Key Challenges Faced by Today's Hospitalists

Medscape

3 days ago

On any given day, Andrea Braden, MD, must make quick clinical decisions about hospital patients who require emergency care.
Her biggest challenge as a hospitalist is 'the anxiety around never knowing what is going to come in the door that day,' said Braden, who is also an OB/GYN and lead clinical educator for TeamHealth in Atlanta.
'There is no way to predict whether your day will be calm or disastrous. I think having to be prepared for both scenarios at all times is what keeps us hospitalists on edge. It's also what makes us great at our jobs — the ability to take control of emergencies and guide our teams appropriately.'
Braden and other hospitalists share their most common day-to-day challenges with Medscape Medical News .
Healthcare Funding and Insurance
The role of a hospitalist doesn't end at discharge, said Monique Nugent, MD, a hospitalist at South Shore Hospital in Weymouth, Massachusetts.
Nugent said her biggest challenge is the ever-changing landscape of healthcare funding and what insurance companies will cover, such as medical services and devices that help her ensure the continued health of her patients after they leave the hospital.
'It affects the care I can give people and affects their long-term prognosis,' she said.
While Nugent is thankful for the work of her case management team, she said she still spends a lot of time working around what insurance will pay for patients' healthcare needs.
'I have to make sure I prescribe meds they can get,' Nugent said. 'Can they get into rehab or long-term care? Can they safely be at home? Are they able to access specialists after discharge?'
If a patient qualifies for certain services, such as hospital-at-home, the next step would be to ensure that service is available in their area, Nugent said.
For instance, someone who lives in a rural community may come to a Boston-area hospital for a stroke. After discharge, however, a patient may not have access to certain rehabilitation services, or their insurance may not cover services to ensure they continue to improve once they are released from the hospital, she said.
Another example: If a patient prefers hospice care at home, will their insurance cover what's needed for this? 'How can I help navigate that so that they will be supported?' Nugent said.
Balancing Act
Ethan Molitch-Hou, MD, cited time constraints as a primary challenge for hospitalists.
'We have limited time to care for complex patients who are only getting sicker as we move more care to outside of the hospital,' said Molitch-Hou, who is an assistant professor of medicine and director of the Hospital Medicine Sub-Internship at the University of Chicago Medicine, Chicago.
'There is a constant battle to balance handling your sickest patients who need your focus and time to get the correct diagnosis and treatment, while the push for an early discharge or assuring your patient who is unhappy about events in the hospital (that may be out of your control) is also cared for,' he said.
'Conversations that you know require time and nuance can be interrupted by a page about something that, at the moment feels, less consequential, such as a stool softener when in the middle of a rapid response for a hypotensive patient.'
Despite the time constraints, Molitch-Hou said hospitalists need to clearly communicate their care plans to their patients and families to ensure compliance.
He said hospital physicians need to remember the reason they went into medicine and focus on the positives. Those are keys to having a long career in hospital medicine, he said, 'and for me, having variety in my week-to-week responsibilities has kept the job fresh.'
Between Empathy and Burnout
As a hospitalist working in a cancer hospital for the last 9 years, Nikhil Sood, MD, said one of his most persistent challenges is 'managing clinical uncertainty amid high emotional intensity.'
'On particularly tough days, when I feel mentally and physically drained after a difficult conversation about prognosis and care goals with a family, it becomes harder to be fully present, listen intentionally, or provide the high level of care I expect of myself,' said Sood, an internist and hospitalist at Banner Gateway Medical Center in Gilbert, Arizona.
Unlike in general medicine, the symptoms of his patients tend to be specific to the individual and don't always align with typical textbook patterns, Sood said.
'Each decision comes with substantial weight and little margin for mistakes,' he said.
Many oncology patients are immunocompromised, and complications may escalate quickly from seemingly benign symptoms, such as a low-grade fever or vague abdominal pain, he said.
'Symptoms frequently represent a delicate balance between disease progression, treatment side effects, and secondary issues, such as infections, thromboses, or metabolic imbalances,' he said.
Lab results can be ambiguous with imaging yielding inconclusive findings. 'Layers of uncertainty often obscure the 'right' answer,' said Sood.
'As a hospitalist, I am expected to swiftly navigate these gray areas, assimilating comprehensive oncologic histories and making urgent choices in the absence of perfect information, all while ensuring compassionate communication with patients and their families.'
Meanwhile, many of his patients and their families are knowledgeable, highly engaged, and expect informed answers, he said. 'Delivering bad news is a routine part of my work, yet it never feels ordinary. Compassion fatigue is a genuine concern, and I continuously navigate the fine line between empathy and burnout.'
Sood said he's grateful to his employer for understanding the intense challenges of oncology care and offering social outings, regular wellness initiatives, and 'a culture that prioritizes mental health and self-care.'
Despite the challenges, Sood finds his role 'profoundly meaningful and rewarding,' he said. 'The privilege of being part of a patient's most vulnerable moments — whether filled with hope or heartbreak — is something I always value.'