As a medical specialty, the number of hospitalists, along with the number of institutions using hospitalists, has grown rapidly since the mid-1990s. There were about 11,000 hospitalists working in the United States in 2003, according to a Society of Hospital Medicine (SHM) estimate, and about 35,000 in 2012.
Traditionally, hospitalists have been physicians trained in internal medicine who provide care to hospitalized patients. But hospitalist programs have expanded beyond being the "generalist," and have moved into specialties such as neurology, orthopedic surgery, pediatrics, general surgery, and oncology.
Although not yet a universal phenomenon, cancer centers and multispecialty medical centers offering cancer care have been increasingly adopting the hospitalist model for oncology during the past decade. According to the SHM, the growth of oncology hospitalists has been fueled by factors such as the aging of the population and restrictions on the number of hours that residents can work.
Traditionally, cancer inpatients have been cared for by house staff at academic institutions, absorbed into general medicine services, or cared for by an outpatient-based oncologist. The hospitalist model allows for onsite coverage, and lends itself to the better coordination of tests and treatments and the monitoring of progress. There is no standard model for an oncology hospitalist program, although most manage complications stemming from the disease and treatment and provide end-of-life services. Oncology hospitalists are generally either oncologists or are hospitalists trained in internal or family medicine who have an interest in cancer patients.
Beginning With One
"Our program started with 1 oncologist — me," said Jonathan Wynbrandt, MD, who leads the oncology hospitalist program at University Hospitals Case Medical Center in Cleveland. "Oncologists were spending more time in the clinic and less time with hospitalized patients, so we thought that this would be better for continuity of care."
When the program began in 2010, Dr. Wynbrandt evaluated the needs of inpatients. "We went ahead and recruited 2 more doctors to join me the following year," he said.
"There are now 6 of us, and we are looking to expand further," he told Medscape Medical News. "We are looking to cover the cancer center 24/7. By this time next year, I'm hoping to have 10 or so faculty who will work as oncology hospitalists."
The main benefit of this program has been the ability to provide more patient care at the Seidman Cancer Center in Cleveland, he explained. "We have been able to open up more services."
Dr. Wynbrandt and his team handle all hematology patients, including those with noncancer hematologic conditions, and oncology patients. They work in collaboration with the patient's hematologist and oncologist, he emphasized.
"We also have a very active hematology and oncology service. If there are things that occur outside of our scope, we will work and collaborate and develop a plan with the consulting team," he explained.
Pushback From Oncologists
At the University of Texas M.D. Anderson Cancer Center in Houston, hospitalists are internal medicine physicians who work closely with oncologists to manage other health issues and the adverse effects of cancer treatment.
That program began 2006 with 1 hospitalist, and now there are 9. The hospitalists primarily take care of complications related to the disease and treatment, and comorbidities, explained Maria-Claudia Campagna, MD, a hospitalist and assistant professor in the Department of General Internal Medicine.
"Many of these patients are already undergoing chemotherapy and they have complications, so we take care of that," she told Medscape Medical News. "They also have medical conditions that aren't related to their cancer."
About 60% of the patients come in through the emergency department; the other 40% come from the clinic. Some of the patients are brand new to M.D. Anderson, whereas others have already been treated for their cancer but are coming in with medical problems such as pneumonia, she reported. "We have both cancer patients and survivors."
The oncologists were less than enthusiastic about the advent of a hospitalist program at M.D. Anderson, and they did not want to give up caring for their patients when they were hospitalized. "They were very reluctant at the beginning," Dr. Campagna said, "but then they realized the value of a trained hospitalist. Now we work very well together."
Those sentiments were echoed by Dr. Wynbrandt, except at his center, it was never an issue for the outpatient oncologist to relinquish primary care of the patient. "From the beginning, the mindset was that we would be working as a collaborative group, and the oncologists appreciated it," he said. "I think it was that we, as a hospitalist group, understood the importance of communication, and the oncologist is always kept in the loop."
"At this point," he noted, "they are grateful that we are able to provide this service."
Patient and Physician Satisfaction
The emerging use of hospitalists reflects several trends in medicine. One is that cancer care is becoming increasingly outpatient-based, and oncologists want to spend more time in their office and less in the hospital. There are also workforce issues.
According to the American Society of Clinical Oncology (ASCO), the projected number of new cancer cases in the United States will increase by 42% by 2025. During the same period, the number of oncologists will increase by only 28%, which will lead to a projected shortage of 1487 oncologists. Because the average oncologist sees about 300 new patients each year, this figure extrapolates to roughly 450,000 new patients who may not get appropriate care. Hospitalists can help accommodate the patient load.
Hospitalist medicine has been linked to more efficient, less costly, and better-quality care. This improved efficiency has been observed at both teaching and nonteaching institutions.
Although there are few data specifically on oncology hospitalists, a pilot oncology hospitalist program was a "universal success," according to a study presented at the 2007 ASCO annual meeting (J Clin Oncol. 2007;25[18 suppl]:19630).
In that pilot program, not only did patient satisfaction significantly improve, the number of graduating residents pursuing fellowships in oncology increased from 3 or 4 per year to 7 or 8.
The data showed that attending physicians were able to continue their clinic schedules and research activities without interruption. Overall, the authors concluded that their model of inpatient oncology care "improved patient satisfaction, teaching, and faculty utilization."
Dr. Wynbrandt explained that the Cleveland program has been well received by the patients as well. "We are very focused on patient-centered medicine, we are able to spend a lot of time with patients, and we have received a lot of great feedback," he said. "Not that outpatient oncologists don't spend time with their patients, but we don't have a full clinic waiting for us. The oncologists are happy with it because we coordinate with them."
But there is a need for "some numbers" because there are no real data on outcomes, according to Dr. Campagna. "I think we are a growing practice, but we need to put the data together and analyze them."
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Cite this: Oncology Hospitalists: An Emerging and Growing Specialty - Medscape - Aug 15, 2014.
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