The Hospitalist Role
More than almost any other medical specialty,
hospitalists play an active role in improving the
hospital environment as a whole by participating in
quality initiatives, protocol development and other
leadership activities. In many hospitals they are the
de-facto providers of pain and symptom management
for seriously ill patients, and they frequently interact
with the ER and ICU, as well.
This focus for hospital medicine suggests a natural
affinity with palliative care. In fact, the professional
organization for hospitalists, the Society for Hospital
Medicine (SHM), recognizes palliative care as a
core
competency for hospitalists.1 SHM’s
past president, Dr. Stephen Pantilat, director of the
palliative care service at the University of
California-San Francisco Medical Center, has
been an important
national advocate for the hospitalist’s role in
advancing palliative care in the hospital.
The Growing Field
“Hospitalists are becoming predominant medical
providers of hospital care,” Pantilat noted in a
CAPC-sponsored national audio conference on May
18. Forty percent of U.S. hospitals now employ
hospitalists to manage in-hospital patient care; many
others are planning to do so. There are approximately
12,000 working hospitalists in the United States and
the number could grow to 30,000 by
2010. “Hospitalists are providing care for many
hospitalized patients who need palliative care,”
including the half of all Americans who die in
hospitals, he said.
Hospitalists, in growing numbers, recognize the
importance of palliative care to their work, but many
feel they have not received adequate training in
palliative care. Pantilat added that data from the
Robert Wood Johnson-funded California Hospital
Initiative in Palliative Services (CHIPS) project care
suggest that the presence of hospitalists in a hospital
is positively correlated with success in establishing a
palliative care service, regardless of whether the
hospitalists were actively involved in the program’s
development.
Hospitalists are uniquely qualified and positioned to
lead efforts to improve access to palliative care in
the hospital setting, with natural alignments in care
goals and parallel competencies, Dr. Howard Epstein,
a hospitalist at Regions Hospital in St. Paul, Minn.,
said in a presentation at the National Hospice and
Palliative Care Organization’s Clinical Team
Conference in San Diego, Calif., in April.
Epstein led a two-year planning process to launch
the palliative care consulting service at Regions in
2005 and now participates with six other members of
the hospitalist service in providing palliative care at
the hospital. They also assume medical management
of patients from an affiliated hospice program who
are placed in the hospital for inpatient hospice care.
Creating the Alliance
How can palliative care advocates take advantage of
this natural affinity? Epstein said they can start by
recognizing the parallels between hospital medicine
and palliative care, such as:
- The need to document improved clinical, customer
satisfaction and financial outcomes for the hospital in
justifying each service’s existence;
- The need to educate other physicians about the
value and appropriate utilization of each service;
- Their shared focus on helping patients transition
to other levels of care including, when appropriate,
referral to hospice; and
- Recognition of the importance of the
interdisciplinary team.
Palliative care advocates are advised to learn the role
hospitalists play in their institutions, identify and
recruit potential palliative care champions from within
the hospitalist service, and suggest roles that those
champions can play in the development and provision
of palliative care.
The most basic role is for the hospitalist to recognize
which hospitalized patients could benefit from
palliative care consultations and refer them to the
palliative care service. With education and
convenient printed referral guides from the palliative
care service, hospitalists could become major
referrers to palliative care.
Hospitalists who recognize a personal interest in
palliative care can obtain additional training from
CAPC, the American Academy of Hospice and
Palliative Medicine or similar groups. The palliative
care tools, concepts and perspectives they learn
could then be incorporated into their daily practice.
They can also participate in quality improvement
initiatives such as writing protocols for ventilator
weaning or pain management.
If there is no palliative care service at the hospital,
hospitalists can advocate for establishing one,
participate in a planning or organizing committee, and
then remain active on the palliative care
interdisciplinary team or medical advisory committee.
Some may take on direct clinical responsibilities as
attending physicians on the palliative care service.
An advanced step is for the hospitalist to become
board-certified in hospice and palliative medicine and
take a leadership role in palliative care for the
hospital.
However, experienced practitioners caution against
the danger of trying to add palliative care
responsibilities to existing full-time commitments as a
hospitalist. “Zero FTEs is not viable in the long run”
for a palliative care physician, Dr. Susan Block of
Harvard Medical School noted in a recent article in
The Hospitalist, a magazine published by
SHM.2 Many hospital medicine services
are busy and struggling to hire enough staff to keep
up with demand, while a day working on the
hospitalist service can be intense, Pantilat added.
A more viable alternative might be for several
members of a hospitalist group practice to
incorporate palliative care rotations into their
schedules, or to have a reduced hospitalist caseload
on days when they are covering the palliative care
service. Other creative scheduling approaches may
need to be explored. Hospitalists could also provide
medical back-up to a full-time nurse practitioner who
carries most of the caseload for the palliative care
service, or round with the palliative care service one
hour a day.
For hospitalists who find that they enjoy and are
good at family meetings, medical goal planning or pain
management, palliative care can offer opportunities
for diversity and enhanced satisfaction in their jobs,
for working with a high-functioning interdisciplinary
team, and perhaps for an additional revenue stream
of billing for medical consultations.
Hospitalists can either lead, participate in or refer to
palliative care, Pantilat concluded. The natural link
between hospital medicine and palliative care can be
a win-win proposition for the hospitalist, the hospital,
the palliative care service and the patient and family.
1See: www.hospitalmedicine.org/Content/NavigationMe
nu/Education/CoreCurriculum/Core_Curriculum.htm.
2Beresford L. Palliative care services
offer new horizons for hospitalists. The
Hospitalist, July/August 2005, p. 10-15.
