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A Week in the Life of a GI Hospitalist
Stanley Miller, MD Gastrointestinal Associates, PC Knoxville, TN
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Objectives of Talk What is a GI hospitalist?
What does Stan Miller do as a GI hospitalist? How does it affect patient care to have a GI hospitalist? What does it mean for the GI lab staff and other patient care personnel to have a GI hospitalist in the hospital? TSGNA October 2011
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Introduction Started September 1998 Currently 11 Physician GI group
2 nurse practitioners 1 full-time GI hospitalist Started GI practice in 1989, last 13+ years as GI hospitalist TSGNA October 2011
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Definition of GI Hospitalist
Physicians whose primary focus of care is inpatient medicine are called hospitalists. (Wikipedia) In my case, I practice full time gastroenterology on inpatients so I call myself a GI hospitalist. TSGNA October 2011
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GIA Hospitalist Team One full time physician
One full time Registered Nurse One full time nurse practitioner Splits time at two hospitals, mornings with me at Physicians Regional Medical Center and afternoons at smaller North Hospital TSGNA October 2011
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Melanie R.N. and Amy F.N.P TSGNA October 2011
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Objectives of Hospitalist
More efficient use of physician time More efficient use of hospital GI lab More efficient use of office and office based gastroenterologists Cost savings and improved patient outcomes TSGNA October 2011
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Duties of a GI Hospitalist
See inpatient consults Round on hospitalized patients with GI issues Perform specialized hospital based GI procedures (to be discussed later) Admit primary GI focused patients Answer emergency calls TSGNA October 2011
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Job Description Dr. Miller
Monday-Friday 6AM-4PM on call All night admits, consults held over unless an emergency consult No office work Nights, weekends covered by partners One holiday a year in rotation TSGNA October 2011
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Job description I see consults, take calls from ER and patients referred from office Round on inpatients for our group daily All new patients are assigned to office doctor for outpatient followup as needed TSGNA October 2011
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Hospital based specialized procedures
ERCP’s, a main area of expertise ERCP’s each year Rare referrals to tertiary centers now Problem-back up support when I am gone TSGNA October 2011
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Other types of patients
Defibrillator patients Food impactions Nursing home patients Obese, over 400# Argon plasma coagulation Balloon dilations Stents outside biliary tract, ie esophagus TSGNA October 2011
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Hospital expertise Bleeding of gut is common, adept at clips, cautery, injection Numerous foreign bodies removed of all types over the years Towels, pens, razors, flossing devices, toenail clippers, coins, batteries, paper clips, sex toy (unsuccessful) and lots and lots of meat. TSGNA October 2011
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Hospitalist Contract Base Salary with guarantee
Productivity based income Full partnership 4 weeks off per year, work one holiday Low office overhead, charging for what is used instead of full share due to lower revenue stream TSGNA October 2011
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Advantages More efficient use of office ASC
Office M.D.’s with few or no interruptions from hospital, earlier start at office Less congestion in hospital GI lab TSGNA October 2011
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Advantages Hospital M.D. expertise in hospital procedures and patients such as ERCP’s, bleeding, working with defibrillators, anticoagulants Staff knows who to call in hospital for problems Working relationship with pathology, radiology, Medicine hospitalists TSGNA October 2011
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Advantages Hospital likes it due to built in efficiencies of expediting care, shorter length of stay Office doctors have less call time Hospitalist has no nights or weekends TSGNA October 2011
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Impact on Patient Care Consistent Patient Flow
GI lab staff Same routines working with me daily Fewer errors with standard protocols i.e. preop antibiotics for PEG, biliary obstruction, etc Scheduling consistencies since usually I perform/function same way day to day I learned quirks of GI lab and adapt some also I have been able to teach as well as learn from my close working relationship with nurses/techs TSGNA October 2011
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Impact on patient care Hospital Staff in ICU and on floors
They know who to call for orders, problems Staff does not have to go through office voic jail to find me Service and call backs (at least by me) are more prompt and responsive since I am in the hospital providing patient care TSGNA October 2011
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Impact on Patient care For Hospital/Administration
Quicker response for procedures Decreased length of stay. We showed 0.5 day decrease in length of stay $400 decrease cost per stay for acute GI bleeding TSGNA October 2011
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Impact on Patient care For partners of GI hospitalist
Less “on-call” time More efficient use of time, no lost travel time back and forth Disadvantage is lose touch on some procedures like ERCP’s TSGNA October 2011
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Impact on Patient care Patients Fewer complications due to expertise
Fewer transfers out to tertiary centers Shorter length of stay Lower cost Consistent face to see while in hospital although not always their primary MD TSGNA October 2011
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Impact on Patient care For other hospital physicians
They know who to call and what response will be instead of a different GI consultant each day Faster service in seeing consults, getting procedures since I am in house each day TSGNA October 2011
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Disadvantages-Patients
Not able to see usual GI physician Not able to see GI Hospitalist after discharge from hospital TSGNA October 2011
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Disadvantages-GI Lab Staff
If MD is a jerk, you are stuck day to day with a jerk TSGNA October 2011
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Disadvantages-Hospitalist
Lower reimbursement for hospital patients Hospitalist burnout Consults for everything (red jello, pepto bismol) Unpredictable work load day to day TSGNA October 2011
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The WEEK September 2011 Colonoscopies 9 EGD 15
Varices banded 1 Foreign Body 1 PEG 3 ERCP 3 Flexible Sigmoidoscopies 9 Consults 25 Followup Hospital Visits 68 TSGNA October 2011
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Diagnosis for 1 Week Anemia, GI bleeding, CBD stones, Jaundice, Spontaneous Esophageal Perforation (2), Duodenal AVM bleeding, Nausea and vomiting, Diarrhea, Clostridium difficile diarrhea, Infectious colitis, Colon polyps, Rectal bleeding, Short bowel diarrhea, Ileus, Pancreatitis, Dysphagia, Pyloric stenosis, Bleeding duodenal diverticulum, MALT lymphoma, Esophageal stricture, GE reflux, Post Op Ileus, Heme positive stool, Ischemic colitis, Esophageal Varices bleeding, Gastroparesis, Stercoral rectal ulcer bleeding, Foreign body (nail), Diverticular bleed colon, Crohns colitis, Liver mass, Abdominal Pain, Ascites, Rectal cancer, Iron deficiency anemia, Liver Failure, Cirrhosis, Acute Diverticulitis, Abnormal liver tests shock liver. (39 different Dx) TSGNA October 2011
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The Day 6AM-4PM on call officially 6AM-pick up consults from night
6:35AM-ICU rounds 7-8:30AM-see new consults 8:30-midday-procedures 1pm-finish, f/u rounds see more consults as they come in TSGNA October 2011
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THE DAY, scrutinized Pick up overnight consults, 4 See ICU patients
Ischemic colitis GI bleed, 2 of them Dysphagia See ICU patients 3, one esophageal perforation, one massive GI bleed from ulcer and one abnormal liver tests from sepsis TSGNA October 2011
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The Day, scrutinized, cont.
Procedures Screening colonoscopy, 1 PEG in cancer patient, 1 Heme positive stool colonoscopy in patient with defibrillator ERCP with stone removal Colonoscopy in diverticular bleed patient Colonoscopy in hospitalized iron deficiency patient EGD, hematemesis, esophagitis Sigmoidoscopy, bleeding stercoral rectal ulcer Esophageal Motility studies, 2, reflux and dysphagia TSGNA October 2011
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The Day, scrutinized, cont.
PM rounds 10 inpatient followup visits Consult for PEG in demented patient Consult for anemia Consult for abdominal pain in chronic narcotic user, 2 Consult for abnormal liver tests Urgent scope to remove meat bolus TSGNA October 2011
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What type of patients do I see as a full time GI Hospitalist?
2010 data Top 12 diagnosis GI bleeding Dysphagia Diarrhea Blood in stool Iron deficiency anemia Nausea and vomiting TSGNA October 2011
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What type of patients do I see as a GI Hospitalist, cont?
2010 data, top 12 diagnosis, cont Esophageal reflux Hematemesis Abdominal pain Colon polyps Abnormal liver tests Bile duct stones (choledocholithiasis) TSGNA October 2011
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Diagnosis of interest 2010 Data
Foreign bodies esophagus 19 Acute pancreatitis Jaundice Obstruction of bile duct, unsp 34 Crohn’s disease Total of 246 total GI diagnosis coded for my encounters on hospital patients TSGNA October 2011
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What type of procedures do I perform as a GI Hospitalist?
2010 Data Upper endoscopies of all types Percutaneous gastro tubes PEG exchanges ERCP’s Sphincterotomies Stone removal Stent placement TSGNA October 2011
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Procedures performed 2010 Data Colonoscopies 367 Sigmoidoscopies 125
Only 18 true screening colonoscopies Sigmoidoscopies Esophageal motility readings Hospital consults Hospital followup visits TSGNA October 2011
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Unusual Consults Red Jello ostomy output-GI bleed
Black stools-iron or pepto bismol Razor blade ingestion Toenail clippers ingested Sex toy in wrong place 100’s of tiny gallstones entire biliary tree Marijuana Nausea and Vomiting, Hot Showers/Hot Tub TSGNA October 2011
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Life as a GI Hospitalist
Summary: Why I am a hospitalist Reasonable hours that are relatively stable Fix it and move on Appropriate compensation Development of niche expertise Lifestyle choice TSGNA October 2011
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Summary Objectives met What a GI hospitalist is and does.
How having a dedicated physician to hospital GI care improves outcomes How a GI hospitalist improves patient flow and care in a large suburban hospital. THANK YOU TSGNA October 2011
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