Job Description
It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?
If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.
Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.
The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?
What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?
The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.
But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.