In Response to a Colleague’s Question…

Q:Dear Colleagues,
We are starting a new hospitalist service (non teaching) in an academic institution. Currently we have a system that mandates ED physician to call hospitalist (non teaching) for all inpatient admissions. Then hospitalist will decide whether patient needs to be admitted or not. If needs admission, he needs to decide whether it is for teaching and non teaching. All the non teaching admissions will go for hospitalist service. If it is a teaching admission he needs to call the resident for the admissions.
I am curious about thoughts. Is it going to be sustainable for long time without hospitalist being burn out quickly and treated as a second grade academician?
I am also curious how to integrate the non teaching service with teaching service.

Reply:

This is a very common scenario at many teaching programs (both university and community types).

In my opinion, the “non-teaching service” concept can be difficult to manage. As one of my former professors stated in Oslerian fashion,”All patients are teaching cases.”

That being said, the reality of life post-ACGME mandate is not conducive to such altruistic axioms.

When developing a model that puts Emergency Room Physicians in a position to “justify” the admission, a whole new paradigm manifests.  My first recommendation is to take a close look at how those admission decisions will be made. If you give the Hospitalist the option to “refuse” an admit, you are setting the stage for conflict. So, to avoid “negotiating” admissions my recommendation follows:

If the ED Attending (not PA, or NP, or R3) feels that the best disposition for a patient is the hospital, AND the patient meets INTERQUAL or other standard criteria, the patient should be admitted.  Even if the INTERQUAL criteria are not met, and the ED Attending makes the disposition to Observation status, this should be honored. Now, if the Hospitalist or Nocturninst has gone to the ED, seen and evaluated the patient and still disagrees with the ED Attending’s disposition, the Hospitalist may  be in a position to offer advice to the ED Attending on how to most safely and effectively dispo the patient. This should be a rare circumstance. In no case should a hospitalist deny an admission without having personally seen, evaluated and discussed the patient with the ED staff.

With respects to the distribution of “teaching” cases:

Clearly define what your group feels is a “teaching case” compared to the residency director’s definition of “teaching case.” This MUST be negotiated and the criteria must be clearly written. In no situation do you want the on-call hospitalist “negotiating” admissions with the trainees. Likewise, you do not want to jeopardize the training program by “breaking the rules.”

Oh, and remember not to wake up the intern during their nap….

I hope this is helpful advice and I welcome discussion from the community.

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