Latest news with #hospitalist
Forbes
26-06-2025
- Health
- Forbes
Patient Survival Jumps If In-Hospital MD Aced Assessment Test: Study
Patients are significantly likelier to survive a hospital stay if their hospitalist scored in the ... More top quartile on a knowledge test linked to board certification. The odds that a patient survives a hospital stay sharply increase if the physician overseeing in-hospital care aced a special test designed to assess doctor knowledge and judgment, according to a new study. The study found that patients of hospitalists who placed in the top quartile of a professional exam from the American Board of Internal Medicine were nearly 8% less likely to die within a week than the patients of doctors with lower scores. In an interview, Furman McDonald, a hospital medicine specialist who's president and chief executive officer of ABIM, emphasized that the actual number of patient lives affected by the relative difference among physicians was 'massively significant.' 'The absolute difference in mortality is about four people per thousand hospital admissions,' said McDonald. 'By way of comparison, the mortality from cardiovascular disease, the number one killer in this country, is about two patients per thousand. So this is a massively significant result.' Assessing Knowledge The professional exam, known as the Longitudinal Knowledge Assessment, is given quarterly and is designed to both assess physician clinical knowledge and encourage learning. Every five years, ABIM determines whether the physician maintains board certification – a prestigious designation that also has concrete economic value. The study examined the medical records of more than 260,000 Medicare patients and the test scores of more than 4,000 physicians specializing in hospital medicine. If all hospitalized patients had fared as well as those cared for by physicians who achieved the top quartile in knowledge and judgment, 1,069 lives would have been saved yearly just considering the first week of care, the study's lead author, ABIM health economist Bradley Gray, said in an interview. Top scorers also had fewer readmissions, suggesting fewer complications. 'The patient has a better prognosis if the doctor knows more,' said McDonald. The expertise of the doctor really matters." The predictive value of tests of doctor knowledge has known for decades and has been repeatedly reaffirmed in focused studies involving hundreds of thousands of patients and many different specialties, McDonald said. This study, published as a research letter in JAMA Internal Medicine, was designed to assess whether the results of this newer exam correlated with better patient outcomes. The connection between ABIM board certification and patient outcomes, if substantiated for all the subspecialties the ABIM certifies, could easily affect many millions of Americans. The group oversees some 270,000 physicians practicing in 22 different subspecialties. A previous study sponsored by the ABIM found that the score on its exam for internal medicine trainees applying for certification for the first time was also associated with improved patient outcomes and reduced readmissions. McDonald says the group plans to continue its test assessment effort. One notable feature of this study was a methodology that allowed researchers to compare different doctors as if they were working in the same hospital so as to minimize any influence the facility might have on outcomes. In addition, various adjustments to reduce the risk of misleading conclusions meant the researchers were 'underestimating the extent to which the higher scores are flags of quality,' said Gray. 'We really wanted to have a believable research design.' Open Book Beats Closed Room Before the Longitudinal Knowledge Assessment exam was instituted as an option in 2022, all physicians seeking to be recertified by the ABIM took a detailed, all-day test in a controlled environment every ten years. The LKA, in contrast, is a 30-question, open-book exam given every quarter, with a dashboard telling the doctor the correct answer to each question and, in detail, how they fared in comparison to the ABIM certification standard and their peers. That continual feedback is meant to prompt focused improvement before the recertification test, which is given every five years. McDonald acknowledged he was 'stunned' when a clinical trial the group ran to evaluate alternative approaches to administering the new test showed that the open-book approach most produced results most likely to accurately discriminate among different clinicians. 'It was better able to tell the doctors who knew less from the doctors who knew more,' said McDonald. 'It was amazing.' The approach worked, McDonald suggested, because of the way the questions are designed. ABIM spends a substantial amount of time and money developing and validating realistic clinical vignettes. The goal is for the answers to reflect reliable judgment, not rote knowledge. 'It turns out the doctors who know more are even able to know what to look up and how to look it up,' McDonald said. Thus far, use of artificial intelligence chatbots has not been a problem, but the group is closely monitoring the potential for abuse. Physicians seeking board certification are highly motivated to learn how to be better doctors, Gray and McDonald both noted. Over time, looking at how doctors' scores change and evolve, 'we'll be able to see whether learning results in improvement in patient care,' Gray said.
Medscape
13-06-2025
- Health
- Medscape
More Hospitals Turning to Nurse Practitioners. Here's Why
Every evening, nurse practitioner (NP) Arnold Facklam arrives at South Georgia Medical Center in Valdosta, Georgia, an hour before his two physician counterparts. As an NP nocturnist, a hospitalist who works overnight, Facklam's role is to supplement the care provided by the physicians on his team. He believes he offers a valuable service to his Apogee Physicians hospitalist group, able to spend more time with patients than his doctor colleagues, who carry bigger patient loads, while freeing them up to handle more acute cases. 'Both physicians and NPs do the same tasks, but they divide them up differently,' said Facklam, a hospitalist for 18 years. 'Programs of a certain size need to bring in experienced NPs and PAs [physician assistants] that can step into the role and do the tasks to take care of the patients from admissions to discharge, and consultations.' The classic definition of a hospitalist as a primary care physician is rapidly evolving and the vast majority of hospital medicine groups today use advanced practice providers such as NPs like Facklam, for adult care, according to the Society of Hospital Medicine (SHM)'s latest industry reports. In most hospitals, NP hospitalists supplement the care their physician counterparts provide, though some small rural hospitals may staff their hospitalist programs entirely with NPs with oversight from a collaborating physician who may not be on duty at the time. Whether to reduce staffing costs or fill gaps in physician shortage areas, hospitalists are navigating a new landscape to determine the most effective use of NPs in the hospital setting. Physicians and NPs sharing hospitalist responsibilities are learning how to divide their duties, improve their professional relations, and maintain job satisfaction. Medscape Medical News consulted a handful of hospitalists about the pros and cons of the new staffing models. Value of NP Hospitalists Saving money tends to be the biggest advantage of using NPs as hospitalists. The average total compensation for NPs was $135,000 in 2023 or about 60% less than for physician hospitalists, $321,000, according to Medscape's 2024 compensation reports for physicians and NPs. Third party private insurers and the Centers for Medicare and Medicaid Services reimburse NPs at 85% of the physician rate, which can help reduce costs. Among the other benefits of using NPs, they help reduce hospital wait times and because they tend to manage fewer patients than doctors, can spend more time with them, according to research cited by the American Association of Nurse Practitioners. NPs also fill a void in patient care when hospitals have difficulty attracting physicians or are short-staffed in small or rural hospitals, which tend to be workforce shortage areas. The Health Resources & Services Administration projects a 22% staff shortage of hospital physicians by 2035. Meanwhile the US Bureau of Labor Statistics consistently reports NPs among the nation's fastest-growing occupations with a projected 46% growth rate between 2023 and 2033. Nikhil Sood, MD In the past few years, Nikhil Sood, MD, has witnessed 'a monumental' increase in the number of NPs working alongside him as a hospitalist at Banner Gateway Medical Center in Gilbert, Arizona. 'Utilizing NPs' expertise can significantly improve care delivery,' said Sood, who treats patients with cancer. NPs also can alleviate physician burnout and enhance patients' access to care, he said. 'I have partnered with NPs who are outstanding clinicians, meticulous in their work, empathetic in nature, and collaborative. They bring a nursing perspective…often identifying psychosocial or care coordination issues that might otherwise go unnoticed.' Monique Nugent, MD, MPH, appreciates the specialty care the advanced practice providers on her hospitalist team offer patients. She finds them fully capable of supplementing physician care. 'They work really well with our group. They are a huge support, and they are no less hospitalists than physician hospitalists,' Nugent said about her Advanced Practice Professional (APP) colleagues specializing in cardiac and oncology care at South Shore Hospital in Weymouth, Massachusetts. 'Patients benefit from people with a specialty and who know how to navigate medicine.' Challenges of NP Hospitalists Nugent doesn't believe hospitals should focus solely on the savings just because APPs traditionally earn less than doctors. 'You still need highly qualified people…You have to invest in the person if you want them to do good work,' she said. Hospitals should provide support such as case management, a safe patient load, and an appropriate level of malpractice insurance, Nugent said. Monique Nugent, MD, MPH 'If a hospital has 200 patients and there are 20 doctors who take care of 10 patients each, you can't replace the doctors with APPs and expect them to be comfortable caring for the same number of patients. It's not simply a math question,' she said. Staffing calculations also need to include additional administrative requirements for APPs mandated by law and whether states require physician oversight of APPs, Nugent stressed. More than half of the states give NPs full practice authority to manage patients independently of physicians, but only a handful of states offer full or optimal practice authority for PAs. 'If the system employs PAs and NPs simply because it costs less, they are missing the value they bring to the system,' she said. 'How can we support everyone in their practice so we can support the patient? I work with NPs that are really great at their job. Working that way allows us to be great,' Nugent said. John Nelson, MD, who co-founded the SHM, said hospitals may add NPs or PAs because they can't recruit doctors in rural areas, or they want to pay less for staffing. But those hospitals may not have carefully considered exactly what the APPs will do, their job description, how they will help doctors see patients, said Nelson, a hospitalist and partner in Nelson Flores Hospital Medicine Consultants. In some cases, physician hospitalists are partly to blame for the lack of direction APPs receive. The doctors are happy to gain assistance even with menial tasks and without the responsibility of paying salaries, they don't worry about wasteful spending, Nelson said. 'Hospitals are not paying enough attention to realize what is going on.' Facklam said his hospitalist program clearly defines the job responsibilities of the team. When he starts his duties at 6 PM, he works on admissions and when physicians come in at 7 PM, he provides cross coverage for the hospital and three outlying facilities. He realizes there has been a rapid increase in APPs as hospitalists created a challenging dynamic for physician hospitalists. Some understand and trust the credentials and capabilities of APPs and allow them the freedom to work effectively. But those who never worked with NPs may not know what to expect and may fear NPs will take their jobs. 'It's a work in progress,' Facklam said of physician-APP relationships. 'I think it takes time for people to realize [APPs] are qualified and capable of serving in the role they are asked to do.' But Facklam admits he may have been accepted by physicians faster than other NP hospitalists with a quicker adjustment period as a former critical and emergency care nurse and paramedic. 'I had experience that led up to it. If it was someone else, they may take a little longer to feel comfortable,' he said. Hospitals also have to navigate state and federal regulations regarding NPs, including how they can bill state and federal insurance companies and whether they need physician oversight, hospitalists said. Nearly half of NP and PA work is billed as a combination of both independent and shared services billing with the collaborating or supervising physician, according to SHM's latest State of Hospital Medicine Report. Working Effectively as a Hospitalist Team For NPs to make a smooth transition into hospitalist teams, ensuring quality and safety, requires a strategic and organized environment, Sood said. He added that such integration is particularly important when providing specialty care, such as in cancer hospitals, where there's a high rate of clinical complexity. 'Patients frequently require intricate decisions regarding chemotherapy side effects, palliative care strategies, or complications from immunotherapy. Practical experience and oncology-specific training are essential,' he said. John Nelson, MD He doesn't think NPs should be expected to operate autonomously in high-acuity or complex settings without sufficient support. 'This not only affects patient outcomes but can also create unnecessary pressure on the NPs.' A team-based approach allows NPs and physicians to regularly consult each other and manage patient care, Sood said. While NPs deserve to be respected and empowered, they also should be 'guided by clear practice scopes, mentorship, and structured clinical pathways,' he said. Nelson believes APPs can contribute professionally to the hospitalist team and find greater job satisfaction if they collaborate with physician hospitalists and receive appropriate training. In 2024, about 11% of NPs held certifications in acute care, according to AANP. Acute care generally focuses on the type of treatment patients receive in a hospital such as for accidents or emergencies. APPs also should have a 'significant say' about their roles on the team and how they could have the most impact, Nelson said. 'They should be part of the conversation if not leading it.'
Medscape
30-05-2025
- Health
- Medscape
Key Challenges Faced by Today's Hospitalists
On any given day, Andrea Braden, MD, must make quick clinical decisions about hospital patients who require emergency care. Her biggest challenge as a hospitalist is 'the anxiety around never knowing what is going to come in the door that day,' said Braden, who is also an OB/GYN and lead clinical educator for TeamHealth in Atlanta. 'There is no way to predict whether your day will be calm or disastrous. I think having to be prepared for both scenarios at all times is what keeps us hospitalists on edge. It's also what makes us great at our jobs — the ability to take control of emergencies and guide our teams appropriately.' Braden and other hospitalists share their most common day-to-day challenges with Medscape Medical News . Healthcare Funding and Insurance The role of a hospitalist doesn't end at discharge, said Monique Nugent, MD, a hospitalist at South Shore Hospital in Weymouth, Massachusetts. Nugent said her biggest challenge is the ever-changing landscape of healthcare funding and what insurance companies will cover, such as medical services and devices that help her ensure the continued health of her patients after they leave the hospital. 'It affects the care I can give people and affects their long-term prognosis,' she said. While Nugent is thankful for the work of her case management team, she said she still spends a lot of time working around what insurance will pay for patients' healthcare needs. 'I have to make sure I prescribe meds they can get,' Nugent said. 'Can they get into rehab or long-term care? Can they safely be at home? Are they able to access specialists after discharge?' If a patient qualifies for certain services, such as hospital-at-home, the next step would be to ensure that service is available in their area, Nugent said. For instance, someone who lives in a rural community may come to a Boston-area hospital for a stroke. After discharge, however, a patient may not have access to certain rehabilitation services, or their insurance may not cover services to ensure they continue to improve once they are released from the hospital, she said. Another example: If a patient prefers hospice care at home, will their insurance cover what's needed for this? 'How can I help navigate that so that they will be supported?' Nugent said. Balancing Act Ethan Molitch-Hou, MD, cited time constraints as a primary challenge for hospitalists. 'We have limited time to care for complex patients who are only getting sicker as we move more care to outside of the hospital,' said Molitch-Hou, who is an assistant professor of medicine and director of the Hospital Medicine Sub-Internship at the University of Chicago Medicine, Chicago. 'There is a constant battle to balance handling your sickest patients who need your focus and time to get the correct diagnosis and treatment, while the push for an early discharge or assuring your patient who is unhappy about events in the hospital (that may be out of your control) is also cared for,' he said. 'Conversations that you know require time and nuance can be interrupted by a page about something that, at the moment feels, less consequential, such as a stool softener when in the middle of a rapid response for a hypotensive patient.' Despite the time constraints, Molitch-Hou said hospitalists need to clearly communicate their care plans to their patients and families to ensure compliance. He said hospital physicians need to remember the reason they went into medicine and focus on the positives. Those are keys to having a long career in hospital medicine, he said, 'and for me, having variety in my week-to-week responsibilities has kept the job fresh.' Between Empathy and Burnout As a hospitalist working in a cancer hospital for the last 9 years, Nikhil Sood, MD, said one of his most persistent challenges is 'managing clinical uncertainty amid high emotional intensity.' 'On particularly tough days, when I feel mentally and physically drained after a difficult conversation about prognosis and care goals with a family, it becomes harder to be fully present, listen intentionally, or provide the high level of care I expect of myself,' said Sood, an internist and hospitalist at Banner Gateway Medical Center in Gilbert, Arizona. Unlike in general medicine, the symptoms of his patients tend to be specific to the individual and don't always align with typical textbook patterns, Sood said. 'Each decision comes with substantial weight and little margin for mistakes,' he said. Many oncology patients are immunocompromised, and complications may escalate quickly from seemingly benign symptoms, such as a low-grade fever or vague abdominal pain, he said. 'Symptoms frequently represent a delicate balance between disease progression, treatment side effects, and secondary issues, such as infections, thromboses, or metabolic imbalances,' he said. Lab results can be ambiguous with imaging yielding inconclusive findings. 'Layers of uncertainty often obscure the 'right' answer,' said Sood. 'As a hospitalist, I am expected to swiftly navigate these gray areas, assimilating comprehensive oncologic histories and making urgent choices in the absence of perfect information, all while ensuring compassionate communication with patients and their families.' Meanwhile, many of his patients and their families are knowledgeable, highly engaged, and expect informed answers, he said. 'Delivering bad news is a routine part of my work, yet it never feels ordinary. Compassion fatigue is a genuine concern, and I continuously navigate the fine line between empathy and burnout.' Sood said he's grateful to his employer for understanding the intense challenges of oncology care and offering social outings, regular wellness initiatives, and 'a culture that prioritizes mental health and self-care.' Despite the challenges, Sood finds his role 'profoundly meaningful and rewarding,' he said. 'The privilege of being part of a patient's most vulnerable moments — whether filled with hope or heartbreak — is something I always value.'
Medscape
06-05-2025
- Health
- Medscape
FAQs About Working as a Hospitalist
Hospitalists serve a unique role in patient care. Rather than focus on a specific organ system or disease, hospitalists specialize in the comprehensive care of hospitalized patients. They see patients of all ages and backgrounds dealing with chronic and acute illnesses, emergencies, surgeries, and a range of other causes that have put them in the hospital. A 2022 report from the Society of Hospital Medicine determined that there were around 44,000 hospitalists in the United States, and those numbers were only climbing. For medical students seeking a better understanding of what it means to pursue a career in hospital medicine, we turned to Heather Nye, MD, professor of medicine at the University of California San Francisco and associate chief of medicine at San Francisco VA Health Care System, San Francisco. She also serves on the Board of Directors of the Society of Hospital Medicine. Medscape Medical News asked Nye to share five key aspects about working as a hospitalist. Her responses are given below: At what point did you decide to become a hospitalist and why? 'I decided to become a hospitalist near the beginning of the movement in the late 1990s. I worked with brilliant hospitalists as a resident and learned about their jobs, their ability to teach residents and make quick, high-impact decisions for sick inpatients. It seemed fun and not at all mundane. It's been a thrill to watch the field grow into many different niches in need of experts, such as skilled nursing facilities, palliative medicine, perioperative medicine, addiction medicine, etc. We are problem solvers with a broad lens and our impact continues to grow. Hospitalists are now the healthcare system experts — often serving in C-suite roles, quality and patient safety leadership roles, and many other critical operational areas. [Hospitalists are] well-poised to address the rapidly changing landscape of medicine today.' What are work-related challenges that may be unique to hospitalists compared with other specialists? 'Hospitals never close. As a result, hours and schedules for hospitalists can be intrusive — and regularly include nights, weekends, and holidays. While the spry and youthful hospitalist just out of residency is accustomed to this work schedule, as family responsibilities grow — and as we enter mid-to-late career — the 7 days on, 7 days off or other common schedules can be grueling. Another challenge is the breadth of our practice. Like outpatient primary care physicians, our ground covers every organ system, psychosocial issues, and everything in between. In a patient with heart failure, acute coronary syndrome, kidney failure, and out of control diabetes, the fourth left toe pain is still under your purview and may be a meaningful sign of underlying process that must be addressed.' What are keys to effective communication with patients? 'I've always believed that hospitalists are the consummate interpreters. We synthesize loads of complex information coming from specialists, diagnostic studies, and knowledge of procedures and treatments and must simply describe options, connect the dots between systems, and help patients make decisions around treatment options. This is a heavy lift, and my favorite part of being a hospitalist. Creating an 'aha' moment for a patient by drawing a simple figure on a piece of paper — for example, the kidneys and bladder and how urinary obstruction causes problems — is a very effective strategy. Writing out on a whiteboard pain regimen options available to patients or discussing medications and indications for each is often eye-opening and not done nearly enough for patients. Sitting at the bedside has been shown to be effective time and again for making patients feel heard and promoting good communication.' What's a typical schedule for a hospitalist? 'Many hospitals employ 7 days on, 7 days off strategy with 8- to 12-hour shifts for days and 8- to 12-hour shifts for nights. Academic centers, like my own, have a number of different services — such as resident ward teams, hospitalist ward teams, surgical comanagement, and consults — each of which may have a different stretch of time covered. In systems with resident inpatient teams, a hospitalist attending physician will often be on for 1-2 weeks at a time. At my facility, we do sporadic weekend and evening shifts to ensure a hospitalist is available 24/7 for admitting, resident supervision, and hospital emergencies.' What's a common misconception about hospitalists? 'One misconception might be that hospitalists are glorified residents and do not have a specific skillset or knowledge base required for practice. This couldn't be further from the truth. First of all, acute care medicine is very different than primary care and requires procedural skills, quick synthesis of information, and knowledge of appropriate diagnostic studies. The syntheses of multi-organ illnesses is also a unique area in which hospitalists excel. Secondly, understanding and mastering hospital systems is sometimes as important as clinical knowledge in caring for patients admitted to the hospital. Navigating these systems swiftly and effectively can be critical for optimal outcomes, and most especially, transitions back to the community. I like to say hospital medicine is 'full service' medicine — bedside to home.'
