By Marina Dundjerski
Photography by Ann Johansson
It's a typical day for Jason Napolitano, M.D. He arrives at 7 a.m. at Ronald Reagan UCLA Medical Center and checks the overnight results of his patients' X-rays, blood work and other lab tests. He reviews their vital signs, medications and updates provided by his medical team. Armed with the most up-to-date information, Dr. Napolitano sets out on rounds, prioritizing the sickest of his 15 hospitalized patients.
His first stop is Jean Hawkins, a 50-year-old woman who had spiked a fever in the night. She had been admitted through the emergency department a week earlier and was being treated for staph pneumonia. The bacteria had entered Hawkins' blood stream and also infected a heart valve. Dr. Napolitano conducts a physical examination to look for any new complications that might explain the re-emergence of fever. Finding none, he decides it is safe to continue with the same antibiotics under close monitoring.
Dr. Jason Napolitano is among UCLA Health System’s 58 hospitalists.Their speciality is to manage inpatient care from admission to discharge.
He then visits Louise Campbell, 61. Campbell has breast cancer that was left untreated for months as she grappled with her diagnosis and sought additional opinions at institutions across the country before seeking treatment at UCLA. She has a gaping hole where her left shoulder once was - a result of the cancer traveling through her lymphatic system into her arm, eating through lymph nodes, nerves and skin. Overnight she complained of increased pain. Dr. Napolitano adjusts her medications. Because of the abscessed wound and a paralysis of her left arm, Campbell has been lying on her right side almost continuously. Dr. Napolitano contacts the occupational-therapy department to see if they can improve her positioning.
After completing his morning rounds, Dr. Napolitano heads to his office. But he doesn't have far to go. That's because his office is right there, within Ronald Reagan UCLA Medical Center. Dr. Napolitano is a hospitalist - one of 58 employed by UCLA Health System who work in the Westwood hospital as well as at UCLA Health - Santa Monica Medical Center and at St. John's Health Center in Santa Monica.
As the name conveys, hospitalists are physicians who specialize exclusively in the care of hospitalized patients. They come from a variety of backgrounds - internal medicine, pediatrics, family medicine - and hold primary responsibility for inpatients from their admission to discharge. Hospitalists collaborate with specialists, nurses, social workers and other medical professionals to ensure the best transition of care within the hospital and also serve as the liaison to the inpatients' primary-care doctors.
"We're general doctors by training and experts in treating patients with acute illnesses that make them sick enough to require hospitalization," Dr. Napolitano says. "We will take care of people with any medical problem ranging from pneumonia to skin infection to a stroke. Because we do this every day, we get good at it."
Hospital medicine is the fastest-growing specialty in the history of modern American medicine. Over the past decade, practicing hospitalists have grown from just a few hundred to more than 35,000 nationwide, according to the "father" of the hospitalist movement, Robert Wachter, M.D., chief of the Division of Hospital Medicine at the University of California, San Francisco (UCSF). In 1996, Dr. Wachter, along with Lee Goldman, M.D., current dean of health sciences and medicine at Columbia University and then-chair of UCSF's Department of Medicine, coined the term "hospitalist" in the New England Journal of Medicine. The number of hospitalists is expected to grow, reaching 40,000 in the next few years.
"Hospitalists are emerging as a critical group of physicians for the safe and effective running of any acute-care hospital," says Tom Rosenthal, M.D., chief medical officer for UCLA Health System, "but certainly for this acute-care hospital."
The reason is simple, Dr. Rosenthal explains. Historically, the hospital
Dr. Napolitano talks with patient Karin Sheard about her upcoming discharge.
service at UCLA was run by academic physicians. These doctors had a lot of research responsibilities but perhaps only two-to-four weeks a year dedicated to clinical rotation as attending physicians overseeing residents. "That model of having someone new every two weeks worked fine for 40 years, when the pace was slower and the complexity of the integration of pre-hospital and post-hospital care wasn't as great as it is today," Dr. Rosenthal says.
In addition to their expertise managing the clinical problems of inpatients, hospitalists work to improve the systematic quality of medical care, while simultaneously streamlining operating efficiencies. "The coordination of care is much, much better," Dr. Rosenthal says. "The ability for patients to get in and out of the hospital efficiently has improved. The continuity of post-hospital care has vastly improved, including getting their home-health needs or skilled-nursing-facility needs met at a much better rate. It's hard to imagine running the hospital under the old paradigm."
The expansive growth in the field has been fueled by several factors. With the enactment of the Health Maintenance Organization Act of 1973, the role of the primary-care doctor began to evolve. In the past, physicians routinely cared for patients in both the outpatient setting and, when they were hospitalized, by coming to see them on rounds. By the 1990s, however, primary-care doctors were being required to spend a greater amount of time with outpatients in their offices to determine their care. All the while, managed care emphasized shorter hospital stays, and fewer and fewer patients were being hospitalized. On the whole, however, hospitalized patients were sicker than they had been in the past and required more specialized doctors and procedures that didn't exist in the 1970s and 1980s. Patients coming in for surgery often had underlying medical conditions such as diabetes, heart disease, hypertension or emphysema, all requiring health management.
A large measure of Dr. Napolitano’s day is coordinating care with other physicians such as kidney specialists Drs. Suphamai Bunnapradist (center) and Carl Schulze, as transplant patient David Reed listens in.
As a result, doctors became less proficient in navigating hospital systems that were themselves growing more and more complex. Insurance- and Medicare-reimbursement practices, multiple consultations with varied specialties and advances in technology and diagnostic tools all played a role. Hospitalists, who initially cropped up organically across the country in various representations, were the innovation that in part allowed primary-care doctors to focus on their patients in the outpatient setting.
"The emergence of the hospitalist was a solution to what was evolving in American healthcare," says Jan H. Tillisch, M.D., executive vice chair of the UCLA Department of Medicine, who helped form the hospitalist movement at UCLA in the mid-1990s. "It creates effective care in the inpatient setting and so far is working amazingly well."
More changes are on the horizon. The Obama administration's healthcare reforms, many of which will be phased in by 2014, are anticipated to affect the need for more hospitalists. Under the new legislation, for example, hospitals will be penalized with reduced Medicare reimbursements for readmissions of patients.
"Hospitalists are more comfortable with a changing healthcare environment because we are not procedure driven," says Michael Lazarus, M.D., director of the UCLA Hospitalist Service. "We'll be adaptable to whatever decisions the government gives us under the Affordable Care Act."
Several UCLA surgical specialties are increasingly calling upon hospitalists to assist with their patients' medical problems. "What we have found over the years is that it's too much for a sub-surgery specialty, whether it be urology or orthopaedics - the sicker the patient is, the more challenges there are," says Mark S. Litwin, M.D., M.P.H., chair of the UCLA Department of Urology. "We have long been very collaborative with the hospitalists because they are focused entirely on new thinking and the best practices for perioperative and postoperative care."
Later that morning, Dr. Napolitano meets with his medical team, which includes a resident, two interns and two medical students. Several new patients were admitted overnight. There is a 32-year-old man with severe abdominal pain, recent weight loss and a lesion on his left leg. Indications point to ulcerative colitis, an autoimmune disease of the colon, often accompanied by a skin condition called pyoderma gangrenosum that causes ulceration of the skin
Dr. Napolitano checks in on patient Lester Alan Scharlin.
over the shin. Another man in his 30s entered the ER after swallowing a razor and pieces of a nail clipper, among other things. After being admitted for observation, it was determined he didn't need surgery - the items would pass on their own. Dr. Napolitano and his team also consulted doctors from the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA, and they adjusted the patient's psychiatric medications.
Managing hospital efficiencies and improving quality of care are two of the cornerstones of UCLA's healthcare system, and hospitalists are playing a significant role in improving both, according to Dr. Rosenthal. When done systematically with the same group of doctors, the health system can adopt procedures that ensure all patients have a safety net. For example, every inpatient at risk for deep-vein thrombosis now receives anti-blood-clotting prophylaxis. "It used to be that if patients received this prophylaxis 90 percent of the time, that was thought to be good enough. Now we know that it's not," Dr. Rosenthal says. "It was virtually impossible to do that with a degree of reliability with a different doctor every two weeks whose main focus was somewhere else."
Nasim Afsar, M.D., a hospitalist and associate medical director for UCLA Health System's Quality and Safety Program, is working on added measures, such as formulating an official discharge form - akin to the surgical checklist that counts sponges to make sure nothing is inadvertently left in the patient.
"You actually get to affect patient care at a very fundamental level," Dr. Afsar says, "not only with the patient in front of you, but really for all patients that come after them. When you implement systemic change and improvement, you shift the culture toward one where individuals proactively look for opportunities of improvement."
Dr. Wachter, the hospitalist pioneer, believes that hospitalists will reshape the future of medicine. "We're beginning to see that hospitalists think broadly and as generalists know more about the general enterprise than anybody," he says. "They interact with trainees, administrators and surgeons; they go to the ER, they go to the ICU, they see all the parts of the business in a way that no other doctor does. They were brought up believing that improving the performance of the system is a core competence of the field - all thingsthat a good administrator has to do, but tend not to be natural acts for physicians."
Near the end of a 13-hour day, Dr. Napolitano goes back on rounds. He checks in on Hawkins, the woman with the staph infection. Her fever has broken. Next he stops in to see Campbell. The new pain medications are working, she says, and for the first time in days she is sitting upright. Occupational therapy had put her arm in a sling and she was able to move about better. Campbell and Dr. Napolitano have struck a congenial rapport. She asks many questions and makes a request: Would it be possible to have a notebook and pen so she could write down her observations and symptoms to share with the doctor? Dr. Napolitano brings them to her on a subsequent visit. "That's a reasonable request to help someone out in a small way - you just do it," he says.
Says Campbell, with a broad smile: "Dr. Napolitano is like the integrative part of the brain. This place would be a tornado without him."
Marina Dundjerski is a freelance writer in Los Angeles and the author of UCLA: The First Century (Third Millennium Publishing Ltd., 2012).