Faculty Profile: Ben Sneed

Division of General Medicine, Geriatrics and Palliative Care:

UVA Hospitalist Ben Sneed Talks About His Specialty

Why did you choose to become a hospitalist?

I went to medical school in Seattle, Washington, and hospitalists were fairly commonplace there. Several of my friends had chosen to pursue this field, and they got me interested in it.

During my residency at UVA, I really enjoyed the inpatient blocks — both the pace and the patient mix. When I learned that UVA was recruiting for hospitalists in my final year, I decided to apply. I really liked Charlottesville, so it was an easy decision.

What kind of training do hospitalists receive?

There are more than 40,000 hospitalists in the U.S.; most have completed residencies in internal medicine. Some train in family medicine, then choose hospital medicine as their practice setting. Pediatric hospitalists complete a general pediatric residency. Both pediatric and adult hospital medicine are rapidly growing fields.

“Hospitalist” as a distinct specialty within Internal Medicine is relatively recent – the term was first used in 1996. In what ways is the field still evolving?

Now that hospitalists have become commonplace – at large and small hospitals, university-based and non-academic – they are starting to take a lead role in nearly every aspect of hospital care. That includes both clinical and administrative roles, and, in academic medical centers, an important role in resident training.

What are the hot-button issues for your profession?

Hospital medicine is at the forefront of all of the big issues in healthcare — including quality of care, patient safety, length of stay, and reducing readmissions. Without a doubt, the first two are the top issues, and will be most important in shaping our field.

Tell us about your practice: how many patients do you see in a typical day? Do your rounds take you all over the hospital, or are you usually working in one area?

At UVA, hospitalists work in several different roles. Our hospitalist service has a daily census of ten patients. We also serve as attendings on the general medicine teaching wards, which are part of the internal medicine residency program. Along with the house staff, we care for 10 to 20 patients daily.

We also staff UVA’s Transitional Care Hospital, a long-term acute care facility; the current maximum census there is 14 patients per hospitalist. Lastly, we manage a consult service that assists specialists from other fields with general medicine issues; the number of patients seen through this service varies quite a bit from day to day. While our practice tends to be focused on the medicine wards, we see patients in several other wards and floors as well.

Who are the people you and your hospitalist colleagues interact with on a typical day? On what kinds of hospital committees and policy boards do you and your colleagues serve?

Patient care in the hospital setting is like a wheel with many spokes, with hospitalists serving as the hub; our goal is to provide seamless, coordinated care. So we interact with just about everybody on a patient’s care team. A lot of our time, of course, is spent with patients themselves, and their families. But we’re also in constant communication with the ward nurses and the medical staff, particularly emergency room physicians, surgeons, and radiologists. Nurses’ aides, physical and occupational therapists, unit coordinators, nutritionists, pharmacists, case managers, social workers, chaplains — all are essential spokes in the wheel.

And of course, we do all this while also serving as teachers and mentors for our undergraduate and graduate medical trainees.

Does UVA have any dedicated “nocturnists”?

We don’t; our group shares responsibility for nighttime care. We typically work a short series of nights – usually three in a row — with some days off before and after to make the transition easier. We might consider hiring a “nocturnist”; our main concern as a group is to maintain an around-the-clock presence in the hospital, to provide uninterrupted patient care and constant oversight of the house staff.

Transitions and continuity of care are big areas of concern for hospitalists. How is your team addressing these issues?

Our group is constantly working on quality improvement when it comes to transitions of care between physicians. We appreciate that this is a critical step in terms of both patient safety and quality of care. When patients are at the hospital, we try to limit the number of times they are “handed off” from one physician to another, and maintain a tight focus on quality when hand-offs are necessary. When patients leave the hospital, our focus is on communication: making sure both patients and their primary care physicians have detailed information about the services and care we provided – including any changes in medications, and new diagnoses for which we initiated treatment.

Another key step is tracking when and with whom patients have their first follow-up visits post-discharge. The transition from hospital to home – or wherever patients go to — is one of the most critical for their long-term recovery; but primary care physicians can’t always see them right away. Some hospitalist groups run post-discharge clinics to facilitate immediate follow-up care; this model could prove beneficial for our health system, as we adjust to changes in the healthcare industry and move forward with programs like Well Virginia [[what is this?]] and with the process of becoming an Accountable Care Organization.

What kinds of research do you and your colleagues conduct?

We focus on key issues related to quality and patient safety, including urinary tract infections associated with indwelling catheters. Catheter-related infectious are both a safety issue for patients, and a cost and quality issue for hospitals, since they are considered an avoidable hospital-associated complication. We’re looking at ways to reduce catheter use, and the length of time they are indwelling when used. Other areas include preventing central venous catheter-associated infections; best practices for treating sepsis; and improving blood sugar control in patients with diabetes.

What impact will implementation of the Affordable Care Act have on hospitalists?

We’ve seen a gradual, but important, shift in healthcare to ‘patient-centered’ care; the Affordable Care Act will speed that transition. Hospital medicine, by definition, is where many of these changes will occur. Hospitals and physicians are increasingly being compared to peers in measures of patient safety, quality, and cost of care; reducing the overall cost of hospital care is essential. As hospitalists, we are focused on providing excellent patient care in the most efficient and economical manner possible, so we are right at the center of these changes.

Is the Hospitalist program at UVA expanding?

Yes. Our program has tripled in size over the last two years, and we expect that trend to continue. Right now we are recruiting year-round, with “onboarding” of new hires occurring on a quarterly basis.

– Medicine Matters, Jane Perry, April 2014