Hospitalists See Benefit from Working with ‘Surgicalists’

For a Model That Many Say Makes Sense, Why Not More Growth?

Surgicalists and hospitalists say that collaboration between the two groups of specialists brings a smoother process, generates better outcomes, and offers greater job satisfaction.

So why hasn’t the surgicalist field exploded? About 10 years ago, that’s what was predicted. In 2007, John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM, wrote an article saying the field could be close to a “surge” similar to the medical hospitalist explosion.1

It’s not known how many of the nation’s roughly 5,600 hospitals use a surgicalist model. There is no association for surgicalists, who are also sometimes called “surgical hospitalists.”

But according to Dr. Nelson’s anecdotal impressions, the number could range from 300 to 800 hospitals, he says. That would mean it is in place only in roughly 10% of U.S. hospitals.

Expansion of the field has been slowed by cost and politics.

Most hospitals don’t have enough surgeons to pull off a surgicalist program, and adding the right number of surgeons costs money, Dr. Nelson says.

And at smaller community hospitals that have used on-call surgeons for years, it’s a thorny issue. Those surgeons often get a call stipend for being on call. If surgeons don’t have a full slate of elective surgeries, they could rely on that on-call pay and resist the adoption of the surgicalist model, which would mean losing that pay, Dr. Nelson says.

“Some of the surgeons in the community might say, ‘I don’t really like ED call, but I have to keep doing it because of the stipend. I depend on it for my income,’” he says.

Even those who wouldn’t mind losing that on-call pay might not be enthusiastic about a move to a surgicalist model because it would bring more general surgeons into the region.

Some, Dr. Nelson says, might say, “How do I know that in two years they aren’t stealing my referrals? The new surgical hospitalist is also a potential competitor for referrals I depend on.”

And other surgeons might resist simply because they like the professional gratification of emergency surgery work, he says.

According to John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,2 “In a lot of academic centers that didn’t pay call stipend, this was just very simple for them to implement some model of this. … Once you try to send someone to an established group where there was already someone taking call, that became very controversial, and I’ve seen litigation result from that.”

Trauma surgeons resisted the model, at least in part, because of semantics: The term “surgical hospitalist” was too similar to “medical hospitalist,” and they worried it might imply a lack of surgical training, says Dr. Maa.

For now, the typical assessment of the model that Dr. Nelson hears is: “They’ve thought about it, they may in the future, but no, they don’t have one.”

“It’s not growing as fast as the medical hospitalist idea did,” he says. “But it is growing. It’s not going to go away, but it’s still relatively small.”

—Thomas R. Collins

References

1. Nelson J. The surgical surge. The Hospitalist website. Accessed October 25, 2016.
2. Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 ;205(5):704-711.