By Vicki Hyatt

Jun. 11, 2008 (McClatchy-Tribune Regional News delivered by Newstex) -- As Haywood Regional Medical Center returns to normalcy, one of the challenges involves bringing the hospitalist service back on line.

A hospitalist is a physician who admits patients cared for in the emergency or urgent care departments that need to be hospitalized or cares for hospitalized patients without a family physician or whose doctor only sees patients in an office setting.

Before the February decertification by the Centers for Medicare and Medicaid Services, Haywood Regional had six hospitalists under contract through PrimeDocs, a national company that provides physician staffing. That number was pared down by half when the hospital's census plummeted for the three-month period it operated without Medicare certification.

Now, said Al Byers, HRMC interim CEO, the hospital is ready to replace the March 1 temporary contract where physicians are working at an hourly rate with a permanent one. He gave a 30-day notice to begin negotiating a new contract last week, but it will take time to complete the process because hospitalists are in short supply.

The transition is especially difficult for the physicians in the community, Dr. Shannon Hunter, chief of medical staff, explained to hospital governing board members at their meeting last week.

Before the Medicare shakeup, Haywood had a "hybrid" system where part of the physician practices relied exclusively on the hospitalists to handle all their patient needs during a hospital stay, and two practices, Midway Medical and Mountain Medical, counted on the hospitalist to frequently handle the patient admittance process, but then made rounds to visit their patients during their hospital stay.

With the hospitalist staff down by three, physicians from just Midway Medical and Mountain Medical are often called upon to disrupt their own patients waiting for an office visit to travel to the hospital to admit patients.

The situation has created considerable stress and has been the topic of several medical staff meetings, Hunter said.
Former hospital board chairwoman Dr. Nancy Freeman of Midway Medical Center said the community physicians who do work with hospitalized patients are helping out as much as they can for now. But summer vacations are scheduled and the part-time county population is back for the summer, which creates an increased workload.

"I'm giving up my patients to admit for a group that isn't participating and therein lies the resentment," Freeman said. "In the short term, we'll all bite the bullet and take care of not only Midway patients but the overflow from other groups in town who are our competition."

But that situation cannot continue indefinitely, she warned.
"The sad truth of the matter is hospitalists are in short supply," Byers said. "The program has taken off and cannot find enough. Even if we went with another company, we may still have problems."

At a Monday evening medical staff meeting, a short-term "call support schedule" was worked out to address the inpatient admission situation when the hospitalist service has reached capacity, Hunter said.

"We will be looking at this situation in greater detail over the coming weeks for longer- term solutions, but I feel we have a stopgap in place that will provide safe patient care with adequate physician coverage," Hunter indicated in a Tuesday e-mail. "I am thankful to have such dedicated, wonderful colleagues who have risen to yet another challenge in the interest of the citizens of Haywood County."

Having only three hospitalists means there is only one on duty at any given time, Byers said, but one physician can only handle 15 to 18 patients.

"Normally we would have at least two hospitalists on duty during days and evenings --one to admit and consult ER and one to 'round' on patients," he said in an e-mail interview.

"The internal medicine and family practice docs had a meeting prior to the medical staff meeting and worked out a solution to cover the shortage until we can get more hospitalists.

We will continue to try to obtain additional hospitalists as soon as possible."

The hospitalist shortage is also impacting the emergency department operations because a patient who needs admittance will have to wait in the room until a private practitioner arrives.

HRMC trustee Roy Patton suggested it would be better for the patient to be followed by their own doctor once they are admitted to the hospital.

The trend nationally is for more primary care practices to allow hospitalists to care for their hospitalized patients, Hunter said. That's because it offers physicians regular work hours in both fields.

"It becomes a quality of life issue from both perspectives," she said, noting the hospitalist model definitely represents the future of medical care.

Hospitalists generally work one week on and one week off, she said, and those in private practices are increasingly working more regular hours on weekdays only.

"Gen X is not like the baby boomers," Freeman said of the many older physicians who sacrificed personal and family time for their patients.

Dr. Richard Steele agreed there is a "cultural change" within the physician community.

To complicate the situation, there is a shortage of primary care physicians in Haywood County, Freeman said, noting that patients are being booked five months out.

"It is not that easy to put patients back in the schedule if a doctor leaves to admit a hospital patient," she said. "It is an emotionally charged and stressful situation for them to be working under."

Hunter said many part-time patients prefer their Haywood County medical care over that they get elsewhere. Their summer return will put even more pressure on the short physician supply, she added.

"The administration and board needs to let the community know we will do everything we can to get hospitalists up to speed," said Dr. Henry Nathan, who was appointed to the hospital board in March. "I hate for physicians to short-change patients in the waiting room to admit patients, especially when we're getting into busy season with extra people."

There have been problems recruiting an adequate number of physicians for the emergency department, too.

Byers said he is meeting is with a representative from Phoenix Physicians, the firm under contract to provide physician staff for the ER, this week.

A physician assistant will begin working in the ER next week.

Newstex ID: KRTB-0259-25925555