On July 1, after five years in the department of otolaryngology-head and neck surgery at the University of California, San Francisco (UCSF) Medical Center, most recently as chief resident, Matthew Russell, MD, is joining the faculty there as an assistant professor. Normally, that career arc is not nationally noteworthy.
But Dr. Russell’s new job title—ENT hospitalist—is worth noting. In fact, it could be groundbreaking.
Hospital medicine, a term coined 15 years ago by two physicians at UCSF, refers to doctors who provide care solely to hospitalized patients. According to the Society for Hospital Medicine, there are approximately 30,000 hospitalists currently practicing in North America.
When Dr. Russell begins work this summer, he may be the only otolaryngologist in the country whose entire patient load and surgical pipeline will be generated only by admissions to his hospital. While there are already otolaryngologists around the country who spend the vast majority of their time working with inpatients, nearly all work a clinical service as well.
“The hospitalist model turns the traditional ENT practice on its head,” Dr. Russell said. “An otolaryngology practice we think of as being centered around the clinic, and the clinic and referrals is where we generate our operative cases and our patient load. The question really becomes: Can you sustain a practice without a clinic-based model?”
While the answer at UCSF appears to be yes, the otolaryngology world at large has not yet answered in unison.
Job Duties
Some physicians believe the least glamorous duties of medical otolaryngology, say, cleaning out ear wax to test hearing before an ototoxic medication regimen or responding to a general complaint of forehead pain, would make the workflow of an oto-hospitalist unappealing to many physicians.
Michael Seidman, MD, FACS, chair of the board of governors for the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), said the concept of so-called oto-hospitalists has yet to gain any traction within industry circles. He wonders if physicians would be “bored” handling fewer surgical responsibilities as they focused on more medical issues and consultations on other wards.
“I just can’t see that happening in ENT, and my colleagues have often credited my visionary character,” said Dr. Seidman, director of the division of otologic/neurotologic surgery and medical director of wellness for the Henry Ford Health System in Detroit, Mich. “I don’t see that happening, but maybe I’m wrong.”
In 2000, Nasir Bhatti, MD, associate professor of otolaryngology-head and neck surgery at Johns Hopkins University in Baltimore, started a program at Hopkins similar to the one at UCSF. At Hopkins, Dr. Bhatti, and now his successors, acted primarily as an ENT hospitalist, although he maintained minimal clinic duties as well.
He said the model could work efficiently because it would allow physicians, by choice, to determine whether they wanted to focus on surgical procedures or nonsurgical medical services. Those with a predilection toward surgery and more intensive procedures could focus on those subspecialties without feeling distracted by the demands of less intensive duties, Dr. Russell added.
Also, Dr. Bhatti pointed out, the setup could even create more revenue capture opportunities from consultations that are currently handled by nurse practitioners (NPs) and physician assistants (PAs).
“Lots of these consultations go unstaffed and, therefore, unbilled,” Dr. Bhatti said.
Dr. Russell said some physicians may be dismissive of the idea of an oto-hospitalist because they’re not clear on the role. They may picture a glorified resident constantly walking between wards to serve as a secondary opinion for other specialists.
“There is a perception that this may not be a glamorous position,” he added. “There’s an assumption that the position is nonsurgical.”
Dr. Russell’s workflow will, of course, include rounding and consultations across different wards and assistance with complex airway issues. But he will also perform surgeries and work on quality improvement (QI) initiatives, patient safety and systems-based practices. For those who doubt the variety that a purely inpatient setting can deliver, Dr. Russell eagerly quotes statistics from a two-year pilot program UCSF ran before hiring him as a full-time ENT hospitalist. In the program’s first year, the service saw 300 inpatient consultations (not including ED and urgent care). The most common consults were sinonasal and laryngotracheal, which translated to surgical/procedural volume. Two hundred procedures generated billings, of which 45 percent were laryngotracheal, 33 percent were sinonasal/anterior skull base and 10 percent were otologic.
“The hospitalist movement, in general, fills a need for the acute-care setting and manages a different set of problems than is seen in the ambulatory clinics,” Dr. Russell said, noting that the administration at UCSF should be praised for being committed to trying a new approach. “That same basic issue is found in otolaryngology. I think it’s an area that is perhaps underappreciated and may be, in my mind, worth looking at and developing as an entity itself.”
Lifestyle Factors
The concept may have potential fans, according to David Nielsen, MD, executive vice president and chief executive officer of AAO-HNS. Dr. Nielsen said that while there is no current groundswell for the model, he can envision physicians being drawn to it for two reasons.
First, as an aging cohort of otolaryngologists, “my age, the Baby Boomers,” moves to the end of its career, its members may be looking for a less intensive medical role that takes advantage of their experience without keeping them tethered to operating rooms. Second, and, conversely, younger physicians looking for balance in their personal and professional lives could be drawn to the lifestyle advantages that internal medicine physicians like about hospital medicine. These advantages are often credited with helping to fuel the boom in internal medicine hospitalists that has pushed that field to some 30,000 practitioners in a decade and a half. “The conversations that are related to this are probably going to increase,” Dr. Nielsen said.
—Nasir Bhatti, MD
Workforce Shortage
One driver of those conversations is the potential shortage of ENT physicians forecast by a team of researchers led by David Kennedy, MD, professor of otorhinolaryngology: head and neck surgery at the University of Pennsylvania School of Medicine in Philadelphia. Dr. Kennedy presented research late last year at a Society of University Otolaryngologists meeting suggesting that by 2025, the field needs to increase the number of practitioners from about 8,500 to more than 11,000, a 29 percent increase. He said this figure is based primarily upon predicted population increases.
More disconcerting, according to research from Dr. Kennedy and colleagues, is that “if nothing changes in terms of residents, the scope of the specialty remains and people retire at the preferred age of 65,” the number of practitioners would remain nearly static through 2025.
According to Dr. Kennedy, ENT hospitalists might be one solution to the shortage, with a major caveat regarding their ability to improve efficiency, perhaps by decreasing lengths of stay. “However,” Dr. Kennedy wrote in an e-mail to ENT Today, “a significant part of the coming shortage is going to be geographic, and ENT hospitalists are most likely to be utilized in the largest institutions and major cities, where the coming shortage is likely to have least or no impact.”
Robert Wachter, MD, MHM, professor, chief of hospital medicine and chief of the medical service at UCSF Medical Center, helped coin the term hospitalist in 1996 in a published paper titled “The Emerging Role of ‘Hospitalists’ in the American Health Care System” (N Engl J Med. 1996;335(7):514-517). Dr. Wachter believes the needs of otolaryngology present the same set of circumstances that allowed internal medicine-based hospital medicine to flourish.
“The forces,” Dr. Wachter wrote in January on his blog, “are the same: sick patients, highly specialized providers who may not be comfortable with all the issues that arise in the hospital, and the need to focus on system improvement.”
The flip side of the case for oto-hospitalists is whether using a board-certified otolaryngologist to handle more pedestrian encounters is the most economical use of a physician’s time. According to Dr. Seidman, NPs and PAs can be useful, handling less intensive cases and freeing experienced physicians to focus on larger issues.
“The favorite part of my practice, frankly, is being in the operating room,” Dr. Seidman said. “So if you just had a hospitalist seeing consults…we cover this all well already. We have residents who see these patients.”
An Alternative
Dr. Russell understands the reticence. He doesn’t expect that an oto-hospitalist model will be the right fit for all institutions, or even most. He suggests, however, that people focus less on the nomenclature of hospitalists and instead consider the idea that the hospital setting, completely devoid of a clinical service, can provide enough intrigue and opportunity for an otolaryngologist.
“It’s going to vary depending on the size of the institution, the complexity of the other clinical activities,” he said. “This may or may not be beneficial elsewhere. At our university, we have a lot of complex problems. Inevitably, some of those problems are going to involve the head and neck and will benefit from consultation with an otolaryngologist.”
Hopkins’ Dr. Bhatti is more optimistic, particularly in the age of generational health care reform that pledges to increase medical access to more patients.
“I totally think this is the way of the future, especially if the increase in capacity that all hospitalists are trying to build infrastructure for actually happens,” Dr. Bhatti said. “I have no reason to believe it’s not going to happen.”