The many faces of hospital medicine
International hospitalists share their common and unique experiences and challenges.
Some parts of being a hospitalist are universal, but other aspects of the job vary dramatically from country to country.
Hospital medicine leaders from Argentina, Brazil, Chile, and Japan offered details on these similarities and differences at Mayo Clinic Hospital Medicine: Managing Complex Patients, held in early November in Scottsdale, Ariz.
They covered topics from scheduling and training to relations with other specialties, contrasting their experiences with what they know of U.S. hospital medicine.
“In the United States, almost all admitted patients are cared for by general internal medicine (GIM). On the other hand, in Japan, many subspecialists directly care for admitted patients because GIM is a minority,“ said Jun Ehara, MD, MPH, ACP Member, chief of the department of general internal medicine at Tokyobay Urayasu Ichikawa Medical Center in Chiba, Japan.
Overall, subspecialists outnumber general internal medicine and family physicians in Japan, the reverse of the U.S., he noted. “In most big hospitals in Japan, general medicine doesn't function. Subspecialists focus on their specialized area and consult other departments,” Dr. Ehara said. “It leads to a flood of consultations and much more workload for each other.”
That situation has started to change only recently. In 2018, new board accreditations for internal and general medicine were established and those training for subspecialty careers were required to spend at least a year learning general internal medicine, he reported.
“General medicine is gradually being recognized as a solution for a highly aging society and increasing health care costs,” Dr. Ehara said, noting that subspecialists still hold most of the power, especially in urban hospitals. His facility is a “U.S.-style educational hospital,” he explained, and the first departmental chiefs were trained at American institutions.
Careers for hospitalists are growing at other hospitals in Japan, he noted, and the Japanese hospitalist network holds seminars and publishes a journal and textbooks. “General medicine is still minor, but the importance is being recognized,” Dr. Ehara concluded.
Teaching physicians and nurses more about the importance of high-quality hospital care is part of the job in Brazil. Fabricio Fonseca, MD, current president of the Brazilian Society of Hospital Medicine, reported on quality improvement efforts in the state of Espírito Santo (also described in the June 21, 2023, Newman's Notions).
“We don't have health care workers trained in hospital medicine principles,” said Dr. Fonseca. The statewide improvement program he led started with basics such as creating criteria for admission and structuring medical records. “And we implemented quality and safety tools—the safety huddle, multidisciplinary rounds, and early warning scores,” he said.
The hospitalist model also upended physicians' usual schedules for seeing hospitalized patients. “It's traditional for the physicians to work at two or three hospitals at the same time. So that's a great barrier for us to educate physicians to work at one institution for more hours in a day,” he said.
Another focus of Brazilian improvement efforts has been length of stay. Research has shown this to be a major source of waste in health care, explained André Wajner, MD, MSc, PhD, FACP, founder of the Brazilian Society of Hospital Medicine and CEO of Eficiência Hospitalista. A 2022 study of more than 4 million discharges from Brazilian hospitals found that about half of health care resources were wasted.
“The main problem is that our length of stay is longer than expected,” said Dr. Wajner. In response, he and colleagues created the concept of a hospital discharge office, a team consisting of at least a physician, nurse, social worker, and records manager, all specialists in effective discharge and safe transitions of care.
“The main work of the discharge office is to identify patients with pending hospital discharge earlier and create strategies to overcome these barriers to hospital discharge,” he said. The result has been decreases in length of stay significant enough to make the news, for example, a 21% drop at one large pediatric hospital.
“With proven results in several hospitals, the health secretary was convinced to change policies,” said Dr. Wajner. “In a brand-new policy last year, they incentivized most hospitals in the state to have a hospital discharge office, and the state will support this implementation.”
Money is a major problem in Argentina right now, noted Mariano de la Serna, MD, ACP Member, a hospitalist at Hospital Italiano in Buenos Aires, Argentina, and president of the Council of Hospital Medicine of the Argentine Society of Medicine.
Helpfully, hospitalists have proven that they can save costs by reducing length of stay and readmissions and smoothing patient flow, he reported. At his academic medical center, they cover about 134 of the 300 beds, with each team of an attending, resident, and nurse caring for 15 to 20 patients.
“When we started the model in Argentina, it was a novelty and we were the first hospital in my country to roll it out,” said Dr. de la Serna, adding that hospitalist services have since grown in popularity within the country's private health system.
“The hospitalist teams are the most important teams in the hospital,” he said. “We assure quality, patient safety, and accessibility to medical care with the least possible cost.”
In Chile, hospitalists have been gathering data that prove their value, explained Eduardo F. Abbott, MD, ACP Member, an assistant professor and program director of the internal medicine residency at Universidad Católica de Chile in Santiago, Chile.
“We have implemented multiple QI projects,” he said. These include an insulin improvement program that switched from using sliding-scale to basal-bolus dosing. “The control has been much better with significantly lower hyperglycemia rates,” Dr. Abbott reported, noting that the hospital also created hypoglycemia treatment kits as part of this project.
Hospitalists also created algorithms to guide venous thromboembolism prophylaxis and prescription of proton-pump inhibitors and implemented delirium protocols. In technological developments, the hospital medicine service also has its own app.
“Roughly three years ago, one of our hospitalists created an app,” said Dr. Abbott. “It has different types of calculators and medications and transfusions. It's very useful for us, and especially for our residents. It's something we use on a daily basis.”
Now the team at his urban hospital is trying to work more closely with their colleagues in other parts of the country. They created a Chilean hospital medicine network in 2021 and have 46 members.
Dr. Abbott recently surveyed the network about their interest in building more formal structures to work together. “Asked if they believe that we should create a hospital medicine society, all responded yes. And as for creating a hospital medicine fellowship, they all agree, so hopefully, that's something that can happen in the future,” he said.
More hospitalist collaboration and networking is in the works on the international level, too, noted moderator Aleksandra Murawska Baptista, MD, a hospitalist at Mayo in Rochester, as she wrapped up the session.
“Our next project is going to be our international hospital medicine conference in Europe,” she said. “I think it's going to be in Italy and it's going to be in 2025, but more to come. You're all invited!”
