A summer on the hospitalist team

An Irish medical student gives his first impressions of U.S. hospital medicine.

Last summer, as a visiting medical student, I undertook two memorable electives on hospitalist teams in the U.S. Before this, my only clinical experience was in the Irish health care system, where the hospitalist role is non-existent. Instead, specialists rotate on-call for general medicine, so patient care is assumed by a busy physician whose expertise may be misaligned with the needs of the patient. I was eager to clarify the precise role of a hospitalist and ascertain if it could be a career choice for me.

I began my first rotation at a private hospital in June. It took me awhile to acclimatize to the U.S. hospital environment. For example, I remember assessing a patient who presented as acutely dehydrated. A voice came around the curtain, “ID team here!” to which I politely replied that I was part of the medical team and would be just five more minutes. I was bewildered at the early engagement of the infectious diseases team. “Does your patient not require an IV line ASAP?!” the man replied. I then realized the misunderstanding—the IV team was here.

Courtesy of Thomas Cotter
Courtesy of Thomas Cotter.

I looked down at my patient, with his sunken eyes and dry mouth, and concluded that he needed the IV line more than I needed to take my history. In Ireland, interns insert all IV lines, nasogastric tubes and catheters, which is why I was taken off guard. But I quickly learned the importance of having specialized hospital teams. Although patients may see many teams, each one is an expert in its field. This system elevates patient care to an unparalleled priority, and creates a platform where physicians can concentrate completely on patient management.

Later, as I drank yet another large latte in the hospital's cafeteria, I asked my attending, “Why do hospitals need a hospitalist?” He retorted, “In Ireland, when the cardiologist is busy seeing his outpatients all day in clinic, who is looking after his inpatients?” I had never reflected upon this before. Specialists' time is often consumed with outpatients and procedures. The patient might only see the specialist briefly during morning rounds, if he or she is lucky. This is not a criticism of the specialist—it is just the nature of the system currently in place, which may leave patients neglected.

Throughout my rotation, I noted that hospitalists were perpetually available to meet with family members, diligently follow up on tests, answer nurses' questions, and deal promptly with any problems that arose. Furthermore, they facilitated improved communication as they straddled different doctors caring for a patient, and secured superior clinical outcomes. Hospitalists are like a patient's quarterback.

Hospitalist care is managed down to the most minute detail, a point that was emphasized during the third week of my first rotation. With my background as a pharmacist, my consultant assigned me the onerous task of clarifying a patient's full medication list. I eagerly accepted his challenge, innocently overlooking the glint in his eye. Two minutes later, I was at a bedside staring at a list that would give Kris Kringle's a run for its money. There were 20 non-prescription medications ranging from black cohosh to horse chestnut. I was amazed as the patient gave the precise indication and dose for each one. The entire list was carefully inputted on the computer system and meticulously screened for drug interactions. One wonders if a busy specialist would have the time for this level of detail.

An appealing aspect to a hospitalist's job is the unpredictability of patient presentations, which was highlighted during my second rotation in a public hospital. I was assessing a patient in the emergency department who had an anti-cholinergic overdose. He looked frightening, and the famous “mad as a hatter” mnemonic for this condition came to mind. While I was determining the best course of action, the patient seized the initiative and head-butted me in the stomach, sending me onto the ancillary bed. I regained my composure and gingerly made my way back to the ward. I decided that it was premature of me to intervene in this patient's care and deferred to the experts in the emergency department. The next morning when presenting the patient, I was tempted to add that perhaps a head CT should be done to rule out hemorrhage.

Reflecting on my summer experience, I have concluded that hospitalists are in the perfect place to bridge the gaps across the continuum of care from the emergency department to the medical ward to discharge. With the hospitalist at the wheel, the harmonization of patient care becomes smooth and seamless. Research also attests that hospitalists save the health system thousands of days through shorter lengths of stay, while reducing costs and enhancing quality of care.

I envisage hospitalists playing a vital role in future reforms of the Irish health system, as the government seeks to minimize costs while maximizing patient outcomes. Hospitalists certainly fit the bill in the U.S., and have inspired me to pursue this rewarding career path.