Expand beyond traditional roles: The push for improved quality will lead to expanded roles for pediatric hospitalists—some of which may be unwelcome.
In particular, larger programs will move to 24/7 in-house hospitalist presence. Given the acuity and complexity of the patients we care for, particularly in tertiary care centers, the quality argument for 24/7 in-house coverage will quickly trump the economic argument against it. The choice is obvious in terms of quality and safety and from the perspective of the most important “decider” when it comes to healthcare—the patient.
As educators exploit the opportunities of 24/7 coverage, resident teaching will increase and academic hospitalists will master the art of promoting autonomy 24/7 while providing appropriate supervision. If we learned to teach with family-centered rounds, we can learn to teach at 3 a.m.
In addition to expanded hours, we will follow the lead of adult hospitalists and increase our co-management role beyond the traditional general medical patient on the hospitalist service. This will include surgical and subspecialty patients. From the patient’s and family’s perspective the improved care that can result is valuable. It may not be necessary for every patient or for every surgeon or subspecialist, but on the whole hospitalists provide added value.
Within individual programs and among various physicians, the rules of engagement will need to be defined to promote collegial, respectful relationships with clear lines of communication and defined clinical responsibilities. “Inappropriate behavior” from “difficult” physicians (surgeons, subspecialists, and hospitalists) will need to be addressed. Specific arrangements will need to be defined (co-management versus specialist/surgeon attending with hospitalist consultation or hospitalist attending with specialist/surgeon consultant). But once the rules of engagement are established and appropriate resources allotted, it becomes impossible for hospitalists to argue that it’s not within our job description to contribute to improved quality of care for hospitalized patients. Improving patient care is not scutwork.
In particular, given the limited availability of pediatric sub-specialists and surgeons, to the extent that we as hospitalists can increase the efficiency of our subspecialty and surgical colleagues, we can improve access to pediatric subspecialty care within both the inpatient and outpatient settings These manpower issues will also drive involvement of pediatric hospitalists into other parts of the hospital such as sedation services, the ED, the NICU, and PICU. As these other services become vocal advocates for pediatric hospitalists, the economic viability of pediatric hospital medicine programs will increase.
Make the economic argument for value-added services: Pediatric hospitalists must do better at the economic arguments of value-added services.
Until pediatric inpatient stays are reimbursed on a DRG basis or physician charges are based on a global fee, we most move beyond the simple formulation of decreased costs for inpatient stays. We must highlight the value of our critical roles in coordination of care; quality and safety; 24/7 coverage; improved throughput in the emergency department (ED), ward, and PICU; and increased efficiency for surgeons and subspecialists.
Success for pediatric HM in these arenas will come only at the cost of failed individual programs. As implied above, it is only natural for non-hospitalist administrators and department leaders to push the limits of hospitalist programs to the maximum. Programs that place excessive demands on hospitalists will implode. Good hospitalists will leave for positions that offer them respect, autonomy, and a reasonable workload and lifestyle. Small community programs with low-volume services may not be economically viable. As we develop a history of successful programs and failed programs, hospitalists and administrators will have more realistic expectations of the ingredients of success.
Conclusion
Programs that meet the above challenges will succeed. Pediatric HM is a tremendously rewarding and challenging field. National recognition of pediatric HM as a unique field combined with the respect of local pediatricians, subspecialists, and surgeons will create the pride and ownership among hospitalists necessary for us to raise the bar for standards of inpatient care.