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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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Presentation on theme: "A Week in the Life of a GI Hospitalist Stanley Miller, MD Gastrointestinal Associates, PC Knoxville, TN."— Presentation transcript:

1 A Week in the Life of a GI Hospitalist Stanley Miller, MD Gastrointestinal Associates, PC Knoxville, TN

2 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

3 Introduction Started September 1998 Started September 1998 Currently 11 Physician GI group Currently 11 Physician GI group 2 nurse practitioners 2 nurse practitioners 1 full-time GI hospitalist 1 full-time GI hospitalist Started GI practice in 1989, last 13+ years as GI hospitalist Started GI practice in 1989, last 13+ years as GI hospitalist TSGNA October 2011

4 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. 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

5 GIA Hospitalist Team One full time physician One full time physician One full time Registered Nurse One full time Registered Nurse One full time nurse practitioner One full time nurse practitioner Splits time at two hospitals, mornings with me at Physicians Regional Medical Center and afternoons at smaller North Hospital Splits time at two hospitals, mornings with me at Physicians Regional Medical Center and afternoons at smaller North Hospital TSGNA October 2011

6 Melanie R.N. and Amy F.N.P TSGNA October 2011

7 Objectives of Hospitalist More efficient use of physician time More efficient use of physician time More efficient use of hospital GI lab More efficient use of hospital GI lab More efficient use of office and office based gastroenterologists More efficient use of office and office based gastroenterologists Cost savings and improved patient outcomes Cost savings and improved patient outcomes TSGNA October 2011

8 Duties of a GI Hospitalist See inpatient consults See inpatient consults Round on hospitalized patients with GI issues Round on hospitalized patients with GI issues Perform specialized hospital based GI procedures (to be discussed later) Perform specialized hospital based GI procedures (to be discussed later) Admit primary GI focused patients Admit primary GI focused patients Answer emergency calls Answer emergency calls TSGNA October 2011

9 Job Description Dr. Miller Monday-Friday 6AM-4PM on call Monday-Friday 6AM-4PM on call All night admits, consults held over unless an emergency consult All night admits, consults held over unless an emergency consult No office work No office work Nights, weekends covered by partners Nights, weekends covered by partners One holiday a year in rotation One holiday a year in rotation TSGNA October 2011

10 Job description I see consults, take calls from ER and patients referred from office I see consults, take calls from ER and patients referred from office Round on inpatients for our group daily Round on inpatients for our group daily All new patients are assigned to office doctor for outpatient followup as needed All new patients are assigned to office doctor for outpatient followup as needed TSGNA October 2011

11 Hospital based specialized procedures ERCP’s, a main area of expertise ERCP’s, a main area of expertise ERCP’s each year ERCP’s each year Rare referrals to tertiary centers now Rare referrals to tertiary centers now Problem-back up support when I am gone Problem-back up support when I am gone TSGNA October 2011

12 Other types of patients Defibrillator patients Defibrillator patients Food impactions Food impactions Nursing home patients Nursing home patients Obese, over 400# Obese, over 400# Argon plasma coagulation Argon plasma coagulation Balloon dilations Balloon dilations Stents outside biliary tract, ie esophagus Stents outside biliary tract, ie esophagus TSGNA October 2011

13 Hospital expertise Bleeding of gut is common, adept at clips, cautery, injection Bleeding of gut is common, adept at clips, cautery, injection Numerous foreign bodies removed of all types over the years 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. Towels, pens, razors, flossing devices, toenail clippers, coins, batteries, paper clips, sex toy (unsuccessful) and lots and lots of meat. TSGNA October 2011

14 Hospitalist Contract Base Salary with guarantee Base Salary with guarantee Productivity based income Productivity based income Full partnership Full partnership 4 weeks off per year, work one holiday 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 Low office overhead, charging for what is used instead of full share due to lower revenue stream TSGNA October 2011

15 Advantages More efficient use of office ASC More efficient use of office ASC Office M.D.’s with few or no interruptions from hospital, earlier start at office Office M.D.’s with few or no interruptions from hospital, earlier start at office Less congestion in hospital GI lab Less congestion in hospital GI lab TSGNA October 2011

16 Advantages Hospital M.D. expertise in hospital procedures and patients such as ERCP’s, bleeding, working with defibrillators, anticoagulants 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 Staff knows who to call in hospital for problems Working relationship with pathology, radiology, Medicine hospitalists Working relationship with pathology, radiology, Medicine hospitalists TSGNA October 2011

17 Advantages Hospital likes it due to built in efficiencies of expediting care, shorter length of stay Hospital likes it due to built in efficiencies of expediting care, shorter length of stay Office doctors have less call time Office doctors have less call time Hospitalist has no nights or weekends Hospitalist has no nights or weekends TSGNA October 2011

18 Impact on Patient Care Consistent Patient Flow GI lab staff GI lab staff Same routines working with me daily Same routines working with me daily Fewer errors with standard protocols i.e. preop antibiotics for PEG, biliary obstruction, etc 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 Scheduling consistencies since usually I perform/function same way day to day I learned quirks of GI lab and adapt some also 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 I have been able to teach as well as learn from my close working relationship with nurses/techs TSGNA October 2011

19 Impact on patient care Hospital Staff in ICU and on floors Hospital Staff in ICU and on floors They know who to call for orders, problems They know who to call for orders, problems Staff does not have to go through office voic jail to find me 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 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

20 Impact on Patient care For Hospital/Administration For Hospital/Administration Quicker response for procedures Quicker response for procedures Decreased length of stay. Decreased length of stay. We showed 0.5 day decrease in length of stay We showed 0.5 day decrease in length of stay $400 decrease cost per stay for acute GI bleeding $400 decrease cost per stay for acute GI bleeding TSGNA October 2011

21 Impact on Patient care For partners of GI hospitalist For partners of GI hospitalist Less “on-call” time Less “on-call” time More efficient use of time, no lost travel time back and forth More efficient use of time, no lost travel time back and forth Disadvantage is lose touch on some procedures like ERCP’s Disadvantage is lose touch on some procedures like ERCP’s TSGNA October 2011

22 Impact on Patient care Patients Patients Fewer complications due to expertise Fewer complications due to expertise Fewer transfers out to tertiary centers Fewer transfers out to tertiary centers Shorter length of stay Shorter length of stay Lower cost Lower cost Consistent face to see while in hospital although not always their primary MD Consistent face to see while in hospital although not always their primary MD TSGNA October 2011

23 Impact on Patient care For other hospital physicians For other hospital physicians They know who to call and what response will be instead of a different GI consultant each day 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 Faster service in seeing consults, getting procedures since I am in house each day TSGNA October 2011

24 Disadvantages-Patients Not able to see usual GI physician Not able to see usual GI physician Not able to see GI Hospitalist after discharge from hospital Not able to see GI Hospitalist after discharge from hospital TSGNA October 2011

25 Disadvantages-GI Lab Staff If MD is a jerk, you are stuck day to day with a jerk If MD is a jerk, you are stuck day to day with a jerk TSGNA October 2011

26 Disadvantages-Hospitalist Lower reimbursement for hospital patients Lower reimbursement for hospital patients Hospitalist burnout Hospitalist burnout Consults for everything (red jello, pepto bismol) Consults for everything (red jello, pepto bismol) Unpredictable work load day to day Unpredictable work load day to day TSGNA October 2011

27 The WEEK September 2011 Colonoscopies9EGD15 Colonoscopies9EGD15 Varices banded1Foreign Body 1 Varices banded1Foreign Body 1 PEG3ERCP3 PEG3ERCP3 Flexible Sigmoidoscopies9 Flexible Sigmoidoscopies9 Consults25 Consults25 Followup Hospital Visits68 Followup Hospital Visits68 TSGNA October 2011

28 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) 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

29 The Day 6AM-4PM on call officially 6AM-4PM on call officially 6AM-pick up consults from night 6AM-pick up consults from night 6:35AM-ICU rounds 6:35AM-ICU rounds 7-8:30AM-see new consults 7-8:30AM-see new consults 8:30-midday-procedures 8:30-midday-procedures 1pm-finish, f/u rounds see more consults as they come in 1pm-finish, f/u rounds see more consults as they come in TSGNA October 2011

30 THE DAY, scrutinized Pick up overnight consults, 4 Pick up overnight consults, 4 Ischemic colitis Ischemic colitis GI bleed, 2 of them GI bleed, 2 of them Dysphagia Dysphagia See ICU patients See ICU patients 3, one esophageal perforation, one massive GI bleed from ulcer and one abnormal liver tests from sepsis 3, one esophageal perforation, one massive GI bleed from ulcer and one abnormal liver tests from sepsis TSGNA October 2011

31 The Day, scrutinized, cont. Procedures Procedures Screening colonoscopy, 1 Screening colonoscopy, 1 PEG in cancer patient, 1 PEG in cancer patient, 1 Heme positive stool colonoscopy in patient with defibrillator Heme positive stool colonoscopy in patient with defibrillator ERCP with stone removal ERCP with stone removal Colonoscopy in diverticular bleed patient Colonoscopy in diverticular bleed patient Colonoscopy in hospitalized iron deficiency patient Colonoscopy in hospitalized iron deficiency patient EGD, hematemesis, esophagitis EGD, hematemesis, esophagitis Sigmoidoscopy, bleeding stercoral rectal ulcer Sigmoidoscopy, bleeding stercoral rectal ulcer Esophageal Motility studies, 2, reflux and dysphagia Esophageal Motility studies, 2, reflux and dysphagia TSGNA October 2011

32 The Day, scrutinized, cont. PM rounds PM rounds 10 inpatient followup visits 10 inpatient followup visits Consult for PEG in demented patient Consult for PEG in demented patient Consult for anemia Consult for anemia Consult for abdominal pain in chronic narcotic user, 2 Consult for abdominal pain in chronic narcotic user, 2 Consult for abnormal liver tests Consult for abnormal liver tests Urgent scope to remove meat bolus Urgent scope to remove meat bolus TSGNA October 2011

33 What type of patients do I see as a full time GI Hospitalist? 2010 data Top 12 diagnosis 2010 data Top 12 diagnosis GI bleeding GI bleeding Dysphagia Dysphagia Diarrhea Diarrhea Blood in stool Blood in stool Iron deficiency anemia Iron deficiency anemia Nausea and vomiting Nausea and vomiting TSGNA October 2011

34 What type of patients do I see as a GI Hospitalist, cont? 2010 data, top 12 diagnosis, cont 2010 data, top 12 diagnosis, cont Esophageal reflux Esophageal reflux Hematemesis Hematemesis Abdominal pain Abdominal pain Colon polyps Colon polyps Abnormal liver tests Abnormal liver tests Bile duct stones (choledocholithiasis) Bile duct stones (choledocholithiasis) TSGNA October 2011

35 Diagnosis of interest 2010 Data Foreign bodies esophagus 19 Foreign bodies esophagus 19 Acute pancreatitis 51 Acute pancreatitis 51 Jaundice 33 Jaundice 33 Obstruction of bile duct, unsp 34 Obstruction of bile duct, unsp 34 Crohn’s disease 20 Crohn’s disease 20 Total of 246 total GI diagnosis coded for my encounters on hospital patients Total of 246 total GI diagnosis coded for my encounters on hospital patients TSGNA October 2011

36 What type of procedures do I perform as a GI Hospitalist? 2010 Data 2010 Data Upper endoscopies of all types 880 Upper endoscopies of all types 880 Percutaneous gastro tubes 113 Percutaneous gastro tubes 113 PEG exchanges 28 PEG exchanges 28 ERCP’s 285 ERCP’s 285 Sphincterotomies 117 Sphincterotomies 117 Stone removal 83 Stone removal 83 Stent placement 70 Stent placement 70 TSGNA October 2011

37 Procedures performed 2010 Data 2010 Data Colonoscopies 367 Colonoscopies 367 Only 18 true screening colonoscopies Only 18 true screening colonoscopies Sigmoidoscopies 125 Sigmoidoscopies 125 Esophageal motility readings 93 Esophageal motility readings 93 Hospital consults 952 Hospital consults 952 Hospital followup visits 1652 Hospital followup visits 1652 TSGNA October 2011

38 Unusual Consults Red Jello ostomy output-GI bleed Red Jello ostomy output-GI bleed Black stools-iron or pepto bismol Black stools-iron or pepto bismol Razor blade ingestion Razor blade ingestion Toenail clippers ingested Toenail clippers ingested Sex toy in wrong place Sex toy in wrong place 100’s of tiny gallstones entire biliary tree 100’s of tiny gallstones entire biliary tree Marijuana Nausea and Vomiting, Hot Showers/Hot Tub Marijuana Nausea and Vomiting, Hot Showers/Hot Tub TSGNA October 2011

39 Life as a GI Hospitalist Summary: Why I am a 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

40 Summary Objectives met Objectives met What a GI hospitalist is and does. What a GI hospitalist is and does. How having a dedicated physician to hospital GI care improves outcomes 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. How a GI hospitalist improves patient flow and care in a large suburban hospital. THANK YOU THANK YOU TSGNA October 2011


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