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Saturday, November 19, 2011

how to become a hospitalist part 1

The field of "hospital medicine" has become increasingly popular in the last 10 years, especially for internal medicine physicians. When a person finishes medical school and enters residency, there are nearly boundless possibilities. Residency choices can include specialties such as radiology, surgery, dermatology, emergency medicine, neurology, psychiatry, family practice, pediatrics, obstetrics and gynecology, pathology and lab medicine and even internal medicine. I'm sure I'm missing something. If a person chooses internal medicine, she can still choose to become a cardiologist, rheumatologist, endocrinologist, oncologist or...again I'm sure I'm missing something. But after 4 years of medical school and then 3 years of internal medicine residency, which is a job, but with almost no time off and very little pay, some people are ready to start doctoring. I wanted to be able to be useful anywhere and be able to use the knowledge I'd spent so much time  picking up in medical school to its fullest, and felt that specializing in one organ of the body would be a waste. That is why I am a general internist rather than a specialist. But internal medicine residency was full of taking care of enormously sick patients in the hospital, with small amounts of supervised clinic time, and when I first finished, I was really good at hospital medicine and pretty clueless about taking care of the many issues that come up in primary care. This is also true of internal medicine residents finishing up today. These doctors now have the choice of continuing to work just in the hospital, a choice that I didn't have. It is attractive. The schedule for a hospital physician is pretty cushy compared to a resident's schedule, and the pay is excellent. A standard hospitalist schedule is 7 days on, 12 hours a day, then 7 days off.  What's not to like?

After quitting my primary care internal medicine practice, I have, by default, become a hospitalist. It is possible to do hospital medicine pretty much anywhere and still have time at home. Committing for the long term is not strictly necessary since most patients come in to the hospital, are discharged, and don't come back for a long time, unlike primary care where the relationship with a single physician is key to good care. I will certainly not do it forever, but I'm doing it now. I am presently helping to cover the shifts at my local hospital which is only 25 beds, so quite small. The standard schedule for tiny hospitals which have hospitalists is 24 hours shifts, but typically seeing no more than 12 patients a day, and sleeping at home most of the time. Our hospital is just now developing this program, which will allow the primary care doctors to not come in to admit patients on their off hours if they don't want to, and will give sick patients without a doctor someone who is pleased to take care of them.

There are many companies that just do the job of providing doctor manpower and organization for a hospital that needs hospitalists. These companies are kind of like temp agencies, making sure that the job is done to certain specifications and taking on the responsibility for coverage. I have recently signed up with one of these companies to provide services in a community about 6 hours drive away from where I live.

The company first has to credential me, and the hospital needs to credential me as well. This means I have to submit all of my vital statistics, including history of malpractice suits, even if frivolous, licensing information, straight from any licensing board that has licensed me, and a complete education and job history with verification from all of those places, plus letters of reference and yet more stuff. After credentialing, I need to complete an online training course in how this company does things. One of the primary focuses of the online training is making sure that I document (write, type, dictate) notes sufficient to avoid losing a malpractice case should I be unlucky enough to be called in one, and be paid at the highest ethical rate for anything I do.

I have been dutifully watching the required videos, and have been feeling like maybe this is the wrong job for me. Perhaps I should go to cooking school or start selling real estate or better yet go overseas to treat the really truly sick in a situation in which what I do has more to do with helping people and less to do with satisfying payers and covering my vulnerable rump. I love taking care of people, learning what their issues are, using my experience to help them navigate their way toward better health. In order to document as this company requires, I actually need to change what I do to fit a framework that revolves around billing.

Each encounter I have with a patient in the hospital must be billed in order for the hospital to be paid for what I do. In the notes for these encounters I need to document various elements of the history of present illness, the family, past medical, personal and social histories, specific elements of a physical exam, even if I don't consider them relevant, a systems review, make notes of all of the data that I review and in some situations document start and stop times. After awhile this will become natural to me, and take up less of my brain, but when it becomes natural, the patient encounter will be a different thing than it should be. It will have elements of a checklist and will not truly be about hearing my patients' stories and collaborating on a solution to their problems.

I do think this whole bizarrely complex routine will someday be obsolete, since it seems clear that medical care will move in the direction of being paid for results, that is making people well, rather than by the individual nit that is picked. Still, in the meantime I am feeling like my brain is being filled with drivel.

It appears that all of the good hospitalist companies do training similar to the one that has signed me on.  Even though I don't like learning the intricacies of evaluation and management coding, it is the system we are presently using, and standardizing the way we interact with that system is not entirely a bad thing. It would be disappointing to learn that when I worked very hard taking care of a patient my hospital was paid as if I had done very little, simply because I had failed to mention that I had asked about new rashes or ear discharge or that I had personally looked at the chest x-ray.

The primary inventor of the complex billing schemes is Medicare, though many other insurance agencies follow the same guidelines. If I had my way, physicians and payers would sit down to produce a payment system that wasted minimal amounts of doctor and biller time on producing and reviewing documentation, focusing on making it serve the purpose of communicating important information among caregivers. Payment would be based on achieving goals derived through communication between the patient and or family and the care providers.

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