A Week in the Life of a GI
Hospitalist
Stanley Miller, MD
Gastrointestinal Associates, PC
Knoxville, TN
Objectives of Talk
 What is a GI hospitalist?
 What does Stan Miller do as a GI hospitalist?
 How does it affect patient care to have a GI hospitalist?
 What does it mean for the GI lab staff and other patient
care personnel to have a GI hospitalist in the hospital?
TSGNA October 2011
Introduction
 Started September 1998
 Currently 11 Physician GI group
 2 nurse practitioners
 1 full-time GI hospitalist
 Started GI practice in 1989, last 13+ years as GI hospitalist
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Definition of GI Hospitalist
 Physicians whose primary focus of care is inpatient
medicine are called hospitalists. (Wikipedia) In my case, I
practice full time gastroenterology on inpatients so I call
myself a GI hospitalist.
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GIA Hospitalist Team
 One full time physician
 One full time Registered Nurse
 One full time nurse practitioner
 Splits time at two hospitals, mornings with me at Physicians
Regional Medical Center and afternoons at smaller North
Hospital
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Melanie R.N. and Amy F.N.P
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Objectives of Hospitalist
 More efficient use of physician time
 More efficient use of hospital GI lab
 More efficient use of office and office based
gastroenterologists
 Cost savings and improved patient outcomes
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Duties of a GI Hospitalist
 See inpatient consults
 Round on hospitalized patients with GI issues
 Perform specialized hospital based GI procedures (to be
discussed later)
 Admit primary GI focused patients
 Answer emergency calls
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Job Description Dr. Miller
 Monday-Friday 6AM-4PM on call
 All night admits, consults held over unless an emergency
consult
 No office work
 Nights, weekends covered by partners
 One holiday a year in rotation
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Job description
 I see consults, take calls from ER and patients referred
from office
 Round on inpatients for our group daily
 All new patients are assigned to office doctor for
outpatient followup as needed
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Hospital based specialized
procedures
 ERCP’s, a main area of expertise
 200-300 ERCP’s each year
 Rare referrals to tertiary centers now
 Problem-back up support when I am gone
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Other types of patients
 Defibrillator patients
 Food impactions
 Nursing home patients
 Obese, over 400#
 Argon plasma coagulation
 Balloon dilations
 Stents outside biliary tract, ie esophagus
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Hospital expertise
 Bleeding of gut is common, adept at clips, cautery,
injection
 Numerous foreign bodies removed of all types over the
years
 Towels, pens, razors, flossing devices, toenail clippers, coins,
batteries, paper clips, sex toy (unsuccessful) and lots and lots
of meat.
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Hospitalist Contract
 Base Salary with guarantee
 Productivity based income
 Full partnership
 4 weeks off per year, work one holiday
 Low office overhead, charging for what is used instead of
full share due to lower revenue stream
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Advantages
 More efficient use of office ASC
 Office M.D.’s with few or no interruptions from hospital,
earlier start at office
 Less congestion in hospital GI lab
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Advantages
 Hospital M.D. expertise in hospital procedures and
patients such as ERCP’s, bleeding, working with
defibrillators, anticoagulants
 Staff knows who to call in hospital for problems
 Working relationship with pathology, radiology, Medicine
hospitalists
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Advantages
 Hospital likes it due to built in efficiencies of expediting
care, shorter length of stay
 Office doctors have less call time
 Hospitalist has no nights or weekends
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Impact on Patient Care
Consistent Patient Flow
 GI lab staff
 Same routines working with me daily
 Fewer errors with standard protocols i.e. preop antibiotics for
PEG, biliary obstruction, etc
 Scheduling consistencies since usually I perform/function same
way day to day
 I learned quirks of GI lab and adapt some also
 I have been able to teach as well as learn from my close working
relationship with nurses/techs
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Impact on patient care
 Hospital Staff in ICU and on floors
 They know who to call for orders, problems
 Staff does not have to go through office voicemail jail to find
me
 Service and call backs (at least by me) are more prompt and
responsive since I am in the hospital providing patient care
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Impact on Patient care
 For Hospital/Administration
 Quicker response for procedures
 Decreased length of stay.
 We showed 0.5 day decrease in length of stay
 $400 decrease cost per stay for acute GI bleeding
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Impact on Patient care
 For partners of GI hospitalist
 Less “on-call” time
 More efficient use of time, no lost travel time back and forth
 Disadvantage is lose touch on some procedures like ERCP’s
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Impact on Patient care
 Patients
 Fewer complications due to expertise
 Fewer transfers out to tertiary centers
 Shorter length of stay
 Lower cost
 Consistent face to see while in hospital although not always
their primary MD
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Impact on Patient care
 For other hospital physicians
 They know who to call and what response will be instead of a
different GI consultant each day
 Faster service in seeing consults, getting procedures since I
am in house each day
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Disadvantages-Patients
 Not able to see usual GI physician
 Not able to see GI Hospitalist after discharge from hospital
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Disadvantages-GI Lab Staff
 If MD is a jerk, you are stuck day to day with a jerk
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Disadvantages-Hospitalist
 Lower reimbursement for hospital patients
 Hospitalist burnout
 Consults for everything (red jello, pepto bismol)
 Unpredictable work load day to day
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The WEEK September 2011
 Colonoscopies
9
EGD
 Varices banded
1
Foreign Body 1
 PEG
3
ERCP
 Flexible Sigmoidoscopies
9
 Consults
25
 Followup Hospital Visits
68
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15
3
Diagnosis for 1 Week
 Anemia, GI bleeding, CBD stones, Jaundice, Spontaneous
Esophageal Perforation (2), Duodenal AVM bleeding, Nausea
and vomiting, Diarrhea, Clostridium difficile diarrhea, Infectious
colitis, Colon polyps, Rectal bleeding, Short bowel diarrhea,
Ileus, Pancreatitis, Dysphagia, Pyloric stenosis, Bleeding
duodenal diverticulum, MALT lymphoma, Esophageal stricture,
GE reflux, Post Op Ileus, Heme positive stool, Ischemic colitis,
Esophageal Varices bleeding, Gastroparesis, Stercoral rectal
ulcer bleeding, Foreign body (nail), Diverticular bleed colon,
Crohns colitis, Liver mass, Abdominal Pain, Ascites, Rectal
cancer, Iron deficiency anemia, Liver Failure, Cirrhosis, Acute
Diverticulitis, Abnormal liver tests shock liver. (39 different Dx)
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The Day
 6AM-4PM on call officially
 6AM-pick up consults from night
 6:35AM-ICU rounds
 7-8:30AM-see new consults
 8:30-midday-procedures
 1pm-finish, f/u rounds see more consults as they come in
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THE DAY, scrutinized
 Pick up overnight consults, 4
 Ischemic colitis
 GI bleed, 2 of them
 Dysphagia
 See ICU patients
 3, one esophageal perforation, one massive GI bleed from
ulcer and one abnormal liver tests from sepsis
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The Day, scrutinized, cont.
 Procedures
 Screening colonoscopy, 1
 PEG in cancer patient, 1
 Heme positive stool colonoscopy in patient with defibrillator
 ERCP with stone removal
 Colonoscopy in diverticular bleed patient
 Colonoscopy in hospitalized iron deficiency patient
 EGD, hematemesis, esophagitis
 Sigmoidoscopy, bleeding stercoral rectal ulcer
 Esophageal Motility studies, 2, reflux and dysphagia
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The Day, scrutinized, cont.
 PM rounds
 10 inpatient followup visits
 Consult for PEG in demented patient
 Consult for anemia
 Consult for abdominal pain in chronic narcotic user, 2
 Consult for abnormal liver tests
 Urgent scope to remove meat bolus
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What type of patients do I see as a
full time GI Hospitalist?
 2010 data Top 12 diagnosis
 GI bleeding
 Dysphagia
 Diarrhea
 Blood in stool
 Iron deficiency anemia
 Nausea and vomiting
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What type of patients do I see as a
GI Hospitalist, cont?
 2010 data, top 12 diagnosis, cont
 Esophageal reflux
 Hematemesis
 Abdominal pain
 Colon polyps
 Abnormal liver tests
 Bile duct stones (choledocholithiasis)
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Diagnosis of interest
2010 Data
 Foreign bodies esophagus
19
 Acute pancreatitis
51
 Jaundice
33
 Obstruction of bile duct, unsp
34
 Crohn’s disease
20
 Total of 246 total GI diagnosis coded for my encounters on
hospital patients
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What type of procedures do I
perform as a GI Hospitalist?
 2010 Data
 Upper endoscopies of all types
 Percutaneous gastro tubes
 PEG exchanges
 ERCP’s
 Sphincterotomies
 Stone removal
 Stent placement
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880
113
28
285
117
83
70
Procedures performed
 2010 Data
 Colonoscopies
367
 Only 18 true screening colonoscopies
 Sigmoidoscopies
 Esophageal motility readings
 Hospital consults
 Hospital followup visits
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125
93
952
1652
Unusual Consults
 Red Jello ostomy output-GI bleed
 Black stools-iron or pepto bismol
 Razor blade ingestion
 Toenail clippers ingested
 Sex toy in wrong place
 100’s of tiny gallstones entire biliary tree
 Marijuana Nausea and Vomiting, Hot Showers/Hot Tub
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Life as a GI Hospitalist
 Summary: Why I am a hospitalist
Reasonable hours that are relatively stable
Fix it and move on
Appropriate compensation
Development of niche expertise
Lifestyle choice
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Summary
 Objectives met
 What a GI hospitalist is and does.
 How having a dedicated physician to hospital GI care
improves outcomes
 How a GI hospitalist improves patient flow and care in a large
suburban hospital.
 THANK YOU
TSGNA October 2011