Weston G. Chandler's business card reads: "Inpatient internal medicine specializing in the care of the hospitalized patient."
That's about right. Hospitalized patients are the only kind he ever sees.
Chandler is there for them, all day, every day.
An evangelist for the hospitalist gospel, Chandler invited MODERN HEALTHCARE to accompany him for a weekday to understand what a hospitalist actually does on the job, and why it leads, in his view, to better medicine and more economical healthcare.
Chandler divides his time among three hospitals along the California coastline: Long Beach Memorial Medical Center, Orange Coast Memorial Medical Center in Fountain Valley, and Fountain Valley Regional Hospital and Medical Center.
This particular day he starts at about 9 a.m. at Fountain Valley hospital in Orange County. Walking down a corridor on his way to patient rounds, he meets a neurologist. After an impromptu conference, they go to radiology to look at a computed tomography scan. Confusion ensues while a technician searches for the film. Although ordered, apparently the scan hasn't been done. "We were going to look at her brain. She had headache, vomiting, nausea and dehydration," Chandler says.
He visits the patient, Mrs. T, in her room. She tells him how she's feeling (not good), which medicines are working and which aren't, and what she's been eating (almost nothing).
"Did you throw up again?" he asks.
"Yes, at 10 o'clock last night," she answers. They took her to CT scan, but she got sick. They couldn't do it. Assuming she is well enough to do the scan today, Chandler says: "I can come back this afternoon and look at this. That's one of the advantages of this hospitalist system. A regular primary-care doctor, this is his one shot. He might not get back to the hospital until tomorrow."
The next patient he sees, Robert Miller, was hit by a car while crossing the street. He has multiple fractures and the possibility of a cardiac contusion. He's in telemetry and needs an echocardiogram before his fractures can be set.
Both Mrs. T and Mr. Miller are insured through Fountain Coast Health Network, the Medicaid managed-care plan in Orange County. "I have a contract with the (independent practice association) to care for Fountain Coast patients," Chandler explains. "It's voluntary on the part of the primary-care physician." Mrs. T's primary-care doctor called Chandler and asked him to admit her.
Chandler works with Pacific Cardiovascular Associates, which consists of 12 cardiologists and Chandler, their resident hospitalist.
The Fountain Coast Medicaid plan has recently signed a contract with PCA that delegates Chandler as internal medicine specialist for any of its patients admitted to Fountain Valley hospital. That way, the family practice doctors at the IPA don't have to interrupt their day in the clinic to manage their hospitalized patients. PCA cardiologists treat cardiac patients at eight other hospitals but not at Fountain Valley.
Chandler's income derives entirely from PCA, which has a variety of arrangements with payers, including massive capitated contracts for cardiology covering more than 100,000 lives.
Chandler follows those cardiac patients from a medical standpoint. Before he came on board, "the cardiologists were doing all this internal medicine themselves," Chandler says. They brought him into the practice because "they felt I was better suited to manage gastrointestinal bleeds, or complications-stroke, diabetes, hypertension-general care of the patient from hospitalization to discharge."
Now, PCA is trying to expand its hospitalist services, even to the point of creating a new division, Pacific Hospitalist Associates.
Chandler also sees patients referred to him by other physicians, even those on a fee-for-service basis. In addition, he admits patients who come through the emergency department and consults, in effect, with the emergency room doctors.
This is especially useful if it's a borderline case. Chandler can call the patient's primary-care doctor and give an evaluation and a treatment plan. Or he may advise that the patient need not be admitted, thus avoiding a hospital stay.
Chandler estimates he spends about one-third of his hospital time in the emergency department, one-third on medical floors and one-third in the intensive-care unit.
Chandler will make quick decisions on patients assigned to his care, advise the hospital on others, read charts and EKGs, and massage the system to dissolve clots in productivity. He's a pusher, without being pushy.
Over lunch Chandler elaborates on his background and philosophy. From 1992 until early 1996, he worked for FHP International Corp., a Fountain Valley-based HMO, as director of an inpatient admitting team of six physicians. In February 1996, when the HMO sold its hospitals and stopped employing its physicians, about 300 of its former doctors spun off to form Talbert Medical Group, which contracts with FHP. PCA contracts with Talbert for fully capitated cardiology services. At the same time, PCA wanted to get into the business of inpatient internal medicine. When its executives found out Chandler was available, they hired him.
Chandler is the sort of physician who knows exactly why he got into medicine and what keeps his adrenaline pumping. He spent six months once in an office practice. You get to know patients and develop long-lasting relationships, he concedes. You get nights and weekends off.
On the other hand, the patients aren't that sick.
"I was trained in a university hospital, where I saw all kinds of cases, patients in life-and-death situations," he recalls. Then, once you finish residency, "you see a lot of colds, sore throats. You do outpatient management of diabetes. I don't mean to suggest that's not important, but I personally like the practice in a hospital setting better.
"You see more acute illnesses. Like the man today in cardiomyopathy, in active heart failure. Or the lady with the headache and nausea. I can bring somebody through an acute episode in a matter of days and they feel dramatically better. There's more instant gratification."
After lunch he cruises about 10 minutes up Talbert Avenue to a medical office building on the campus of Orange Coast Memorial for a little "administrative function time." There, he will read and sign stress tests for PCA patients and update utilization statistics for the group. Chandler keeps tabs on diagnostic tests for the cardiologists, highly proprietary information essential when contracting for so many capitated lives.
At 2: 30 p.m. he gets paged. Mark Ginkel, an invasive cardiologist with PCA, needs advice. A patient they had admitted two nights earlier, Mr. L, is disoriented and pulling his lines out. Chandler gives Ginkel some suggestions what to do.
Mr. L had come to the emergency room with an arterial blockage. Ginkel opened up the artery and Chandler worked until 3: 30 a.m. to get him stabilized.
That's one of the liabilities of this sort of job. "You never know when the day is going to end," he says in his car at 2: 40 p.m., headed toward Long Beach. "The day ends when all your patients are doing OK."
His beeping pager interrupts him.
"And when the beeper stops going off, if that ever happens."
He places a call to Long Beach Memorial. "Hey, Mark. . . . Oh, you made my day. What happened?" Then: "We don't have to go there. The patient has stabilized."
Back at Fountain Valley, Chandler visits some nurse's stations to read charts and see if tests have been done. He consults with other doctors on the phone. At 3: 10 p.m., he meets with discharge planning nurse Holly King.
A 92-year-old woman who is "in bad shape" and unresponsive should be discharged to a hospice, Chandler believes. But another doctor thinks a procedure could be done to help her, and he has countermanded the discharge order.
Chandler is not the patient's doctor. In fact, he's only here in an advisory role to review hospital utilization. But he sets in motion a series of phone calls he hopes will persuade the other doctor that hospice care is really the best option for the woman at this point.
At 3: 35 p.m. he is paged. "Emergency room. Probably an admit." He says into the phone: "Without seeing the patient, I can't make the call whether he should come in or go home."
Another discharge planning nurse, referring to Mr. Miller, asks: "Can he be moved off telemetrics to orthopedics?"
Chandler responds: "All I want is an echocardiogram result. If that's OK, he can move."
The nurse also tells him a certain physician wants Chandler to take care of all his inpatients. "Well, that's what I'm here for," Chandler replies.
At 3: 45 p.m. he trots the quarter mile from the medical floor to the emergency room. He moves to a gurney in a corner behind a pink curtain.
The patient, Mr. N, is covered through the Fountain Coast Medicaid plan. The hospital emergency physician alerted the man's primary-care doctor, who in turn said the case should be referred to the hospitalist.
In the ER, Chandler gets another page. Mr. Miller's echocardiogram is good. "I have to go to telly (telemetry) and transfer him to orthopedics. He can be scheduled for surgery tomorrow. Let's go tell him." Along the way he flashes a thumbs-up to the orthopedic surgeon.
Back again in the ER, Mr. N is coming along slowly. "He doesn't speak English," Chandler says. "At first I thought he was Vietnamese. So I got an interpreter. The interpreter said, `I can't understand this. He's Cambodian."'
The man's family explains that he hasn't been eating or drinking for three days and has fever chills. Chandler suspects asthma exacerbation and pneumonia and wants to admit him.
At 4: 35 p.m. nurse King calls. The chain of phone calls has worked; the elderly woman's doctor has ordered her discharge to the hospice this afternoon. An ambulance is coming at 5 p.m.
Chandler, meanwhile, continues writing orders for Mr. N, which will take another 30 minutes. Then he'll head for home.
Unless the beeper goes off.