To Him the Hospital
Feels Like Home
words by Susan Glick / photograph by Pete Byron
Cautioned about becoming a doctor by his mother, Emmanuel King persisted, choosing not only to practice medicine, but to be in the vanguard of a new specialty. Unlike most of his primary care colleagues, his sole focus is now providing care to hospitalized patients, a specialization that was just in its infancy when he entered medical scholl 10 years ago.
hile the concept is not entirely new (European doctors have practiced hospital-based medicine for decades), the term “hospitalist” did not enter the American lexicon until 1996, when it was coined by Robert A. Wachter, MD, and Lee Goldman, MD, in an article in The New England Journal of Medicine. The Society of Hospital Medicine was started shortly after, in 1997. But it was obviously the right time and the right place — this new breed of doctor has multiplied exponentially in this country, from a few hundred to 20,000 in a decade.
Many moons ago, before managed care, medical inflation, and the explosion of medical technology, the family doctor made his daily hospital rounds to keep a watchful eye on his own patients. But as the rules changed and insurance companies shortened hospital stays and curtailed hospital admissions, those taking up hospital beds were actually sicker and in need of more around-the-clock intensive medical care.
Added to that were new laws passed in 2003 capping resident work to 80 hours per week, reducing their care of patients by 10 to 25 percent and creating a serious labor shortage in hospitals, particularly academic health centers. King was a third year internal medicine resident at Temple University Hospital at the time.
In fact, had these controversial laws been put in place just a few years earlier, King’s mother would likely have supported his professional leanings. “My mom was a nurse before the era of resident work regulations and hesitated to encourage me to go through residency under those conditions,” he observes. Before July 1, 2003, residents often worked 100 hours per week. The new rules also placed a 24-hour limit on continuous duty time and required that one day in seven be free from all patient care.
In 2004, his last year of residency, Temple University Hospital opened its newly established Section of Hospital Medicine within the Department of General Internal Medicine. King chose to be one of their first hospitalists and his well-fit career was born.
The hospital specialist says he opted for his profession because other specialties or fellowships within medicine “were just not going to get me out of bed every morning.” Furthermore, his love for teaching was balanced by his disinclination to do basic scientific research, which he conducted as an undergraduate Howard Hughes Institute scholar. Hospitalists often do teaching, and very little, or no, basic research. Their investigational work generally focuses on efficiency and quality of hospital care, and reducing medical errors.
Wachter, chief of medical service at Moffitt-Long Hospital, University of California, San Francisco, said in an interview published in the American College of Physicians’ ACP Observer: “Many [hospitalists] are chairing patient safety committees and scores are leading new teamwork-training programs, creating new models for morbidity and mortality conferences…It all comes from a happy coincidence. The hospitalist movement’s evolution took place just as the patient safety movement was heating up, and the merging of the two fields is completely natural.”
As a first-year attending, King immediately set to work completing two such studies and published his work in the Journal of Hospital Medicine and the Joint Commission Journal of Quality and Patient Safety. These articles helped solidify his foothold in the academic world, where he has now landed as an assistant professor of clinical medicine at Penn Hospital Care Physicians, in the Division of General Internal Medicine at the University of Pennsylvania School of Medicine. While King’s career is unfolding in the academic setting, he explains that many hospitalists primarily work in community or private hospitals.
Teaching and inpatient care make up most of King’s work day. He currently participates in an unprecedented quality improvement experiment that assigns a nurse manager to a physician leader and a quality improvement expert to collectively manage day-to-day operations of three hospital floors. He eschews the common criticism that using hospitalists may disrupt continuity of care. For some of his patients, he observes, he is ironically their only line of continuity in the healthcare system.
Like many academic medical centers, the Hospital of the University of Pennsylvania is a safety-net for its urban host community. Without health insurance or access to regular primary care, many community members, particularly those with chronic conditions, use the emergency department when they become ill. If admitted to the hospital, these patients are likely to be cared for by a hospitalist, who not only manages their treatment, but also ensures its quality.
Does he feel that he is having an impact on improving the delivery of healthcare? King tells a story: Not too long ago, two older women under his care were chatting quietly and appeared to be talking about him — not a positive sign, he thought. When he approached, they told him they were planning to switch from their primary care doctor to his practice. And when King explained he only sees patients in the hospital, they responded that in that case, they would just have to come to the hospital more often.