente Santa Clara Medical Center in California. “I think we get more requests for informal consultations because we are there. It’s so easy for another physician to tap you on the shoulder and ask what you think about a patient’s condition or treatment. I am more frequently the giver of information than the receiver because it is so easy for a physician to tap me on the shoulder and ask my opinion.”

Proximity also presents an increased opportunity for hospitalists to seek a curbside consult from another physician in the hall. “I think hospitalists are more likely to ask for help from specialists they see in the hospital because hospitalists are generalists and can see a wide variety of conditions in the hospital,” says Clifford Zwillich, MD, professor of medicine at the University of Colorado and a hospitalist at the Denver Veterans Affairs Medical Center.

Widespread Practice

In an April 2006 study in the Journal of the Medical Library Association, hospitalists reported that they seek a curbside consultation for a variety of reasons. These include:

• Confirm what they already know;
• Get quick answers to a question;
• Continue their medical education;
• Determine if a formal consultation is called for;
• Negotiate an appropriate course of treatment for a particular patient;
• Spread the emotional risk during a difficult case;
• Create or sustain camaraderie with physician colleges;
• Find like thinkers among their physician colleagues;
• Monitor their own knowledge; and
• Obtain help to get out of a difficult situation.

Hospitalists who provide curbside consultations reported doing so to provide good patient care, fulfill professional obligations, serve doctors, and encourage formal referrals.

Another study reported that 70% of primary care hospitalists and 68% of subspecialists surveyed participated in at least one informal consult in the previous week.

Critics say an enormous number of hospitalists put themselves at risk and potentially jeopardize patient care by taking part in these consultations. These dangers seem to increase when the consultation veers from the general educational question to advice on treating a specific patient.

“Medical errors are potentially a lot higher in curbside consultations because much is lost in translation,” Dr. Zwillich explains. “When a curbside is used as a substitute for the physician seeing the patient, it can result in an incorrect diagnosis and medical errors.”

Dr. Zwillich is concerned because a physician can give the best treatment advice, but if the underlying diagnosis is wrong patients can be harmed. Because curbsides are quick, one physician doesn’t know if the other physician is leaving out something critical or even if the underlying diagnosis is correct. “By taking a curbside consult, you are giving up your opportunity to make an alternative diagnosis,” Dr. Zwillich says.

When giving advice on a specific patient nothing beats a formal consultation in which the patient is seen and a complete history is taken, he says: “The best care is given at the bedside.”

Legal Liability

Dr. Nagamine also fears the risk hospitalists take for a medical malpractice lawsuit. “My biggest concern is when hospitalists don’t recognize the risk they take on,” she says. “We shouldn’t take a curbside consult without knowing the risks.”

Traditionally, medical malpractice liability for curbside consultations has hinged on an established physician-patient relationship, generally limited to hospitalists seeing a patient. “Courts have been reluctant to extend liability to specialists consulted informally by the patient’s primary physician,” writes Kim Baker, JD, a healthcare attorney with Williams Kastner, in Seattle, Wash., in an analysis of court rulings.

However, courts are allowing suits to proceed against the consulting hospitalist, trying to decide whether a physician-patient relationship existed—and if so whether the [consulting] physician’s advice led to the alleged malpractice. Particularly relevant to hospitalists is the legal question of whether a pre-existing contract between the consulting physician and the hospital creates a physician-patient relationship with patients in that hospital. On this question courts have been mixed. In other cases, liability turned on whether the consultant physician went beyond giving general advice to participating in the patient’s care.

Courts are continually revising their rulings and may change the way they interpret a physician-patient relationship. Baker cautions that this may be a trend with curbside consults. She says trial attorneys are continually trying to find ways to bring more hospitalists into a suit. Baker sees a “discernible shift away from the longstanding policy that favors physician’s expectations over those of patients when determining whether a particular physician owed a duty of care to a particular patient.” She warns that hospitalists who engage in informal consults “may be at greater risk for medical malpractice liability.”

Can’t Stop Lawsuits

The reality of a litigious society is that even if you aren’t liable for malpractice you can still be sued. Attorneys routinely “paper the hospital,” naming in a suit everyone who came in contact with a patient or gave advice on his treatment, says Robin Diamond, MSN, JD, vice president of patient safety at The Doctors Company, Napa, Calif., a professional liability insurer of hospitalists and other hospitalists.

“Even if you have no responsibility, you still have to go through all the pain, expense, and heartache of getting yourself dismissed from the suit,” she explains. “What makes the curbside consultation easy and convenient for the consulting physician is what turns it into a legal nightmare for both of them.” Because the consult is on the run, the consulting physician may not give all the information that reveals the whole clinical picture.

So far The Doctors Company hasn’t seen a significant number of lawsuits against hospitalists—but this could increase as the subspecialty grows, Diamond says. The closest example she knows of is a pending case in which a hospitalist is being sued for advice he gave in a consult in an emergency department.

Two things concern Diamond most about curbside consults. The first is that because there is no documentation in a curbside consult, the physician giving advice cannot prove later what was said. Insurers worry that because there is no documentation of curbside consults it can be one physician’s word against the other’s if the case goes to court. There can be disagreements about what was said, when, and the advice given—and no way to prove who is right, she says.

Her second area of concern is when the conversation goes from general to specific. A physician is easier to defend if it can be proved that the question asked was general and didn’t have a specific application or sharing of clinical expertise. If a specific patient and a specific history is discussed, courts could establish that this constituted a formal consultation and established a patient-physician relationship. They could also establish that the consulting physician relied on the recommendation, which harmed the patient, Diamond says.

Despite the dangers, are hospitalists likely to stop doing curbside consultations? Even the critics answer with a resounding “no.” They say such consults are a fact of life.

“Curbsides are a part of our professional community of care,” Dr. Zwillich says. “It’s good to ask advice of other hospitalists. The danger comes when a curbside is used as a substitute for a needed full consultation.”

Dr. Nagamine thinks curbside consultations are a good way for hospitalists to continue their medical education. “In the hospital setting, many knowledgeable hospitalists are nearby, and you can learn a lot from them. I don’t think that’s bad or wrong,” she says. “The biggest problem we have is not asking for help when you’re not sure. I’m all for making it easy for hospitalists to ask for advice when they are not sure. But I’m in favor of full consultations when appropriate.”

Safer Consults

If hospitalists are going to participate in curbside consults they can make them safer by following this advice: Tread carefully, keep it general, think before you speak, and consider documenting what you say. And never hesitate to ask to see the patient.

Keep the curbside consultation general and brief: Curbside consultations may be safer when they are more general and used for the physician’s general education, experts agree. It’s when the discussion gets complex or about a specific patient that it’s time to think before you speak and be cautious.

Diamond says it is probably safe to say to another physician: “This is what I just saw. Have you ever seen it before?” But once the question goes from there to asking the physician what he or she did in such a case, “That’s when you’ve got to say, ‘Wait a minute, this is becoming so complex that it would be better if we did a formal consult.’ ”

Consider the risk of being wrong: “You have to ask yourself what is the downside—or the risk—of the question you’re asking,” Dr. Nagamine says. “If you know you’re going to order some tests and want to know which one to do first, this is far less risky than [deciding] if … we admit someone to the hospital or send him home.” In the first case there’s probably not much risk because you can order other tests if the first ones don’t give you the results you need. But in the second, if you send someone home and you are wrong, you can cause harm, she explains.

Dr. Nagamine also recommends considering the seriousness of the patient’s condition. Patients rarely die from a rash but can if you’re wrong about chest pain, for example.

“You need to ask yourself, ‘What’s the complexity of the case and the downside of being wrong and what, exactly [is my colleague] asking me?’ ” she says.

Ask specific questions: “Think very carefully about whether the situation is appropriate for a curbside consultation,” Dr. Nagamine cautions. “Ask probing questions that assure you that the correct and complete information was gathered. What is the quality of the information you’re being given?” If you don’t have complete faith in the ability of the physician asking you for a consult, it’s best to see the patient, she says.

Consider facts not given: Diamond recommends the hospitalists consider the facts not given before deciding to give advice in a curbside consultation. The physician asking for the consult is going to give the information he feels is important at the time. He may have left out or discounted important facts about the patient’s history. Ask “What am I not getting here?” she recommends.

Don’t hesitate to ask to see the patient: Dr. Nagamine urges hospitalists not to refrain from asking to see the patient involved. “Many times I feel like the other physician really wants me to see the patient but doesn’t want to bother me. I find they are relieved when I suggest that I see the patient,” she says. “Other times hospitalists don’t like to admit they are in over their heads and ask for help. In many cases when I see the patient I’m glad I did.”

Document the conversation: The Doctors Company recommends hospitalists document curbside consultations. “Keep a brief record of it in a memo to yourself, “ Diamond says. However, that can be a Catch-22. “If you end up in court you have to supply all the information you have. So we say that if it gets to the point that you feel like you need to document a curbside consult, you need to bump it up to a formal consultation.”

Know your responsibilities to the hospital: For those hospitalists who work at more than one hospital, Diamond recommends you make sure you are following hospital protocol and not doing more than the hospital expects from you. Some hospitalists think it’s their responsibility to take a curbside consult from a facility’s hospitalists, and it may not be the case. All hospitals don’t have the same expectations of hospitalists, she says.

Dr. Nagamine thinks the stakes are higher for hospitalists taking curbside consultations because hospitalized patients are usually sicker than in an office setting. So the hospitalist may need to be even more cautious. TH

Barbara Dillard is a medical journalist based in Chicago.

Resources

1. Manian FA. Curbside consultations: a closer look at a common practice. JAMA. 1996;275(22):145-147.
2. Perley CM. Physician use of the curbside consultation to address information needs. J Med Libr Assoc. 2006 April;94(2);137-144.
3. Pearson SD, Moreno R, Trnka Y. Informal consultations provided to general internists by the gastroenterology department of an HMO. J Gen Intern Med. 1998 July;13(7):435-438.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.

These days you’re just as likely to find Jeffrey Krebs, MD, FACP, in front of a camera as behind a stethoscope. And his patients are as likely to see him in a movie theater as they are by their hospital beds.

That’s because the San Diego hospitalist has a schedule that allows him to build an acting career without giving up the patient care he loves. But don’t expect to see him playing a physician. The youthful-looking 46-year-old doesn’t match Hollywood’s “Marcus Welby, MD” image. He’s usually only considered for resident or intern roles despite almost two decades of experience working in medicine. “I’ve been a physician for more than 17 years, and yet I don’t look like a doctor, casting directors tell me,” he says.

From Dabbling to Passion

Dr. Krebs has been dabbling in acting since he was a resident, but it wasn’t until he became a hospitalist last year that made his acting passion a priority. He first became interested in acting in 1989 while he interned at Cedars-Sinai Medical Center in Los Angeles. Frequent contact with celebrity patients led to the offer of a role as an extra in the movie “Heart Condition,” (1990) a comedy starring Denzel Washington and Bob Hoskins.

“I thought it would be fun,” Dr. Krebs says. “Because they were filming in a restaurant a couple of miles from the hospital, it was convenient.”

The day he spent on the set in his non-speaking role taught him how things are done in Hollywood. Even though his efforts ended up on the cutting-room floor, the experience sparked a passion for acting that has grown stronger every year.

After completing his internal medicine residency in Los Angeles in 1989, Dr. Krebs moved to San Diego to become a primary care physician at Kaiser Permanente San Diego Medical Center. He found an acting teacher who held classes in San Diego on Sundays and began developing his craft.

Despite the demands of his work as a busy primary care physician, Dr. Krebs has racked up an impressive list of film and TV credits through the years. He was cast as a softball attendant in the martial arts film “3 Ninjas: High Noon at Mega Mountain,” (1998) the last of the “tween” movie “3 Ninjas” series. He played Agent Hans in “The English Job” (2006), a food critic in “Single White Female 2: The Psycho” (2005), a computer programmer in “Form 3254-A” (2005), and a young doctor in “True Vinyl” (2000), a romantic musical movie.

He has also performed in local theater, appearing in “Intrusion,” “Hypocrisy,” “Prelude to a Kiss,” “Apres Opera,” and “Ignoto’s Farewell” in San Diego, where he was often recognized by patients and colleagues.

Time for a Change

But the last-minute demands of an actor have conflicted frequently with his responsibilities as a physician. “I would be cast in a film and then not hear from the casting director for months,” Dr. Krebs explains. “Then the travel department could call one day and tell me I had to be on the out-of-town set in three days. There were times when I had to turn down a role because I won’t put my patients’ health on hold to do a film. I began to realize that if I really wanted to make a go of my acting, I needed to make some changes in my life.”

An opportunity presented itself last year when Kaiser Permanente in San Diego created two nocturnist positions for hospitalists. When Dr. Krebs heard about the positions, he quickly applied. “I thought that was perfect because all the auditions and filming happen during the day, and I could attend them if I worked at night,” he explains.

Dr. Krebs and another physician work 12-hour shifts beginning at 6 p.m. three times a week. For Dr. Krebs it’s Sunday through Tuesday nights. When his shift ends Wednesday morning, he drives the 125 miles from San Diego to his apartment in Los Angeles, catches some sleep, then assumes the role of Hollywood actor.

From Wednesday through Saturday, you might find him auditioning, taking acting classes, filming on location, doing the behind-the-scenes business of an aspiring actor, or attending a Hollywood party to network. On Sunday afternoon, he returns to the hospital in San Diego to begin another round of night shifts.

“Sometimes I can put in a 31-hour day if I have an audition in Los Angeles on Wednesday afternoon after my shift in San Diego Tuesday night,” he says. “Then I’ll be running on adrenaline, but it’s worth it.”

Balanced from the Beginning

A Southern California native, Dr. Krebs grew up near Disneyland, where he played clarinet during the bicentennial parade there in 1976. He knew he wanted to be a doctor when he was 7 years old. His grandfather was an optometrist, and Dr. Krebs spent many of his school holidays talking happily to his grandfather’s office patients.

Dr. Krebs graduated with honors from the University of California at Davis and received a medical degree from the University of California, San Diego, School of Medicine. He has been honored by Kaiser Permanente Medical Group with its Distinguished Service Award, its Everyday Hero Award, and its Primary Care Leadership Recognition Award.

Dr. Krebs says being a physician and an actor creates the perfect balance between his right and left brains: “The analytical side of my brain is satisfied by medicine, and my creative side is satisfied by being able to immerse myself in acting on my days off. It’s a perfect balance for me.”

Patients benefit from this balance, Dr. Krebs believes, because he brings to his job the increased empathy he’s developed as an actor. “My acting has absolutely enhanced my relationships with patients,” he says. “Acting requires developing intense listening skills. I’ve become a much better listener. Acting also requires you to focus on what the other person is saying, and that has helped me really focus on what patients tell me.”

Conversely, being a physician has helped him with his acting.

“Physicians are trained observers. Medicine has helped me become a better observer of people’s mannerisms and what they say about their character,” he explains. “And that training in observation makes me better able to relate to other actors.”

Two different careers also fulfill two different aspects of his personality.

“I’m a bit of a ham, although I don’t ham it up in my acting,” admits Dr. Krebs. “I like being noticed. In acting, it’s all about me, so I’m on the receiving end. But when I’m a physician, it’s never about me; it’s about the patient. So I’m the giver. I like that because it balances my life.”

Dr. Krebs played Dolph Lundgren’s brother, Jeff, in “Missionary Man.”

Win-Win Situation

Dr. Krebs isn’t the only one satisfied with his nocturnist position. It’s also “a win, win, win situation for the hospital,” says Ted Geer, MD, chief of internal medicine at Kaiser Permanente San Diego Medical Center.

“Administratively it’s great because there aren’t as many shifts that have to be covered by other physicians,” Dr. Geer explains. “It’s win-win for patients and the emergency room because we have more physicians who are up all night to help.”

While many hospitalists use their off hours to pursue hobbies, it’s unusual for them to have another profession. “It’s a credit to him that he’s able to have a second career,” says Dr. Geer.

Dr. Krebs is a well-respected clinician and a good internist, according to Dr. Geer. “His skills as an internist make him fit into this role very well,” says Dr. Geer. “He takes very good care of his patients.”

Overlapping Worlds

Dr. Krebs says his medical colleagues get a kick out of his acting career. “Many of their children own the “3 Ninjas” movie. They tell me they have spotted me in the film while watching it with their kids,” he says.

Actors are surprised when they find out about his medical career. Although Dr. Krebs doesn’t volunteer the information that he’s a physician, he’ll tell others in the film industry when asked. “I want to keep my two worlds separate, but I am proud of who I am and what I do as a physician.”

Sometimes those two worlds overlap. When Dr. Krebs was cast in “True Vinyl,” “The casting director asked me what I did in my off hours and, when I said I was a physician, he said, ‘OK, so you’re the doctor in the film.’ ”

For that movie, Dr. Krebs also served as the medical consultant, ensuring the medical scenes were accurate.

Even though he enjoyed the experience, Dr. Krebs doesn’t want to pursue more medical consultant opportunities; acting is his passion. “When I’m on the set, I’m an actor and that’s what I want to be,” he says.

Can Do

It takes a focused, high-energy person to succeed as a physician and an actor. Dr. Krebs keeps his stamina high by making his health a priority. He exercises almost every day, eats right, and surrounds himself with positive people. “I have always been a high-energy person; I’m never depressed and always look at the positive side of any situation,” he says.

He credits his parents with instilling in him an optimistic view of life. “They told us we could be anybody and do anything we wanted,” he recalls. “When I was told that I couldn’t compete at a high level in figure skating and go to medical school, I thought, ‘My parents said I could do anything I wanted and I want to do this,’ so I did.”

It may have been his figure-skating background that gave Dr. Krebs the fearlessness required of a successful actor, according to his manager, Fritz Friedman.

“He’s willing to take chances,” notes Friedman. “It’s a fearsome thing to take those leaps in skating that seem so effortless. The risk he takes, as all actors do, is that he will look foolish. But actors don’t care. They try and hope their bodies will listen to their brains.”

Friedman says Dr. Krebs’ acting style is dramatic and intense: “I think he has capabilities of comedic roles but they haven’t been offered to him yet,” he says. “I think, given the right opportunity, he’d be terrific at that. Jeff has a very strong on-screen presence. When he’s on screen, people focus on him. He’s charismatic.”

And That’s Not All He Does …

In his free time, Dr. Krebs loves to cook, travel, and take photographs. He entertains his friends with a meal made from scratch at least once a month and has hired chefs from local restaurants to teach him advanced cooking techniques. In October, he’s going to Tuscany to indulge all three passions with Italian culinary classes, travel, and photography.

With two careers and many interests, Dr. Krebs sometimes finds it hard to get enough sleep. Although he would like to take singing lessons and French classes, that’s more than he can handle right now. “Sleep has to be a priority so I can continue to make good medical decisions,” he says. And he admits that getting his laundry done “is one of my biggest challenges in life.”

Dr. Krebs recently focused his acting career on film and television, giving up theater. “Acting in plays is harder—if not impossible—with my new life as a nocturnist,” he says. Theater requires months of rehearsals, held in the daytime during the week. But choosing film was an easy choice. “I like watching myself on film so that I can learn from it,” he says.

Dr. Krebs says his favorite roles have been “any in which I can learn something new or develop a new aspect of myself.” In a film to be released this spring, “Half Past Dead II: Justified,” he plays an inmate at a maximum-security prison. “That was a stretch because I had to tap into my inner serial killer. Sometimes the roles that I play are in conflict with who I am,” he explains. “You learn that everyone has every possibility inside of them, and you have to tap into that.”

He does this by developing the back story, which in this case meant creating a character who had done something bad enough to be in Alcatraz. The film’s director called Dr. Krebs recently to praise his efforts.

In March, Dr. Krebs was in Dallas filming “Missionary Man,” starring Dolph Lundgren. It is a Western-style movie involving “revenge and redemption at the end of a gun barrel.” In the film, Dr. Krebs plays Lundgren’s brother; the character’s name was changed to Jeff. “Imagine having a character named after me,” Dr. Krebs exclaims.

The Perfect Combination

What would happen if Dr. Krebs landed a major film role or a long-term television series? Would he give up medicine to become star of the next “ER” or “Grey’s Anatomy”? Not if it meant giving up his medical career, he says.

“It would be very difficult for me to give up medicine completely because I really love being a physician,” Dr. Krebs admits. “I might take a leave for a month or two if a big film opportunity came along. But right now I’m happy with the roles I’m getting that allow me to continue my medical career.”

Dr. Krebs says he could not have been the kind of actor he is and practice the kind of medicine he wants to practice without being a hospitalist, and he’s grateful for the opportunity.

“I’m so happy the hospitalist movement has taken off in the last several years,” he says. “My life is much, much better since I became a hospitalist. I feel like I have it all.” TH

Barbara Dillard is a medical journalist based in Chicago.