Over the past couple of decades, and increasingly moreso recently, hospitalists have come to play an important role in the health care community. While there have always been doctors who worked primarily in hospitals, the position has only recently come into its own as a unique and increasingly well-defined specialty (the term was actually first used in an August 1996 article in the New England Journal of Medicine). More than that, it is now the fastest growing specialty in the country with over 35,000 physicians among its ranks.
So what are the specifics of this definition? Well, according to the Society of Hospital Medicine a hospitalist is,
A physician who specializes in the practice of hospital medicine. Following medical school, hospitalists typically undergo residency training in general internal medicine, general pediatrics, or family practice, but may also receive training in other medical disciplines. Some hospitalists undergo additional post residency training specifically focused on hospital medicine, or acquire other indicators of expertise in the field, such as the Society of Hospital Medicine’s Fellowship in Hospital Medicine (FHM) or the American Board of Internal Medicine’s Recognition of Focused Practice (RFP) in Hospital Medicine.
Further, the society defines hospital medicine as,
A medical specialty dedicated to the delivery of comprehensive medical care to hospitalized patients. Practitioners of hospital medicine include physicians (“hospitalists”) and non-physician providers who engage in clinical care, teaching, research, or leadership in the field of general hospital medicine. In addition to their core expertise managing the clinical problems of acutely ill, hospitalized patients, hospital medicine practitioners work to enhance the performance of hospitals and healthcare systems by:
- Prompt and complete attention to all patient care needs including diagnosis, treatment, and the performance of medical procedures (within their scope of practice).
- Employing quality and process improvement techniques
- Collaboration, communication, and coordination with all physicians and healthcare personnel caring for hospitalized patients
- Safe transitioning of patient care within the hospital, and from the hospital to the community, which may include oversight of care in post-acute care facilities.
- Efficient use of hospital and healthcare resources
Medical Malpractice Risks for Hospitalists
The question of risk is a tricky one when it comes to hospitalists. It was long believed that hospitalists faced a greater malpractice risk than most internists. Only surgeons and ob/gyns, the highest risk specialties, were thought to bear a greater malpractice risk. And this seems intuitively plausible. There are all kinds of reasons why it would be easy to assume that hospitalists face higher than average risk.
- The patients that hospitalists see tend to be sicker; they’re people who are already in the hospital.
- Hospitalists don’t have the benefit of a long-term history or relationship with their patients. They have to make diagnosis and treatment decisions based only on what they can learn in the short time they are typically treating a patient.
- Hospitalists are subject to the “innocent bystander” effect whereby they are named in a suit simply because they briefly had charge over a patient, even if they were basically just monitoring until the specialist was available again.
- Finally, hospitalists report being overworked. In a recent study 40% of hospitalists reported that their “typical inpatient census exceeded safe levels at least monthly,” while “36% of these reported a frequency greater than once per week.” These numbers were born out when their reported workloads were compared with estimated safe workloads.
These factors served to foster the belief that hospitalists are at greater than average malpractice risk. Indeed some still hold to this opinion. However, because hospitalists and general internists have not been distinguished in malpractice records by carriers until recently it wasn’t possible to reach any firm, provable conclusions or compare the numbers. That changed last year when Adam Schaffer, MD, presented the first study on the subject—a “retrospective observational analysis” of “the rates, types, and causes of medical malpractice claims made against hospitalists in the United States.” (1)
The results were surprising to say the least. According to Schaffer’s study, hospitalists are approximately four times less likely to be sued than non-hospitalist internists. Why this is the case is still a matter of debate, but there are some theories. One has to do with missed and delayed diagnosis. According to the study those claims makes up 58% of claims made against non-internists, while they only make up 36% of claims against internists. That’s interesting but it also hints at why the numbers might be lower for hospitalists overall. Missed diagnosis for conditions like cancer make up a lot of malpractice claims. However, those types of claims are less likely to be made against internists because they are not with patients over a long period of time, and are not typically the ones who would be expected to diagnose something like cancer. Internists deal with a lot more people who already have diagnosis.
So, maybe the reduced exposure to failure to diagnose situations accounts in part for the findings. Other theories put forth include access to better equipment, more specialist input, and greater support networks. But the truth is we don’t really know. And it’s worth keeping in mind this was just one study. It will be interesting to see if further research confirms these conclusions. And if it does, will we see reduced malpractice premiums for internists? Here’s hoping!
Recommendations to Prevent Risks for Hospitalists
So what can you do as a hospitalist or one who oversees hospitalists to maximize safety and risk avoidance? How can hospitalists make sure they are covered sufficiently in the event of a malpractice claim? Here are some suggestions.
- Coordination of Care – This is a huge one. Coordination of care is absolutely critical and yet it is an area rife with opportunities for breakdown within a hospital setting. Having systems in place to insure that everyone is clear on who is responsible for what at all times is critical. Likewise, effective transfer of records to a patient’s primary physician upon discharge is a critical task.
- Documentation – Coordination of care is facilitated by good documentation. Documentation keeps all the parts of the complex system that is a hospital working together smoothly. Further, for hospitalists, as for all doctors, documentation is a safeguard against lawsuits. As Houston-based hospitalist Stella Fitzgibbons has said, “”I know a hospitalist who was dropped from a lawsuit because his notes described his repeated calls to the neurosurgeon responsible for the delays in diagnosis and treatment of spinal cord compression.”
- Communication – This almost goes without saying, and obviously entails the previous two, but it also includes the subjective judgments that one has to make. It’s not just about following protocol. It’s important to always be evaluating whether you are communicating clearly, whether a note could be ambiguous or a chart clearer. Diligence in good communication is a principal of leadership in life, but it’s also a key to risk avoidance in the practice of medicine.
- Protocol – Speaking of protocol, while it’s not sufficient in itself it is important. It’s much easier to coordinate care, document properly, and communicate well when there is a clear system in place that everyone is aware of. Protocol is the language of an organization.
- Delineation – Finally, avoid mission creep with clear delineation of responsibilities. This is more than coordination of care. Mission creep occurs not when there is a failure of anyone to take responsibility but when a hospitalist, seeking to be helpful or under pressure from another doctor, takes on tasks properly assigned to specialists. Any doctor who was acting outside of his or her defined area of expertise has a hard fight ahead of them in a malpractice case.
- Malpractice Insurance
- If your employer covers it make sure you ask questions. Ideally you want either an occurrence policy that will cover you for any event that occurred during the time the policy was in place (even if the suit occurs years later), or an agreement that the employer will purchase a tail policy for you should you leave the position. Barring one of those two possibilities you will need to try to secure a nose policy from your next employer or plan to purchase your own tail policy. Further, if the limits of coverage on an employer provided plan aren’t as high as the awards typical in your state you may want to think about purchasing additional coverage on your own or trying to negotiate a better policy through your employer.
- If your employer doesn’t cover your insurance make sure you talk to a competent broker that can assess your needs, shop the market, and help you find a solid policy.
Hopefully these tips will remind you of things you already knew and give you some ideas to reduce your malpractice risk!
This post was written by Justin Donathan.
Justin at Google+