A Week in the Life of a A Week in the Life of a GI HospitalistGI Hospitalist

Stanley Miller, MDStanley Miller, MD

Gastrointestinal Associates, PCGastrointestinal Associates, PC

Knoxville, TNKnoxville, TN

Objectives of TalkObjectives of Talk

What is a GI hospitalist?What is a GI hospitalist?

What does Stan Miller do as a GI What does Stan Miller do as a GI hospitalist?hospitalist?

How does it affect patient care to have a GI How does it affect patient care to have a GI hospitalist?hospitalist?

What does it mean for the GI lab staff and What does it mean for the GI lab staff and other patient care personnel to have a GI other patient care personnel to have a GI hospitalist in the hospital?hospitalist in the hospital?

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IntroductionIntroduction

Started September 1998Started September 1998

Currently 11 Physician GI Currently 11 Physician GI groupgroup 2 nurse practitioners2 nurse practitioners

1 full-time GI hospitalist1 full-time GI hospitalist Started GI practice in 1989, last 13+ years as Started GI practice in 1989, last 13+ years as

GI hospitalistGI hospitalist

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Definition of GI Definition of GI HospitalistHospitalist

Physicians whose primary focus of care is Physicians whose primary focus of care is inpatient medicine are called hospitalists. inpatient medicine are called hospitalists. (Wikipedia) In my case, I practice full time (Wikipedia) In my case, I practice full time gastroenterology on inpatients so I call gastroenterology on inpatients so I call myself a GI hospitalist.myself a GI hospitalist.

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GIA Hospitalist TeamGIA Hospitalist Team

One full time physicianOne full time physician

One full time Registered NurseOne full time Registered Nurse

One full time nurse practitionerOne full time nurse practitioner Splits time at two hospitals, mornings with Splits time at two hospitals, mornings with

me at Physicians Regional Medical Center and me at Physicians Regional Medical Center and afternoons at smaller North Hospitalafternoons at smaller North Hospital

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Melanie R.N. and Amy Melanie R.N. and Amy F.N.PF.N.P

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Objectives of Objectives of HospitalistHospitalist

More efficient use of physician timeMore efficient use of physician time

More efficient use of hospital GI labMore efficient use of hospital GI lab

More efficient use of office and office More efficient use of office and office based gastroenterologistsbased gastroenterologists

Cost savings and improved patient Cost savings and improved patient outcomesoutcomes

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Duties of a GI Duties of a GI HospitalistHospitalist

See inpatient consultsSee inpatient consults

Round on hospitalized patients with GI Round on hospitalized patients with GI issuesissues

Perform specialized hospital based GI Perform specialized hospital based GI procedures (to be discussed later)procedures (to be discussed later)

Admit primary GI focused patientsAdmit primary GI focused patients

Answer emergency calls Answer emergency calls

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Job Description Dr. Job Description Dr. MillerMiller

Monday-Friday 6AM-4PM on callMonday-Friday 6AM-4PM on call

All night admits, consults held over unless All night admits, consults held over unless an emergency consultan emergency consult

No office workNo office work

Nights, weekends covered by partnersNights, weekends covered by partners

One holiday a year in rotationOne holiday a year in rotation

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Job descriptionJob description

I see consults, take calls from ER and I see consults, take calls from ER and patients referred from officepatients referred from office

Round on inpatients for our group dailyRound on inpatients for our group daily

All new patients are assigned to office All new patients are assigned to office doctor for outpatient followup as neededdoctor for outpatient followup as needed

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Hospital based Hospital based specialized proceduresspecialized procedures

ERCP’s, a main area of expertiseERCP’s, a main area of expertise 200-300 ERCP’s each year200-300 ERCP’s each year Rare referrals to tertiary centers nowRare referrals to tertiary centers now Problem-back up support when I am goneProblem-back up support when I am gone

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Other types of patientsOther types of patients

Defibrillator patientsDefibrillator patients

Food impactionsFood impactions

Nursing home patientsNursing home patients

Obese, over 400#Obese, over 400#

Argon plasma coagulationArgon plasma coagulation

Balloon dilationsBalloon dilations

Stents outside biliary tract, ie esophagusStents outside biliary tract, ie esophagus

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Hospital expertiseHospital expertise

Bleeding of gut is common, adept at clips, Bleeding of gut is common, adept at clips, cautery, injectioncautery, injection

Numerous foreign bodies removed of all Numerous foreign bodies removed of all types over the yearstypes over the years Towels, pens, razors, flossing devices, toenail Towels, pens, razors, flossing devices, toenail

clippers, coins, batteries, paper clips, sex toy clippers, coins, batteries, paper clips, sex toy (unsuccessful) and lots and lots of meat.(unsuccessful) and lots and lots of meat.

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Hospitalist ContractHospitalist Contract

Base Salary with guaranteeBase Salary with guarantee

Productivity based incomeProductivity based income

Full partnershipFull partnership

4 weeks off per year, work one holiday4 weeks off per year, work one holiday

Low office overhead, charging for what is Low office overhead, charging for what is used instead of full share due to lower used instead of full share due to lower revenue streamrevenue stream

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Advantages Advantages

More efficient use of office ASCMore efficient use of office ASC

Office M.D.’s with few or no interruptions Office M.D.’s with few or no interruptions from hospital, earlier start at officefrom hospital, earlier start at office

Less congestion in hospital GI labLess congestion in hospital GI lab

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AdvantagesAdvantages

Hospital M.D. expertise in hospital Hospital M.D. expertise in hospital procedures and patients such as ERCP’s, procedures and patients such as ERCP’s, bleeding, working with defibrillators, bleeding, working with defibrillators, anticoagulantsanticoagulants

Staff knows who to call in hospital for Staff knows who to call in hospital for problemsproblems

Working relationship with pathology, Working relationship with pathology, radiology, Medicine hospitalistsradiology, Medicine hospitalists

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AdvantagesAdvantages

Hospital likes it due to built in efficiencies Hospital likes it due to built in efficiencies of expediting care, shorter length of stayof expediting care, shorter length of stay

Office doctors have less call timeOffice doctors have less call time

Hospitalist has no nights or weekendsHospitalist has no nights or weekends

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Impact on Patient CareImpact on Patient CareConsistent Patient Consistent Patient

FlowFlow GI lab staffGI lab staff

Same routines working with me dailySame routines working with me daily Fewer errors with standard protocols i.e. preop Fewer errors with standard protocols i.e. preop

antibiotics for PEG, biliary obstruction, etcantibiotics for PEG, biliary obstruction, etc Scheduling consistencies since usually I Scheduling consistencies since usually I

perform/function same way day to dayperform/function same way day to day I learned quirks of GI lab and adapt some alsoI learned quirks of GI lab and adapt some also I have been able to teach as well as learn from I have been able to teach as well as learn from

my close working relationship with nurses/techsmy close working relationship with nurses/techs

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Impact on patient careImpact on patient care

Hospital Staff in ICU and on floorsHospital Staff in ICU and on floors They know who to call for orders, problemsThey know who to call for orders, problems Staff does not have to go through office Staff does not have to go through office

voicemail jail to find mevoicemail jail to find me Service and call backs (at least by me) are Service and call backs (at least by me) are

more prompt and responsive since I am in the more prompt and responsive since I am in the hospital providing patient carehospital providing patient care

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Impact on Patient careImpact on Patient care

For Hospital/AdministrationFor Hospital/Administration Quicker response for proceduresQuicker response for procedures Decreased length of stay.Decreased length of stay. We showed 0.5 day decrease in length of stay We showed 0.5 day decrease in length of stay $400 decrease cost per stay for acute GI $400 decrease cost per stay for acute GI

bleedingbleeding

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Impact on Patient careImpact on Patient care

For partners of GI hospitalistFor partners of GI hospitalist Less “on-call” timeLess “on-call” time More efficient use of time, no lost travel time More efficient use of time, no lost travel time

back and forthback and forth Disadvantage is lose touch on some Disadvantage is lose touch on some

procedures like ERCP’sprocedures like ERCP’s

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Impact on Patient careImpact on Patient care

PatientsPatients Fewer complications due to expertiseFewer complications due to expertise Fewer transfers out to tertiary centersFewer transfers out to tertiary centers Shorter length of stayShorter length of stay Lower costLower cost Consistent face to see while in hospital Consistent face to see while in hospital

although not always their primary MDalthough not always their primary MD

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Impact on Patient careImpact on Patient care

For other hospital physiciansFor other hospital physicians They know who to call and what response will They know who to call and what response will

be instead of a different GI consultant each be instead of a different GI consultant each dayday

Faster service in seeing consults, getting Faster service in seeing consults, getting procedures since I am in house each dayprocedures since I am in house each day

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Disadvantages-Disadvantages-PatientsPatients

Not able to see usual GI physicianNot able to see usual GI physician

Not able to see GI Hospitalist after Not able to see GI Hospitalist after discharge from hospitaldischarge from hospital

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Disadvantages-GI Lab Disadvantages-GI Lab StaffStaff

If MD is a jerk, you are stuck day to day with If MD is a jerk, you are stuck day to day with a jerka jerk

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Disadvantages-Disadvantages-HospitalistHospitalist

Lower reimbursement for hospital patients Lower reimbursement for hospital patients

Hospitalist burnoutHospitalist burnout

Consults for everything (red jello, pepto Consults for everything (red jello, pepto bismol)bismol)

Unpredictable work load day to dayUnpredictable work load day to day

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The WEEK September The WEEK September 20112011

ColonoscopiesColonoscopies 99 EGDEGD 1515

Varices bandedVarices banded 11 Foreign Body 1Foreign Body 1

PEGPEG 33 ERCPERCP 33

Flexible SigmoidoscopiesFlexible Sigmoidoscopies 99

ConsultsConsults 2525

Followup Hospital VisitsFollowup Hospital Visits 6868

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Diagnosis for 1 WeekDiagnosis for 1 Week

Anemia, GI bleeding, CBD stones, Jaundice, Anemia, GI bleeding, CBD stones, Jaundice, Spontaneous Esophageal Perforation (2), Duodenal Spontaneous Esophageal Perforation (2), Duodenal AVM bleeding, Nausea and vomiting, Diarrhea, AVM bleeding, Nausea and vomiting, Diarrhea, Clostridium difficile diarrhea, Infectious colitis, Colon Clostridium difficile diarrhea, Infectious colitis, Colon polyps, Rectal bleeding, Short bowel diarrhea, Ileus, polyps, Rectal bleeding, Short bowel diarrhea, Ileus, Pancreatitis, Dysphagia, Pyloric stenosis, Bleeding Pancreatitis, Dysphagia, Pyloric stenosis, Bleeding duodenal diverticulum, MALT lymphoma, Esophageal duodenal diverticulum, MALT lymphoma, Esophageal stricture, GE reflux, Post Op Ileus, Heme positive stool, stricture, GE reflux, Post Op Ileus, Heme positive stool, Ischemic colitis, Esophageal Varices bleeding, Ischemic colitis, Esophageal Varices bleeding, Gastroparesis, Stercoral rectal ulcer bleeding, Foreign Gastroparesis, Stercoral rectal ulcer bleeding, Foreign body (nail), Diverticular bleed colon, Crohns colitis, body (nail), Diverticular bleed colon, Crohns colitis, Liver mass, Abdominal Pain, Ascites, Rectal cancer, Iron Liver mass, Abdominal Pain, Ascites, Rectal cancer, Iron deficiency anemia, Liver Failure, Cirrhosis, Acute deficiency anemia, Liver Failure, Cirrhosis, Acute Diverticulitis, Abnormal liver tests shock liver. (39 Diverticulitis, Abnormal liver tests shock liver. (39 different Dx)different Dx)

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The DayThe Day

6AM-4PM on call officially6AM-4PM on call officially

6AM-pick up consults from night6AM-pick up consults from night

6:35AM-ICU rounds6:35AM-ICU rounds

7-8:30AM-see new consults7-8:30AM-see new consults

8:30-midday-procedures8:30-midday-procedures

1pm-finish, f/u rounds see more consults as 1pm-finish, f/u rounds see more consults as they come inthey come in

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THE DAY, scrutinizedTHE DAY, scrutinized

Pick up overnight consults, 4Pick up overnight consults, 4 Ischemic colitisIschemic colitis GI bleed, 2 of themGI bleed, 2 of them DysphagiaDysphagia

See ICU patientsSee ICU patients 3, one esophageal perforation, one massive GI 3, one esophageal perforation, one massive GI

bleed from ulcer and one abnormal liver tests bleed from ulcer and one abnormal liver tests from sepsisfrom sepsis

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The Day, scrutinized, The Day, scrutinized, cont.cont.

ProceduresProcedures Screening colonoscopy, 1Screening colonoscopy, 1 PEG in cancer patient, 1PEG in cancer patient, 1 Heme positive stool colonoscopy in patient with Heme positive stool colonoscopy in patient with

defibrillatordefibrillator ERCP with stone removal ERCP with stone removal Colonoscopy in diverticular bleed patientColonoscopy in diverticular bleed patient Colonoscopy in hospitalized iron deficiency patientColonoscopy in hospitalized iron deficiency patient EGD, hematemesis, esophagitisEGD, hematemesis, esophagitis Sigmoidoscopy, bleeding stercoral rectal ulcerSigmoidoscopy, bleeding stercoral rectal ulcer Esophageal Motility studies, 2, reflux and Esophageal Motility studies, 2, reflux and

dysphagiadysphagia

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The Day, scrutinized, The Day, scrutinized, cont.cont.

PM roundsPM rounds 10 inpatient followup visits10 inpatient followup visits Consult for PEG in demented patientConsult for PEG in demented patient Consult for anemiaConsult for anemia Consult for abdominal pain in chronic narcotic Consult for abdominal pain in chronic narcotic

user, 2user, 2 Consult for abnormal liver testsConsult for abnormal liver tests Urgent scope to remove meat bolusUrgent scope to remove meat bolus

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What type of patients do What type of patients do I see as a full time GI I see as a full time GI

Hospitalist?Hospitalist? 2010 data Top 12 diagnosis2010 data Top 12 diagnosis

GI bleedingGI bleeding DysphagiaDysphagia DiarrheaDiarrhea Blood in stoolBlood in stool Iron deficiency anemiaIron deficiency anemia Nausea and vomitingNausea and vomiting

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What type of patients do What type of patients do I see as a GI Hospitalist, I see as a GI Hospitalist,

cont?cont? 2010 data, top 12 diagnosis, cont2010 data, top 12 diagnosis, cont

Esophageal refluxEsophageal reflux HematemesisHematemesis Abdominal painAbdominal pain Colon polypsColon polyps Abnormal liver testsAbnormal liver tests Bile duct stones (choledocholithiasis)Bile duct stones (choledocholithiasis)

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Diagnosis of interestDiagnosis of interest2010 Data2010 Data

Foreign bodies esophagusForeign bodies esophagus 19 19

Acute pancreatitisAcute pancreatitis 51 51

JaundiceJaundice 33 33

Obstruction of bile duct, unsp Obstruction of bile duct, unsp 34 34

Crohn’s diseaseCrohn’s disease 20 20

Total of 246 total GI diagnosis coded for my Total of 246 total GI diagnosis coded for my encounters on hospital patientsencounters on hospital patients

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What type of procedures What type of procedures do I perform as a GI do I perform as a GI

Hospitalist?Hospitalist? 2010 Data2010 Data

Upper endoscopies of all types 880Upper endoscopies of all types 880 Percutaneous gastro tubesPercutaneous gastro tubes 113 113

PEG exchangesPEG exchanges 28 28 ERCP’sERCP’s 285 285

SphincterotomiesSphincterotomies 117 117 Stone removalStone removal 83 83 Stent placementStent placement 70 70

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Procedures performedProcedures performed

2010 Data2010 Data ColonoscopiesColonoscopies 367 367

Only 18 true screening colonoscopiesOnly 18 true screening colonoscopies SigmoidoscopiesSigmoidoscopies 125 125 Esophageal motility readingsEsophageal motility readings 93 93 Hospital consultsHospital consults 952 952 Hospital followup visitsHospital followup visits 1652 1652

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Unusual ConsultsUnusual Consults

Red Jello ostomy output-GI bleedRed Jello ostomy output-GI bleed

Black stools-iron or pepto bismolBlack stools-iron or pepto bismol

Razor blade ingestionRazor blade ingestion

Toenail clippers ingestedToenail clippers ingested

Sex toy in wrong placeSex toy in wrong place

100’s of tiny gallstones entire biliary tree100’s of tiny gallstones entire biliary tree

Marijuana Nausea and Vomiting, Hot Marijuana Nausea and Vomiting, Hot Showers/Hot TubShowers/Hot Tub

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Life as a GI HospitalistLife as a GI Hospitalist

Summary: Why I am a hospitalistSummary: Why I am a hospitalistReasonable hours that are relatively stableReasonable hours that are relatively stable

Fix it and move onFix it and move on

Appropriate compensationAppropriate compensation

Development of niche expertiseDevelopment of niche expertise

Lifestyle choiceLifestyle choice

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SummarySummary

Objectives metObjectives met What a GI hospitalist is and does.What a GI hospitalist is and does. How having a dedicated physician to hospital How having a dedicated physician to hospital

GI care improves outcomesGI care improves outcomes How a GI hospitalist improves patient flow How a GI hospitalist improves patient flow

and care in a large suburban hospital.and care in a large suburban hospital.

THANK YOUTHANK YOU

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