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Dear colleagues and friends,
After an excellent debate on the future of telemedicine in GI in our most recent Perspectives column, we continue to explore changes in the way we traditionally provide care. In this issue, we discuss the GI hospitalist service, a relatively new but growing model of providing inpatient care. Is this the new ideal, allowing for more efficient care? Or are traditional or alternative models more appropriate? As with most things, the answer often lies somewhere in the middle, driven by local needs and infrastructure. Dr. Tau and Dr. Mehendiratta explore the pros and cons of these different approaches to providing inpatient GI care. I look forward to hearing your thoughts and experiences on the AGA Community forum and by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, MSc, is an assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
The dedicated GI hospitalist: Taking ownership not ‘call’
By J. Andy Tau, MD
In my experience, a GI hospitalist provides mutual benefit to patients, employers, and consulting physicians. The patient benefits from more expedient consultations and expert endoscopic therapy, which translates to shorter hospitalizations and improved outcomes. The employer enjoys financial benefits as busy outpatient providers can stay busy without interruption. Consulting physicians enjoy having to only call a single phone number for trusted help from a familiar physician who does not rotate off service. Personally, the position provides the volume to develop valuable therapeutic endoscopy skills and techniques. With one stable physician at the helm, a sense of ownership can develop, rather than a sense of survival until “call” is over.
As a full-time GI hospitalist for a large single-specialty group, I provide inpatient GI and hepatology consultation from 7 a.m. to 5 p.m., Monday-Friday. I do not rotate off service. I cover three hospitals with a total of 1,000 beds with two advanced practice providers and one part-time physician. Except for endoscopic ultrasound, I perform all other endoscopic procedures. The census is usually 25-35 with an average of 10-15 new consults per day.
The most important benefit of a dedicated GI hospitalist is providing expedited consultation and expert endoscopy for patients. I can offer emergent (<6 hour) endoscopy for any patient. An esophageal food impaction is usually resolved within an hour of arrival to the ED during the day. I can help a surgeon intraoperatively on very short notice. As for acute GI bleeding cases, I oversee resuscitative efforts, while the endoscopy team prepares my preferred endoscopic equipment, eliminating surprises and delays before endoscopy. I have developed an expertise in hemostasis and managing esophageal perforations, along with a risk tolerance that cannot be matured in any setting other than daily emergency.
I have enacted evidence-based protocols for GI bleeding, iron-deficiency anemia, colonic pseudo-obstruction, pancreatitis, and liver decompensation, which internists have adopted over time, reducing phone calls and delays in prep or resuscitation.
While the day is unstructured and filled with interruptions, it is also very flexible. As opposed to the set time intervals of an outpatient clinic visit, I can spend an hour in a palliative care meeting or revisit high-risk patients multiple times a day to detect pending deterioration. Combined endoscopic and surgical cases are logistically easy to schedule given my flexibility. For example, patients with choledocholithiasis often can have a combined cholecystectomy and supine endoscopic retrograde cholangiopancreatography (ERCP) in the OR, shaving a day off admission.
My employer benefits financially as the outpatient doctors can stay busy without interruption from the hospital. With secure group messaging, we are able to make joint decisions and arrange close follow up. The relative value units earned from the hospital are high. Combined with proceeds from the professional service agreement with the hospital, they are more than enough to cover my compensation.
Any physician in need of a GI consult needs only to call one number for help. I make it as easy as possible to obtain a consult and never push back, as banal as any consult may seem. I stake my reputation on providing a service that is able, affable, and available. By teaching a consistent message to consulting physicians, I have now effected best evidence-based practices for GI conditions even without engaging me. The most notable examples include antibiotics for variceal bleeding, fluid resuscitation and early feeding for acute pancreatitis, risk stratification for choledocholithiasis, and last but not least, abandoning the inpatient fecal occult blood test.
I am on a first-name basis with every nurse in the hospital now. In exchange for my availability and cell phone number, they place orders for me and protect me from avoidable nuisances.
Many physician groups cover the inpatient service by rotating a week at a time. There can be at times a reluctance to take ownership over a difficult patient and instead a sense of “survival of the call”. However, in my job, “the buck stops with me” even if it is in the form of readmission. For example, I have to take some ownership of indigent patients who cannot easily follow up. Who will remove the stent I placed? How will they pay for Helicobacter pylori eradication or biologic therapy? Another example is diverticular bleeding. While 80% stop on their own, I take extraordinary efforts to endoscopically find and halt the bleeding in order to reduce the recurrence rate. I must find durable solutions because these high-risk patients are my responsibility again when they bounce back to me via the ED.
By way of volume alone, this position has allowed me to develop many therapeutic skills outside of a standard 3-year GI fellowship. While I did only 200 ERCPs in fellowship, I have become proficient in ERCP with around 400 cases per year (mostly native papilla) and have grown comfortable with the needle knife. I have learned endoscopic suturing, luminal stenting, and endoscopic vacuum-assisted therapy for perforation closure independently. Out of necessity, I developed a novel technique in optimizing the use of hemostatic powder by using a bone-wax plug. As endoscopy chief, I can purchase a wide variety of endoscopy equipment, compare brands, and understand the nuances of each.
In conclusion, the dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist. While it can be challenging and hectic, with the right mentality towards ownership of the service, it is also an incredibly rewarding position.
Dr. Tau practices with Austin Gastroenterology in Austin, Tex. He disclosed relationships with Cook Medical and Conmed.
Inpatient-only GI hospitalist: Not so fast
By Vaibhav Mehendiratta, MD
Over the past 2 decades, the medical hospitalist system has assumed care of hospitalized patients with the promise of reduced length of stay (LOS) and improved outcomes. Although data on LOS is promising, there have been conflicting results in terms of total medical costs and resource utilization. Inpatient care for patients with complex medical histories often requires regular communication with other subspecialties and outpatient providers to achieve better patient-centered outcomes.
Providing inpatient gastrointestinal care is complicated. Traditional models rely on physicians trying to balance outpatient obligations with inpatient rounding and procedures, which can result in delayed endoscopy and an inability to participate fully in multidisciplinary rounds and family meetings. The complexity of hospitalized patients often requires a multidisciplinary approach with coordination of care that is hard to accomplish in between seeing outpatients. GI groups, both private practice and academics, need to adopt a strategy for inpatient care that is tailored to the hospital system in which they operate.
As one of the largest private practice groups in New England, our experience can provide a framework for others to follow. We provide inpatient GI care at eight hospitals across northern Connecticut. Our inpatient service at the largest tertiary care hospital is composed of one general gastroenterologist, one advanced endoscopist, one transplant hepatologist, two advanced practitioners, and two fellows in training. Each practitioner provides coverage on a rotating basis, typically 1 week at a time every 4-8 weeks. This model also offers flexibility, such that we can typically accommodate urgent outpatient endoscopy for patients who may otherwise require inpatient care. Coverage at the other seven hospitals is tailored to local needs and ranges from half-day to whole-day coverage by general gastroenterologists and advanced practitioners. We believe that our model is financially viable and, based on our experience, inpatient relative value units generated are quite similar to a typical day in outpatient GI practice.
Inpatient GI care accounts for a substantial portion of overall inpatient care in the United States. Endoscopy delays have been the focus of many research articles looking at inpatient GI care. The delays are caused by many factors, including endoscopy unit/staff availability, anesthesia availability, and patient factors. While having a dedicated inpatient GI Hospitalist offers the potential to streamline access for hospital consultations and endoscopy, an exclusive inpatient GI hospitalist may be less familiar with a patient’s chronic GI illness and have different (and perhaps, conflicting) priorities regarding a patient’s care. Having incomplete access to outpatient records or less familiarity with the intricacies of outpatient care could also lead to duplication of work and increase the number of inpatient procedures that may have otherwise been deferred to the outpatient setting.
Additionally, with physician burnout on the rise and particularly in the inpatient setting, one must question the sustainability of an exclusively inpatient GI practice. That is, the hours and demands of inpatient care typically do not allow the quality of life that outpatient care provides. Our model provides time for dedicated inpatient care, while allowing each practitioner ample opportunity to build a robust outpatient practice.
Some health care organizations are adopting an extensivist model to provide comprehensive care to patients with multiple medical problems. Extensivists are outpatient primary care providers who take the time to coordinate with inpatient hospitalists to provide comprehensive care to their patients. Constant contact with outpatient providers during admission is expected to improve patient satisfaction, reduce hospital readmissions, and decrease inpatient resource utilization.
In conclusion, our experience highlights sustained benefits, and distinct advantages, of providing inpatient GI care without a GI hospitalist model. The pendulum in inpatient care keeps swinging and with progress arise new challenges and questions. Close collaboration between gastroenterologists and health systems to develop a program that fits local needs and allows optimal resource allocation will ensure delivery of high-quality inpatient GI care.
Dr. Mehendiratta is a gastroenterologist with Connecticut GI PC, Hartford, and assistant clinical professor in the department of medicine at the University of Connecticut, Farmington. He has no relevant conflicts of interest to disclose.
Dear colleagues and friends,
After an excellent debate on the future of telemedicine in GI in our most recent Perspectives column, we continue to explore changes in the way we traditionally provide care. In this issue, we discuss the GI hospitalist service, a relatively new but growing model of providing inpatient care. Is this the new ideal, allowing for more efficient care? Or are traditional or alternative models more appropriate? As with most things, the answer often lies somewhere in the middle, driven by local needs and infrastructure. Dr. Tau and Dr. Mehendiratta explore the pros and cons of these different approaches to providing inpatient GI care. I look forward to hearing your thoughts and experiences on the AGA Community forum and by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, MSc, is an assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
The dedicated GI hospitalist: Taking ownership not ‘call’
By J. Andy Tau, MD
In my experience, a GI hospitalist provides mutual benefit to patients, employers, and consulting physicians. The patient benefits from more expedient consultations and expert endoscopic therapy, which translates to shorter hospitalizations and improved outcomes. The employer enjoys financial benefits as busy outpatient providers can stay busy without interruption. Consulting physicians enjoy having to only call a single phone number for trusted help from a familiar physician who does not rotate off service. Personally, the position provides the volume to develop valuable therapeutic endoscopy skills and techniques. With one stable physician at the helm, a sense of ownership can develop, rather than a sense of survival until “call” is over.
As a full-time GI hospitalist for a large single-specialty group, I provide inpatient GI and hepatology consultation from 7 a.m. to 5 p.m., Monday-Friday. I do not rotate off service. I cover three hospitals with a total of 1,000 beds with two advanced practice providers and one part-time physician. Except for endoscopic ultrasound, I perform all other endoscopic procedures. The census is usually 25-35 with an average of 10-15 new consults per day.
The most important benefit of a dedicated GI hospitalist is providing expedited consultation and expert endoscopy for patients. I can offer emergent (<6 hour) endoscopy for any patient. An esophageal food impaction is usually resolved within an hour of arrival to the ED during the day. I can help a surgeon intraoperatively on very short notice. As for acute GI bleeding cases, I oversee resuscitative efforts, while the endoscopy team prepares my preferred endoscopic equipment, eliminating surprises and delays before endoscopy. I have developed an expertise in hemostasis and managing esophageal perforations, along with a risk tolerance that cannot be matured in any setting other than daily emergency.
I have enacted evidence-based protocols for GI bleeding, iron-deficiency anemia, colonic pseudo-obstruction, pancreatitis, and liver decompensation, which internists have adopted over time, reducing phone calls and delays in prep or resuscitation.
While the day is unstructured and filled with interruptions, it is also very flexible. As opposed to the set time intervals of an outpatient clinic visit, I can spend an hour in a palliative care meeting or revisit high-risk patients multiple times a day to detect pending deterioration. Combined endoscopic and surgical cases are logistically easy to schedule given my flexibility. For example, patients with choledocholithiasis often can have a combined cholecystectomy and supine endoscopic retrograde cholangiopancreatography (ERCP) in the OR, shaving a day off admission.
My employer benefits financially as the outpatient doctors can stay busy without interruption from the hospital. With secure group messaging, we are able to make joint decisions and arrange close follow up. The relative value units earned from the hospital are high. Combined with proceeds from the professional service agreement with the hospital, they are more than enough to cover my compensation.
Any physician in need of a GI consult needs only to call one number for help. I make it as easy as possible to obtain a consult and never push back, as banal as any consult may seem. I stake my reputation on providing a service that is able, affable, and available. By teaching a consistent message to consulting physicians, I have now effected best evidence-based practices for GI conditions even without engaging me. The most notable examples include antibiotics for variceal bleeding, fluid resuscitation and early feeding for acute pancreatitis, risk stratification for choledocholithiasis, and last but not least, abandoning the inpatient fecal occult blood test.
I am on a first-name basis with every nurse in the hospital now. In exchange for my availability and cell phone number, they place orders for me and protect me from avoidable nuisances.
Many physician groups cover the inpatient service by rotating a week at a time. There can be at times a reluctance to take ownership over a difficult patient and instead a sense of “survival of the call”. However, in my job, “the buck stops with me” even if it is in the form of readmission. For example, I have to take some ownership of indigent patients who cannot easily follow up. Who will remove the stent I placed? How will they pay for Helicobacter pylori eradication or biologic therapy? Another example is diverticular bleeding. While 80% stop on their own, I take extraordinary efforts to endoscopically find and halt the bleeding in order to reduce the recurrence rate. I must find durable solutions because these high-risk patients are my responsibility again when they bounce back to me via the ED.
By way of volume alone, this position has allowed me to develop many therapeutic skills outside of a standard 3-year GI fellowship. While I did only 200 ERCPs in fellowship, I have become proficient in ERCP with around 400 cases per year (mostly native papilla) and have grown comfortable with the needle knife. I have learned endoscopic suturing, luminal stenting, and endoscopic vacuum-assisted therapy for perforation closure independently. Out of necessity, I developed a novel technique in optimizing the use of hemostatic powder by using a bone-wax plug. As endoscopy chief, I can purchase a wide variety of endoscopy equipment, compare brands, and understand the nuances of each.
In conclusion, the dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist. While it can be challenging and hectic, with the right mentality towards ownership of the service, it is also an incredibly rewarding position.
Dr. Tau practices with Austin Gastroenterology in Austin, Tex. He disclosed relationships with Cook Medical and Conmed.
Inpatient-only GI hospitalist: Not so fast
By Vaibhav Mehendiratta, MD
Over the past 2 decades, the medical hospitalist system has assumed care of hospitalized patients with the promise of reduced length of stay (LOS) and improved outcomes. Although data on LOS is promising, there have been conflicting results in terms of total medical costs and resource utilization. Inpatient care for patients with complex medical histories often requires regular communication with other subspecialties and outpatient providers to achieve better patient-centered outcomes.
Providing inpatient gastrointestinal care is complicated. Traditional models rely on physicians trying to balance outpatient obligations with inpatient rounding and procedures, which can result in delayed endoscopy and an inability to participate fully in multidisciplinary rounds and family meetings. The complexity of hospitalized patients often requires a multidisciplinary approach with coordination of care that is hard to accomplish in between seeing outpatients. GI groups, both private practice and academics, need to adopt a strategy for inpatient care that is tailored to the hospital system in which they operate.
As one of the largest private practice groups in New England, our experience can provide a framework for others to follow. We provide inpatient GI care at eight hospitals across northern Connecticut. Our inpatient service at the largest tertiary care hospital is composed of one general gastroenterologist, one advanced endoscopist, one transplant hepatologist, two advanced practitioners, and two fellows in training. Each practitioner provides coverage on a rotating basis, typically 1 week at a time every 4-8 weeks. This model also offers flexibility, such that we can typically accommodate urgent outpatient endoscopy for patients who may otherwise require inpatient care. Coverage at the other seven hospitals is tailored to local needs and ranges from half-day to whole-day coverage by general gastroenterologists and advanced practitioners. We believe that our model is financially viable and, based on our experience, inpatient relative value units generated are quite similar to a typical day in outpatient GI practice.
Inpatient GI care accounts for a substantial portion of overall inpatient care in the United States. Endoscopy delays have been the focus of many research articles looking at inpatient GI care. The delays are caused by many factors, including endoscopy unit/staff availability, anesthesia availability, and patient factors. While having a dedicated inpatient GI Hospitalist offers the potential to streamline access for hospital consultations and endoscopy, an exclusive inpatient GI hospitalist may be less familiar with a patient’s chronic GI illness and have different (and perhaps, conflicting) priorities regarding a patient’s care. Having incomplete access to outpatient records or less familiarity with the intricacies of outpatient care could also lead to duplication of work and increase the number of inpatient procedures that may have otherwise been deferred to the outpatient setting.
Additionally, with physician burnout on the rise and particularly in the inpatient setting, one must question the sustainability of an exclusively inpatient GI practice. That is, the hours and demands of inpatient care typically do not allow the quality of life that outpatient care provides. Our model provides time for dedicated inpatient care, while allowing each practitioner ample opportunity to build a robust outpatient practice.
Some health care organizations are adopting an extensivist model to provide comprehensive care to patients with multiple medical problems. Extensivists are outpatient primary care providers who take the time to coordinate with inpatient hospitalists to provide comprehensive care to their patients. Constant contact with outpatient providers during admission is expected to improve patient satisfaction, reduce hospital readmissions, and decrease inpatient resource utilization.
In conclusion, our experience highlights sustained benefits, and distinct advantages, of providing inpatient GI care without a GI hospitalist model. The pendulum in inpatient care keeps swinging and with progress arise new challenges and questions. Close collaboration between gastroenterologists and health systems to develop a program that fits local needs and allows optimal resource allocation will ensure delivery of high-quality inpatient GI care.
Dr. Mehendiratta is a gastroenterologist with Connecticut GI PC, Hartford, and assistant clinical professor in the department of medicine at the University of Connecticut, Farmington. He has no relevant conflicts of interest to disclose.
Dear colleagues and friends,
After an excellent debate on the future of telemedicine in GI in our most recent Perspectives column, we continue to explore changes in the way we traditionally provide care. In this issue, we discuss the GI hospitalist service, a relatively new but growing model of providing inpatient care. Is this the new ideal, allowing for more efficient care? Or are traditional or alternative models more appropriate? As with most things, the answer often lies somewhere in the middle, driven by local needs and infrastructure. Dr. Tau and Dr. Mehendiratta explore the pros and cons of these different approaches to providing inpatient GI care. I look forward to hearing your thoughts and experiences on the AGA Community forum and by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, MSc, is an assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
The dedicated GI hospitalist: Taking ownership not ‘call’
By J. Andy Tau, MD
In my experience, a GI hospitalist provides mutual benefit to patients, employers, and consulting physicians. The patient benefits from more expedient consultations and expert endoscopic therapy, which translates to shorter hospitalizations and improved outcomes. The employer enjoys financial benefits as busy outpatient providers can stay busy without interruption. Consulting physicians enjoy having to only call a single phone number for trusted help from a familiar physician who does not rotate off service. Personally, the position provides the volume to develop valuable therapeutic endoscopy skills and techniques. With one stable physician at the helm, a sense of ownership can develop, rather than a sense of survival until “call” is over.
As a full-time GI hospitalist for a large single-specialty group, I provide inpatient GI and hepatology consultation from 7 a.m. to 5 p.m., Monday-Friday. I do not rotate off service. I cover three hospitals with a total of 1,000 beds with two advanced practice providers and one part-time physician. Except for endoscopic ultrasound, I perform all other endoscopic procedures. The census is usually 25-35 with an average of 10-15 new consults per day.
The most important benefit of a dedicated GI hospitalist is providing expedited consultation and expert endoscopy for patients. I can offer emergent (<6 hour) endoscopy for any patient. An esophageal food impaction is usually resolved within an hour of arrival to the ED during the day. I can help a surgeon intraoperatively on very short notice. As for acute GI bleeding cases, I oversee resuscitative efforts, while the endoscopy team prepares my preferred endoscopic equipment, eliminating surprises and delays before endoscopy. I have developed an expertise in hemostasis and managing esophageal perforations, along with a risk tolerance that cannot be matured in any setting other than daily emergency.
I have enacted evidence-based protocols for GI bleeding, iron-deficiency anemia, colonic pseudo-obstruction, pancreatitis, and liver decompensation, which internists have adopted over time, reducing phone calls and delays in prep or resuscitation.
While the day is unstructured and filled with interruptions, it is also very flexible. As opposed to the set time intervals of an outpatient clinic visit, I can spend an hour in a palliative care meeting or revisit high-risk patients multiple times a day to detect pending deterioration. Combined endoscopic and surgical cases are logistically easy to schedule given my flexibility. For example, patients with choledocholithiasis often can have a combined cholecystectomy and supine endoscopic retrograde cholangiopancreatography (ERCP) in the OR, shaving a day off admission.
My employer benefits financially as the outpatient doctors can stay busy without interruption from the hospital. With secure group messaging, we are able to make joint decisions and arrange close follow up. The relative value units earned from the hospital are high. Combined with proceeds from the professional service agreement with the hospital, they are more than enough to cover my compensation.
Any physician in need of a GI consult needs only to call one number for help. I make it as easy as possible to obtain a consult and never push back, as banal as any consult may seem. I stake my reputation on providing a service that is able, affable, and available. By teaching a consistent message to consulting physicians, I have now effected best evidence-based practices for GI conditions even without engaging me. The most notable examples include antibiotics for variceal bleeding, fluid resuscitation and early feeding for acute pancreatitis, risk stratification for choledocholithiasis, and last but not least, abandoning the inpatient fecal occult blood test.
I am on a first-name basis with every nurse in the hospital now. In exchange for my availability and cell phone number, they place orders for me and protect me from avoidable nuisances.
Many physician groups cover the inpatient service by rotating a week at a time. There can be at times a reluctance to take ownership over a difficult patient and instead a sense of “survival of the call”. However, in my job, “the buck stops with me” even if it is in the form of readmission. For example, I have to take some ownership of indigent patients who cannot easily follow up. Who will remove the stent I placed? How will they pay for Helicobacter pylori eradication or biologic therapy? Another example is diverticular bleeding. While 80% stop on their own, I take extraordinary efforts to endoscopically find and halt the bleeding in order to reduce the recurrence rate. I must find durable solutions because these high-risk patients are my responsibility again when they bounce back to me via the ED.
By way of volume alone, this position has allowed me to develop many therapeutic skills outside of a standard 3-year GI fellowship. While I did only 200 ERCPs in fellowship, I have become proficient in ERCP with around 400 cases per year (mostly native papilla) and have grown comfortable with the needle knife. I have learned endoscopic suturing, luminal stenting, and endoscopic vacuum-assisted therapy for perforation closure independently. Out of necessity, I developed a novel technique in optimizing the use of hemostatic powder by using a bone-wax plug. As endoscopy chief, I can purchase a wide variety of endoscopy equipment, compare brands, and understand the nuances of each.
In conclusion, the dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist. While it can be challenging and hectic, with the right mentality towards ownership of the service, it is also an incredibly rewarding position.
Dr. Tau practices with Austin Gastroenterology in Austin, Tex. He disclosed relationships with Cook Medical and Conmed.
Inpatient-only GI hospitalist: Not so fast
By Vaibhav Mehendiratta, MD
Over the past 2 decades, the medical hospitalist system has assumed care of hospitalized patients with the promise of reduced length of stay (LOS) and improved outcomes. Although data on LOS is promising, there have been conflicting results in terms of total medical costs and resource utilization. Inpatient care for patients with complex medical histories often requires regular communication with other subspecialties and outpatient providers to achieve better patient-centered outcomes.
Providing inpatient gastrointestinal care is complicated. Traditional models rely on physicians trying to balance outpatient obligations with inpatient rounding and procedures, which can result in delayed endoscopy and an inability to participate fully in multidisciplinary rounds and family meetings. The complexity of hospitalized patients often requires a multidisciplinary approach with coordination of care that is hard to accomplish in between seeing outpatients. GI groups, both private practice and academics, need to adopt a strategy for inpatient care that is tailored to the hospital system in which they operate.
As one of the largest private practice groups in New England, our experience can provide a framework for others to follow. We provide inpatient GI care at eight hospitals across northern Connecticut. Our inpatient service at the largest tertiary care hospital is composed of one general gastroenterologist, one advanced endoscopist, one transplant hepatologist, two advanced practitioners, and two fellows in training. Each practitioner provides coverage on a rotating basis, typically 1 week at a time every 4-8 weeks. This model also offers flexibility, such that we can typically accommodate urgent outpatient endoscopy for patients who may otherwise require inpatient care. Coverage at the other seven hospitals is tailored to local needs and ranges from half-day to whole-day coverage by general gastroenterologists and advanced practitioners. We believe that our model is financially viable and, based on our experience, inpatient relative value units generated are quite similar to a typical day in outpatient GI practice.
Inpatient GI care accounts for a substantial portion of overall inpatient care in the United States. Endoscopy delays have been the focus of many research articles looking at inpatient GI care. The delays are caused by many factors, including endoscopy unit/staff availability, anesthesia availability, and patient factors. While having a dedicated inpatient GI Hospitalist offers the potential to streamline access for hospital consultations and endoscopy, an exclusive inpatient GI hospitalist may be less familiar with a patient’s chronic GI illness and have different (and perhaps, conflicting) priorities regarding a patient’s care. Having incomplete access to outpatient records or less familiarity with the intricacies of outpatient care could also lead to duplication of work and increase the number of inpatient procedures that may have otherwise been deferred to the outpatient setting.
Additionally, with physician burnout on the rise and particularly in the inpatient setting, one must question the sustainability of an exclusively inpatient GI practice. That is, the hours and demands of inpatient care typically do not allow the quality of life that outpatient care provides. Our model provides time for dedicated inpatient care, while allowing each practitioner ample opportunity to build a robust outpatient practice.
Some health care organizations are adopting an extensivist model to provide comprehensive care to patients with multiple medical problems. Extensivists are outpatient primary care providers who take the time to coordinate with inpatient hospitalists to provide comprehensive care to their patients. Constant contact with outpatient providers during admission is expected to improve patient satisfaction, reduce hospital readmissions, and decrease inpatient resource utilization.
In conclusion, our experience highlights sustained benefits, and distinct advantages, of providing inpatient GI care without a GI hospitalist model. The pendulum in inpatient care keeps swinging and with progress arise new challenges and questions. Close collaboration between gastroenterologists and health systems to develop a program that fits local needs and allows optimal resource allocation will ensure delivery of high-quality inpatient GI care.
Dr. Mehendiratta is a gastroenterologist with Connecticut GI PC, Hartford, and assistant clinical professor in the department of medicine at the University of Connecticut, Farmington. He has no relevant conflicts of interest to disclose.
