JUNE 2004
Volume 28 • No. 6

Hospitalist Lisa Y. Shieh, from Stanford Medical Group, and William M. Cheng, from Palo Alto Medical Foundation chat on the D-ground unti where both frequently see patients.

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Hospitalists believe they contribute to efficiency, safety

You need to be an inpatient to be treated by Lisa Y. Shieh and William M. Cheng, two of nine hospitalists at SHC.

Shieh, Stanford Medical Group's full-time hospitalist, and Cheng, lead hospitalist at SHC for Palo Alto Medical Foundation, both say their role was generated in part by the need for internists to practice efficiently - doctors can't be productive while stuck in traffic, trying to get to the hospital to see one or two patients. But both Cheng and Shieh, members of the Society of Hospital Medicine, also believe they add value to the care and safety of patients.

"As hospitalists we get involved in finding ways to improve quality for inpatients - how to improve beta blockade among surgical patients or improve DVT prophylaxis, for example," said Shieh, who completed her internship and residency in internal medicine at Stanford in 1999.

"The whole issue of reducing medical errors has obviously been a huge push for the past couple of years," Shieh said. There have always been doctors who do a lot of inpatient medicine, but since [UCSF faculty hospitalists] Bob Wachter [See article p. 1 and Larry Shuer's chief of staff column] coined the term hospitalist in a 1996 journal article, there has definitely been a trend of internal medicine residents going into hospital medicine."

Cheng said studies have shown that hospitalists reduce length of stay - in part because they are physically present to discharge patients as soon as they are ready to leave the hospital. Shieu said studies are emerging to suggest that hospitalists might reduce morbidity and mortality as well.

The Stanford faculty and PAMF hospitalist models differ somewhat at SHC. Shieh attends all SMG patients during weekday daytime hours. Housestaff members also provide care, especially at night and on weekends, when Shieh or an SMG outpatient colleague is always on call. Shieh also directs the medicine consult service, and attends patients admitted by Stanford's general internal medicine and family practice services, as well as patients hospitalized from the Vaden Student Health Service at Stanford University.

Cheng, who completed his internal medicine residency at Santa Clara Valley Medical Center, provides care for PAMF patients admitted to the internal medicine service at SHC. A graduate of UCLA medical school, Cheng also attends half-day hospital follow-up clinics for patients at PAMF's Palo Alto Clinic, and consults as needed with other PAMF services. He often works with housestaff.

Both doctors said the number of patients they see varies widely, and between regular attending duties and consults, the number of patients can range up to 10 or more per day.

Although Cheng is fulltime at SHC, some of his seven colleagues divide their time between SHC and Washington Hospital in Fremont. Other current members of the PAMF hospitalist group include Mundeep S. Chawla, Larry Crane, John L. Cunniff, Zubin Damania, Beth Gentilesco and Nancy Wen Hsing Hua.

Both Cheng and Shieh say that while continuity of care between a primary care physician and a hospitalist is a potential issue, the concern is a double-edged sword.

"We always have to be attentive to learn what has happened with each patient before they get here," said Shieh, who holds a PhD in medical engineering in addition to her medical degree from Harvard Medical School. "On the other hand, we often benefit from the continuity of taking care of patients on successive hospital visits, and we have a familiarity with how things work in the hospital - from case management to arranging for subspecialists. Some of our colleagues who aren't here full-time may not have as detailed a perspective of these services."

The two hospitalists say sophisticated electronic charts maintained by their medical groups provide excellent information and both say they maintain regular contact with every patient's primary care physician or referring physicians, usually by phone.

Shieh and Cheng say they welcome not only social visits from patients' PCP, but both hospitalists say they encourage discussions with these doctors before, during and after hospitalization.

Both Cheng and Shieh say they were drawn to internal medicine because of its variety and a preference for cognitive rather than procedural practice. They then became hospitalists because they preferred its faster pace to outpatient medicine.

The two hospitalists said their outpatient colleagues are becoming increasingly comfortable with their services and the hospitalist model, particularly as the outpatient pace picks up for all physicians.

And Shieh does have some advice for physicians sending patients to her or the PAMF hospitalist for care:

"Tell them you have a relationship with a doctor who will be in the hospital most of the day who specializes in care within the hospital. Tell them the hospitalist will be able to answer questions about your care, take care of you and solve difficult issues, and help find whatever services are needed - whether that is finding a case manager to arrange a smooth discharge, or a specialist to take care of an unexpected problem."