It was a typical day for Dr. Jason Napolitano. He arrived at 7 a.m. at Ronald Reagan UCLA Medical Center and checked the overnight results of his patients' X-rays, blood work and other lab tests. He reviewed their vital signs, medications and updates provided by his medical team. Armed with the most up-to-date information, Dr. Napolitano set out on rounds, prioritizing the sickest of his 15 hospitalized patients.
Dr. Jason Napolitano (right) is a hospitalist, specializing in patient care at UCLA's hospitals. He also trains medical students on how to respond to critical situations.
He then visited Louise Campbell, 61, who had breast cancer that was left untreated for months as she grappled with her diagnosis and sought additional opinions at institutions across the country before seeking treatment at UCLA. She had a gaping hole where her left shoulder once was — a result of the cancer traveling through her lymphatic system into her arm, eating through lymph nodes, nerves and skin. Overnight she complained of increased pain. Dr. Napolitano adjusted her medications and, because her condition found her lying on her right side almost continuously, contacted the occupational therapy department to see if they could improve her positioning.
Dr. Napolitano is a hospitalist, a new breed of physician that is changing the face of modern hospital care. With backgrounds in such specialties as internal medicine, pediatrics and family medicine, hospitalists work with a full range of inpatients, overseeing their care from admission to discharge. In collaboration with specialists, nurses, social workers and other medical professionals, they ensure the best transition of care. Hospitalists also serve as the liaison to the patients’ primary-care doctors.
"We're general doctors by training and experts in treating patients with acute illnesses that make them sick enough to require hospitalization," said Dr. Napolitano. "We will take care of people with any medical problem, ranging from pneumonia to skin infection to a stroke. Because we do this every day, we get good at it."
Later that morning, Dr. Napolitano met with his team, which included a resident, two interns and two medical students. Several new patients had been admitted overnight, including a man in his 30s who entered the ER after swallowing a razor and pieces of a nail clipper, among other things. After he was admitted for observation, it was determined he didn't need surgery — the items would pass on their own. But his psychiatric medications were adjusted after Dr. Napolitano and his team consulted doctors from the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA.Hospital medicine is the fastest-growing specialty in the history of modern American medicine. Over the past decade, practicing hospitalists have grown from just a few hundred to more than 35,000 nationwide, and their numbers continue to spiral upward. Several factors are fueling this expansion, among them, a change in the way UCLA doctors work. Historically, the hospital service at UCLA was run by academic physicians who had a lot of research responsibilities but dedicated perhaps only two to four weeks a year to clinical rotation as attending physicians overseeing residents.
UCLA Health Systems employs 58 hospitalists at Ronald Reagan UCLA Medical Center and other locations.
"That model of having someone new every two weeks worked fine for 40 years when the pace was slower and the complexity of the integration of pre-hospital and post-hospital care wasn't as great as it is today," said Dr. Tom Rosenthal, chief medical officer for UCLA Health System.
Also contributing to the growth in hospitalists are increasingly complex, hard-to-navigate hospital systems, advances in technology and diagnostic tools, and, quite likely, the Obama administration's healthcare reforms, many of which will be phased in by 2014.
"Hospitalists are emerging as a critical group of physicians for the safe and effective running of any acute-care hospital," said Dr. Rosenthal, "but certainly for this acute-care hospital."
UCLA Health System employs 58 hospitalists who work in the Westwood hospital as well as at UCLA Medical Center, Santa Monica and at St. John's Health Center in Santa Monica.
Several UCLA surgical specialties are increasingly calling upon hospitalists to assist with their patients' medical problems. "What we have found over the years is that it's too much for a sub-surgery specialty, whether it be urology or orthopaedics — the sicker the patient is, the more challenges there are," said Dr. Mark Litwin, chair of the UCLA Department of Urology. "We have long been very collaborative with the hospitalists because they are focused entirely on new thinking and the best practices for perioperative and postoperative care."
Hospitalists are also playing a significant role in managing hospital efficiencies while ensuring quality patient care — two of the cornerstones of UCLA's healthcare system. For example, every UCLA inpatient at risk for deep-vein thrombosis now receives anti-blood-clotting prophylaxis, a "safety net" for patient health that was brought about by doctors working together systematically.Dr. Nasim Afsar, a hospitalist and associate medical director for UCLA Health System's Quality and Safety Program, is working on added measures, such as formulating an official discharge form — akin to the surgical checklist that counts sponges to make sure nothing is inadvertently left in the patient.
Dr. Nasim Afsar says that, as a hospitalist, "you actually get to affect patient care at a very fundamental level."
"You actually get to affect patient care at a very fundamental level," Dr. Afsar said, "not only with the patient in front of you, but really for all patients that come after them. When you implement systemic change and improvement, you shift the culture toward one where individuals proactively look for opportunities of improvement."
Near the end of his 13-hour day, Dr. Napolitano went back on rounds. He checked in on Hawkins, the woman with the staph infection. Her fever had broken. Next he stopped in to see Campbell. The new pain medications were working, she said, and for the first time in days she was sitting upright. Occupational therapy had put her arm in a sling, and she was able to move about better.
Would it be possible, Campbell asked him, to have a notebook and pen so she could write down her observations and symptoms to share with the doctor? Dr. Napolitano brought the items to her on a subsequent visit. "That's a reasonable request to help someone out in a small way," he said. "You just do it."
Said Campbell with a broad smile: "Dr. Napolitano is like the integrative part of the brain. This place would be a tornado without him."
This story was adapted from a longer version published in the winter, 2013 edition of UCLA Medicine Magazine.