Sunday, July 7, 2002

Dr. Lance Kurata, above, fills in charts while making his rounds at Kuakini Medical Center.

New doctor on duty

Physicians who take over care
for hospitalized patients from
their primary care doctors are
a burgeoning medical specialty

Key questions

By Lyn Danninger

Rapid advances in technology make medicine a fast-paced field. But the basic culture of the medical profession is slow to change.

Traditionally, family doctors have taken care of their hospitalized patients; shuttling between office and hospital while balancing appointments, paperwork, hospital rounds and emergencies.

Typical of that trend is Honolulu physician Tad Iwanuma, who has practiced internal medicine for 28 years.

"For my generation we were trained that we have to do that, to take care of patients whether in the office, the hospital or intensive care," he said.

When he first began his practice, Iwanuma said it was not uncommon for doctors to see patients at hospitals all over town as well as in the office. The result was a hectic schedule, irregular hours and very little free time.

Dr. Lance Kurata checks in on patient Troy Kimura, who is being treated for stomach flu. As a hospitalist, Kurata cares for other doctor's patients.

But a new type of hospital-based physician, called a hospitalist, specializes in the care of in-hospital patients. The trend is changing the way doctors like Iwamura practice their profession.

In the last couple of years, Iwanuma has increasingly been able to concentrate his energies on taking care of patients in the office because when he has a hospital admission, the patient is likely to be cared for by Dr. Lance Kurata.

Kurata, like Iwanuma, specializes in internal medicine. He is one of the growing number of, mostly young, physicians who have specialized in inpatient medicine. Kurata is one of six hospitalists who practice at Kuakini Medical Center. Each works a 12-hour shift.

As the practice has become more accepted and well recognized, physicians like Iwanuma are increasingly turning to hospitalists to care for their hospitalized patients.

The system works well, both men say.

Kurata believes because the choice to turn over patients to a hospitalist is voluntary, physicians have generally accepted the idea well.

Iwanuma said the time not spent at the hospital allows him to improve his office practice. He can now spend extra time with patients who come to see him and put more of an emphasis on preventive care.

Dr. Lance Kurata's distinction as a hospitalist makes him part of a growing trend.

"I think I've become a better outpatient doctor because of it, and that's the bottom line," he said.

Still, switching gears was not easy at first, he said.

"It's hard to change because your whole world revolves around that schedule, you work six days a week," he said.

Iwanuma is still notified when his patients are admitted to the hospital and likes to visit them in the mornings to check on how they are doing. He is also kept informed of their progress by Kurata and sent copies of orders, tests or changes in medication so he is up to date by the time the patient is discharged and returns to his care.

Because he stays in contact, Iwanuma said his patients have accepted the change well.

"As long as I see the patient regularly, it hasn't affected the patient's concept of me as their doctor," he said.

First coined in 1996 by two U.S. physicians, the term hospitalist refers to physicians who specialize in the care of hospitalized patients.

While not new in Europe, the United Kingdom, Canada and Australia, the hospitalist is a rapidly growing phenomenon in U.S. hospitals.

There are an estimated 4,000 to 5,000 hospitalists practicing in U.S. hospitals, according to a study in the American Journal of Medicine. So recognized has the trend become that hospitalists, who are generally trained in internal medicine, now have their own professional organization, the National Association of Inpatient Physicians.

Studies conducted in the last couple of years now show that the use of hospitalists can save money while improving patient care.

Because they are on site and familiar with the hospital system and its routine, hospitalists can expedite care and treatment. They also see a wide variety patients and have developed initiatives to improve care and treatment of diseases or illnesses that occur frequently. In Kurata's case, his team has been working on refinements to care for patients who have pneumonia or have suffered a stroke.

Some hospitalist, like Kurata, maintain a part-time outpatient practice. Others work exclusively for the hospital.

The profession tends to attract younger people for a couple of reasons. Setting up a practice after completing medical school and residency is a challenge. And an increasing number of young physicians are attracted to set hours and the pace of working full-time in the hospital, Kurata said.

Recognizing the growing trend, the University of Hawaii's John A. Burns School of Medicine has begun including a hospitalist rotation in its Internal Medicine Residency training, said Dr. Jim Hastings chief of internal medicine at UH.

"We are doing this in part because so many of our residents are now doing this kind of work and we think we can do a better job educating them. It will also help out the hospitals because you can get the most efficient use of resources," he said.

Under the program, residents will spend time as a hospitalist in both their second and third year of training, he said.

The efficient use of resources is a growing factor for hospitals challenged by declining reimbursements, Hastings said.

"Hospitals are getting very complicated and now have to run very economically in order to survive so if you can cut down on the number of people that have to talk to one another to get the job done that also improves care," he said.

Moreover, after completing residency training, physicians are used to working in the hospital setting as part of a team, he said.

Kurata agreed.

"Acute care medicine is so fresh to you because you spent some much training to do it," he said.

Over at Queen's Medical Center, Dr. Stephen Wallach, a cardiologist, decided to become a full-time hospitalist in 1998. Because Wallach spent about 50 percent of his time at the hospital, the move was not too much of a change, he said.

At 59 years old, Wallach is not the usual demographic attracted to becoming a hospitalist. But he thinks his years of experience made his peers more comfortable initially with entrusting their patients to him.

Last year, Wallach calculates he admitted about 636 patients to the hospital in addition to cardiology cases he still consults on.

Wallach noted he spends a lot of time working with patient's families.

"The thing that surprised me the most is the end-of-life issues. I didn't realize I'd also become a family therapist," he said.

Still, Wallach is enthusiastic about his work and is expanding the service as the demand for hospitalists grows. "It's rewarding work and I work hard but I absolutely like it," he said.

At Kaiser's Moanalua Medical Center, hospitalists have practiced in a variety of capacities, from intensive care to pediatrics and internal medicine for about 10 years, said Dr. Arnold Kop. He believes it was probably easier to integrate hospitalists into Kaiser because the system is set up under one roof.

"We've also had a longer time to get used to it," he said.

An ongoing concern in the use of hospitalists is ensuring effective communication as patients move between their primary care physicians and hospitalists so continuity of care can be maintained.

It's especially important now patients tend to be sicker by the time they are admitted to the hospital, doctors said.

"All major studies show that a very critical part of the care is the transition," said Iwanuma.

But electronic records management should make that easier, doctors said.



Key questions

What are hospitalists?

Hospitalists are doctors who spend more than 25 percent of their time in a hospital setting where they serve as the physicians of record of the hospitalized patients of other primary care physicians. Patients are returned to their primary care doctors at the time of hospital discharge.

Some hospitalists are full-time employees of hospitals, others are private physicians who spend part of their time working in a hospital and bill insurers for their services.

Are hospitalists part of a growing trend?

The need for hospitalists has grown in recent years partly because of the rise of managed-care health insurance plans and the more complicated regulatory environment. Hospital systems have also become more complex and patients are now much sicker by the time they are admitted to hospital, often requiring specialized care. Finally, many private physicians are now busier than ever. Declining reimbursements mean doctors must see more patients just to keep up with the costs of practice and the demands of insurance companies mean physicians must spend more time attending to paperwork.

What do the patients think?

There are no definitive studies, but anecdotal evidence suggests patient reaction to hospitalists is good. Since patients no longer have to wait for physicians to come to the hospital for rounds, the greatest benefit seems to be better access to physicians. This ensures patients have questions answered, medications adjusted, and care revised more quickly.

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