Hybrid Hospitalist Or Fusion
Written by Andrew McWilliams
“Hybrid hospitalist” is a term being heard with increasing frequency. What, exactly, makes a hospitalist or hospitalist practice a “hybrid”?
Actually, the term has a number of different meanings, depending on the context. For instance, it may refer to either
- Hospitalists who have another clinical specialty besides inpatient (hospitalist) care.
- On-site hospitalists who also treat patients in offsite settings such as post-acute care or home care using telehealth technology.
- Hospital-based hospitalists who provide telehospitalist services to other affiliated/non-affiliated hospitals.
It is possible but unusual for the same hospitalist to work both in-person and virtual (telehospitalist) shifts in the same hospital. It is more common for a hospital to supplement its in-house hospitalists with virtual hospitalists, but in these cases the telehospitalists generally work for another collaborating hospital or a private telehospitalist firm. As such, these are not “hybrid hospitalists” in the sense of an individual hospitalist who combines multiple specialties or care modalities, but part of a hybrid staffing model.
Each of these examples is described in greater detail below.
Hospitalists with a Second Clinical Specialty
Clinical specialties that have established inpatient care models based on the hospital medicine model include:
- Neurology
- Psychiatry
- Orthopedics
- OB-GYN
- Surgery
- Gastroenterology
- Oncology
- Cardiology
- Pediatrics
Many of these hybrid specialties originated in the academic setting, but subsequently spread to community hospitals, military and Veterans Affairs facilities, and other settings. The use of such hybrid hospitalists is becoming increasingly widespread for reasons such as:
- It helps to take the pressure off out-patient doctors whose clinics or offices may not be located near the hospital.
- Some medical conditions such as strokes require urgent care and it is logical to have specialists such as neuro-hospitalists close at hand for emergency consults.
- Hybrid hospitalists with specialties like neurology, cardiology help their hospitals achieve specialized certifications such as neuroscience center or cardiac center.
- Hospitals that employ surgical hospitalists report better responses time for surgical consultations, faster waiting times for patients with acute conditions.
- Hybrid hospitalists are afforded the opportunity to specialize in treating patients with serious conditions that are inappropriate for or uncommon in outpatient practice environments, such as severe mental illnesses and psychopathologies.
- Hospitals can minimize litigation and settlement costs by having hospitalists who can manage specialized situations such as obstetric emergencies and deliveries.
On-site Hospitalists Who Also Treat Post-Acute Care Patients Remotely Using Telehealth
Increasingly, inpatient health care services are being pushed out to home and remote outpatient ambulatory facilities, while complex and very ill patients continue to receive acute inpatient services in the hospital. The long-term result will be a “hospital without walls”, embedded in the community. Hospitals as physical entities will certainly continue to exist but they will probably function as specialist hubs, with each specialty concentrated at one or a few hubs in each region, rather than replicated in a large number of generalist hospitals.
In such an environment, hospitalists will monitor, plan and oversee the care of patients spread across a spectrum of venues, including mobile health facilities, rehabilitation centers, skilled nursing facilities and, increasingly private homes. The distinction between in-house hospitalists and telehospitalists will become increasingly blurred, with virtual care, monitoring and guidance becoming the norm. The hospitalist of the future will, almost by definition, be a hybrid hospitalist.
Hospital-Based Hospitalists Who Provide Telehospitalist Services to Other Hospitals
This category includes hospital-based hospitalist programs what provide telehospitalist services to other hospitals within the same health care network. An early example of this approach is the MercyVirtual regional hospitalist program established by Mercy Hospital Fort Smith (Arkansas) to serve three rural critical access hospitals that are part of the Mercy Hospital network.
In the beginning, a hospitalist from Fort Smith travelled every workday to all three hospitals to admit patients and do rounds. Later, Mercy Hospital decided to add telehospital medicine to its service, expanding the availability of the hospitalist’s services overnight and on weekends by enabling them to examine patients virtually rather than losing precious time traveling from facility to facility.
The regional program has helped treat rural patients closer to home and offer a more consistent and higher level of care, according to MercyVirtual. Kaiser Permanente, Intermountain Healthcare, and the Veterans Health Administration (VHA) are among the other providers that are experiment with such a hybrid model. The VHA Office of Rural Health has been pilot-testing a project to provide telehospitalist service to small rural Veterans hospitals that are too small to make a full-time hospitalist economical.
Hospitalists Who Work In-House and Virtual Shifts in the Same Hospital
As discussed earlier, it is uncommon for the same hospitalist to work both in-person and virtual (telehospitalist) shifts in the same hospital. However, it is possible to see how such an arrangement might have advantages under the right circumstances. These advantages include reducing the burden on in-house hospitalists whose regular shift rotation includes nights--the hospitalist could at least work their night shift from home--and increasing the hospital’s flexibility to accommodate short-term caseload surges or staffing shortages.
Obstacles to more hospitalists working combined in-person and virtual shifts vary among individual hospitals, but overall they may include the scepticism with which a significant number of physicians (including hositalists) have traditionally regarded telehealth. COVID-19 forced many physicians to use telehealth technology to see their patients whether they wanted to or not, but according to one recent survey over half of all physicians continue to prefer in-person visits when possible. (Timothy D. Malouff et al., “Physician Satisfaction With Telemedicine During the COVID-19 Pandemic: The Mayo Clinic Florida Experience” Mayo Clin Proc Innov Qual Outcomes 2021 Aug;5(4):771-782 doi: 10.1016/j.mayocpiqo.2021.06.006)
Another, related obstacle may be that functioning successfully as a telehospitalist requires a skill set that does not always come naturally to hospitalists, but must be learned. This skill set includes the interpersonal and media skills needed to establish a mutually trusting relationship with a patient who is not in the same room, as well as the collaborative skills needed to work with the nurse or other “telepresenter” who assists with the examination at the patient’s bedside.
Hospitalist “Hybrid” or Fusion?
However, as we observed earlier of on-site hospitalists who also treat post-acute care patients remotely, hospitalists in the future will have less and less choice whether they practice hospital medicine in-person or virtually. New developments in care models and technologies will force more hospitalists to develop attitudes and skills that are suited to telehospitalist practice.
As the distinction between in-person and virtual hospital medicine becomes increasingly blurred, the future hospitalist that emerges is less likely to be a hybrid of in-person/virtual hospital medicine than a fusion of the two. A hybrid is defined as a mixture of two or more things that keep their separate functions (e.g., on-site vs virtual hospital medicine), as opposed to fusion, which is the merging of different elements into a union so that they become indistinguishable. Likewise, future hospitalists will be equally capable of treating patients, without regard to physical location or time of day, using advanced telehealth technology.