Hospital care is a specialty that helps patients, cuts costs

Dr. Lyn Raible shares a laugh with registered nurse Pamela De Vera on Wednesday at doctors Medical Center in Modesto.  Raible said she may be in charge of as many as 20 patients on any given day.
Dr. Lyn Raible shares a laugh with registered nurse Pamela De Vera on Wednesday at doctors Medical Center in Modesto. Raible said she may be in charge of as many as 20 patients on any given day. Modesto Bee

Raymond Merrill of Chowchilla said he didn't mind that his primary care doctor didn't come to visit him at Doctors Medical Center in Modesto.

For one thing, the doctor retired last year and would have faced a 50-minute drive one way from Merced County.

During his stay at DMC, his primary doctor was Lyn Raible, a hospitalist, a type of physician who does nothing but care for hospitalized patients.

Merrill, who came to DMC with an abdominal infection contracted from cancer surgery at a Fresno hospital, initially required a ventilator and a tracheotomy tube, but his condition improved, and he was sitting up in bed last week.

Merrill, 71, was one of 19 patients assigned to Raible that day, and it was clear she had gained the trust of the patient and his family.

"This is the first time since dad got sick that I have been able to relax and know he is getting good care," said Shelley Meller, Merrill's daughter.

At one time, primary care doctors routinely cared for their patients when they were hospitalized. But it's a fading trend as hospitalists have taken over inpatient care, allowing family practitioners to focus on the throng of patients in their offices.

Doctors Medical Center started using hospitalists in 1997, and the specialists are used extensively at Memorial Medical Center in Modesto and Emanuel Medical Center in Turlock.

They are often the doctors who admit patients to the hospital, take care of the patients during their stay and sign the discharge papers when patients leave. About 20,000 hospitalists are practicing in the United States today, according to the Society of Hospital Medicine.

This field of medicine has taken hold as primary care doctors have been forced by economic factors to see larger numbers of patients in their offices. At the same time, the patients admitted to hospitals have complex medical conditions and require a higher level of expertise.

"There is a gap between what doctors can do in the office and what they can do in the hospital," said Dr. Thomas Wallace, who started the hospitalist program at DMC. "We felt there was a need for giving people more attention in the hospital."

The continuity of care has been a concern since the hospitalist specialty was developed in the 1990s. Wallace acknowledged that a patient who's had the same doctor for 20 years might feel nervous about a hospitalist.

"We assure them we will be working with their doctor; we are not trying to replace them," he said. "If they have an objection and want to see their primary doctor, we let their doctor know about that."

Reasons for hospitalist practical

Local hospitals had other reasons for joining the hospitalist movement. DMC started its program the same year that county-owned Stanislaus Medical Center closed and emergency rooms started receiving more underserved patients who didn't have a doctor.

In addition, it's not practical for a family doctor in Waterford, Newman or another outlying community to follow a patient to a hospital in Modesto or Turlock.

The 398-bed Doctors Medical Center has 12 hospitalists on staff, and the 423-bed Memorial Medical Center of Modesto has 18. Most of the hospitalists were trained in internal medicine and care for patients age 17 and older.

Emanuel Medical Center in Turlock has two hospitalists on duty each day and wants to add a third. Kaiser Permanente, which contracts with Emanuel, provides hospitalists for Kaiser patients at the hospital.

In September, Emanuel entered an agreement with Children's Hospital Central California near Madera to provide pediatric hospitalists 24 hours a day. Because of a pediatrician shortage in Turlock, a doctor often wasn't available to admit a child with a simple case of pneumonia, said Connie Fairchilds, Emanuel's vice president of patient services.

Hospitalists are believed to lower the cost of patient care because they tend to order fewer tests and reduce the time patients stay in the hospital. A study published in the New England Journal of Medicine in December found that hospitalists reduced the average patient stay by 12 percent.

The study found patient outcomes were similar whether hospitalists or primary care doctors cared for the patients.

Hospitalists close at hand

Dr. Abrar Mirza, lead hospitalist at Memorial, said the doctors can respond in a timely fashion if a patient has a problem. One reason hospitalists shorten hospital stays is that they are there to discharge patients when they are ready; a family doctor might wait until the next day, he said.

Before Memorial started its hospitalist program in 2003, family practitioners visited their patients in the hospital before going to the office in the morning or after regular office hours. The hospital arranged for on-call community physicians for patients not assigned to a regular doctor.

That kind of coverage doesn't work so well for busy hospitals, a hospitalist proponent said.

"Many hospitals have difficulty with their ERs being overloaded and the entire hospital being overloaded," said Dr. Laurence Wellikson, chief executive officer of the Society of Hospital Medicine. "With hospitalists being available 24/7, it allows for a more reasonable flow of patients through the hospital."

Initially, some Memorial patients were surprised when instead of their regular doctor, a hospitalist came to see them. But he rarely hears that from patients anymore, Mirza said.

He explains to patients that he's their primary doctor when they are in the hospital and that they go back to their regular physician when they leave. "We notify their doctor about what we did in the hospital," he said. "A lot of the time they appreciate that we can spend more time with them."

Memorial's hospitalists are with the Sutter Gould Medical Foundation, so they have access to patient histories through the physician group's electronic record system. The Central Valley Medical Group, another physicians group with ties to Memorial, contracts with Sutter Gould for hospitalist care.

The hospitalists rely on ER staff to get information from patients who don't have a regular doctor or were transferred from nursing homes.

Mirza might have 18 to 22 patients during a busy 12-hour shift, including patients in intensive care, patients coming out of surgery, elderly people with pneumonia or auto crash victims with fractured bones.

In some cases, he's part of a team of doctors responsible for a patient. For example, a surgeon who has done a hip replacement on an 80-year-old woman will rely on a hospitalist to manage her high blood pressure after surgery.

Raible at DMC said that being personable helps her establish rapport with the 16 to 20 patients she sees in a day.

When starting her rounds on a floor, she pulls the patient charts to review her last notations, the vital signs of patients and the medications they are taking, then gets the latest information from nurses.

Raible had to reintroduce herself during every visit to 96-year-old Waterford resident Lucille Marietta, who had pneumonia.

"You don't remember me? I'm crushed," said Raible, sitting on the bed next to Marietta.

"My mind goes blank sometimes," Marietta said.

A computed tomography scan revealed Marietta had emphysema, and Raible talked with her to find out if she had smoked in the past. Marietta had smoked at one time and also told of working as a welder during World War II.

"We are just working to get you home," Raible told her. Outside the room, Raible said she intended to talk with Marietta's family to make sure she uses her oxygen after she returns home, or Marietta could be back in the hospital soon.

Not all doctors stay away

Some primary care doctors still care for hospitalized patients.

Dr. Tom Wilson, a family practitioner in Turlock, usually has two or three patients at the 187-bed Emanuel Medical Center and takes time in the morning to care for them. He keeps in touch with specialists who are involved in the most serious cases.

"It's hard for hospitalists to have a relationship with patients during the most difficult times in their lives when they don't know them," Wilson said. "Because of lifestyle and low reimbursements, a lot of family doctors have gotten out of (inpatient care). You can be more productive in your outpatient practice."

Before the hospitalist program, local physicians such as Wilson were on a rotation at Emanuel to care for patients who didn't have a doctor.

According to the Society of Hospital Medicine, 40 percent of hospitals in the nation employ hospitalists. The rate is 55 percent among hospitals with 200 to 495 beds.

One challenge for hospitals is recruiting enough of the doctors; there could be a nationwide demand for 40,000 hospitalists in 10 years, Wellikson said. One incentive for medical students to choose the specialty is rising pay and the ability to work where they want, he said.

Memorial wants to add four hospitalists, and other doctors are filling the gaps temporarily while the hospital waits for applicants, officials said.

Bee staff writer Ken Carlson can be reached at kcarlson@modbee.com or 578-2321.