Familiar Territory
At first glance, the significant time commitment and lackluster reimbursement of many bedside procedures would seem to do little to up the incentive for busy hospitalists. “If they have to stop and take two hours to do a procedure that 1) they don’t feel comfortable with and 2) they get very little reimbursement for, why not just put an order in and have interventional radiologists whisk them off and do these procedures?” Dr. Wang says.
Robert L. Vogelzang, MD, FSIR, professor of radiology at Northwestern University Medical School in Chicago and a past president of the Society of Interventional Radiology, says radiologists are regularly called upon to perform bedside procedures because of their imaging expertise.
“Virtually all of us started doing this because we were asked to do cases that couldn’t be done by others because we had imaging—usually ultrasound guidance—and that yielded superior results,” he says.
Dr. Vogelzang says he’s “specialty-agnostic” about who should perform the procedures, as long as they’re done by well-trained providers who use imaging guidance and do them on a regular basis. Hospitalists could defer to radiologists if they’re uncomfortable with any procedure, he says, while teams of physician assistants and nurse practitioners might offer another cost-effective solution. Ultimately, the question over who performs minor bedside procedures “is going to reach a solution that involves dedicated teams in some fashion, because as a patient, you don’t want someone who does five a year,” he says. “Patient care is improved by trained people who do enough of them to do it consistently.”
So why not train designated hospitalists as proceduralists? Dr. Lenchus and other experts say naysayers who believe hospitalists should give up the role aren’t fully considering the impact of a well-trained individual or team. “It’s not just the money that you bring in—it’s the money that you don’t spend,” he says. An initial hospitalist consultation, for example, may determine that a procedure isn’t needed at all for some patients. Perhaps more importantly, a well-trained provider can reduce or eliminate costly complications, such as CLABSIs.
If [busy hospitalists] have to stop and take two hours to do a procedure that 1) they don’t feel comfortable with and 2) they get very little reimbursement for, why not just put an order in and have interventional radiologists whisk them off and do these procedures? —Sally Wang, MD, FHM, director of procedure education, Brigham and Women’s Hospital, and clinical instructor, Harvard Medical School, Boston
Dr. Wang agrees, stressing that the profession still has the opportunity to build a niche in providing care that decreases overall hospital costs. Instead of regularly sending patients to the interventional radiology department, she says, hospitalist-performed bedside procedures can allow radiologists to focus on more complex cases.
A hospitalist, she says, can generate additional value by eliminating the need to put in a separate order, provide patient transportation, or spend more time fitting the patient into another specialist’s schedule—potentially extending that patient’s length of stay. The economic case for hospitalist-led procedures could improve even more under a bundled payment structure, Dr. Wang says.
“I see a future here if the accountable care organizations are infiltrated through the United States,” she says.
Future involvement of hospitalists in bedside procedures also could depend on the ability of programs to deliver top-notch teaching and training options. At Harvard Medical School, Dr. Wang regularly trains internal medicine residents, fellows, and even some attending physicians with a “robust” curriculum that includes hands-on practice with ultrasound in a simulation center and one-on-one testing on patients. Since instituting the training program a few years ago, she says, procedure-related infection rates have dropped to zero. Within the hospital’s ICUs, Dr. Wang says, complication rates have dropped as well.