The landscape of inpatient care within otolaryngology has undergone a significant evolution with the emergence and refinement of the otolaryngology hospitalist role. This specialized position, dedicated to managing the acute care needs of patients within a hospital setting, represents a relatively new paradigm that has demonstrably improved efficiency, quality of care, and resident education. The genesis of this role can be traced back to the University of California, San Francisco’s (UCSF) tertiary-level university medical center in 2011, when the inaugural otolaryngology hospitalist position was established.
The Genesis and Evolution of the Otolaryngology Hospitalist Model
The creation of the first dedicated otolaryngology hospitalist position at UCSF in 2011 marked a pivotal moment. Matthew Russell, MD, now an instructor at Harvard Medical School and a physician at Mass Eye and Ear, held this pioneering role. However, this was not the absolute beginning of a hospitalist-like approach at UCSF. Andrew H. Murr, MD, Professor and Chair of the Department of Otolaryngology—Head and Neck Surgery at UCSF, explained that an earlier iteration involved assigning the faculty member on call for a given week to personally manage all inpatient, emergency department (ED), and acute care consultations. This initial model was conceived to address the logistical challenges posed by the otolaryngology department’s relocation miles away from the main hospital, necessitating a more efficient and timely provision of care. The rationale was clear: a dedicated, on-site otolaryngologist could ensure more prompt and higher-quality care for acute otolaryngologic needs.
The success of this initial on-call coverage model provided compelling data that underscored the positive impact of having a physician specifically designated to manage the high volume of otolaryngologic service demands within the hospital. This led to the formal establishment of the otolaryngology hospitalist position. This structural change fostered significant interdepartmental collaborations, leading to improved patient throughput in intensive care units (ICUs) and urgent care settings. Crucially, it resulted in demonstrably higher quality care and a reduction in adverse outcomes, particularly in emergency airway events.
Dr. Russell articulated his primary motivation for accepting the inaugural hospitalist role: to elevate the standard of inpatient care. He aimed to redefine the traditional approach where otolaryngologists often handled inpatient consults as an afterthought to their primary outpatient responsibilities. By being physically present within the hospital, Dr. Russell could efficiently manage consults, perform necessary surgeries, and actively engage in resident education. This on-site presence proved instrumental in delivering timely patient care and providing immediate, valuable teaching opportunities for residents.
Furthermore, the hospitalist role facilitated enhanced integration of otolaryngology with other hospital specialties. Dr. Russell described the model as fundamentally team-based and highly collaborative, involving close partnerships with departments such as anesthesia, intensive care, internal medicine, and infectious diseases. His responsibilities encompassed both consultations and surgical interventions for inpatients requiring complex acute care.
Challenges and Refinements: The Path to Sustainability
The demanding nature of managing acute care patients, characterized by high stress and unpredictability, eventually led to the third iteration of the hospitalist model at UCSF. Dr. Russell experienced burnout after several years in the solo hospitalist role, noting that the intense demands left insufficient time for academic pursuits. His subsequent recommendation was to divide the hospitalist responsibilities among multiple rotating physicians. This distributed model is now the standard at UCSF, with three faculty members sharing the hospitalist duties, each covering specific blocks of days.
For departments considering a solo hospitalist role, Dr. Russell emphasized the importance of careful job structuring to ensure long-term sustainability, acknowledging the inherent unpredictability of the work. He stressed the necessity of protected time for academic or other essential professional activities. A significant challenge identified by Dr. Russell and echoed by others in the field is the issue of reimbursement, which remains a critical factor in the establishment and maintenance of hospitalist positions.
The Evolving Role and Expanding Footprint
The otolaryngology hospitalist role is a dynamic and evolving aspect of inpatient care. Beyond UCSF, several institutions have adopted this model, including Louisiana State University, Houston Methodist, Emory University, the University of California at Los Angeles, and Montefiore Einstein.
At a recent meeting of the Society of University Otolaryngologists, a panel of experts, including hospitalists from these leading institutions, convened to discuss the shifting paradigm of inpatient otolaryngologic care and its impact on resident education. They provided insights into the daily realities of being a hospitalist and addressed critical issues such as reimbursement.
Steven Pletcher, MD, Professor and Vice Chair for Education at UCSF, moderated the session. Dr. Pletcher himself transitioned from a traditional otolaryngologist role to one of the three rotating hospitalists at UCSF. For the past three years, he has dedicated Mondays and Wednesdays to hospitalist duties, a schedule that allows him and his colleagues to maintain their existing surgical and clinical practices.
Dr. Pletcher highlighted a common misconception: that a hospitalist role might not involve significant surgical intervention. He stressed that otolaryngology hospitalists are indeed surgeons, engaging in a robust surgical component alongside their medical and patient evaluation responsibilities. This clarification is crucial in understanding the scope and importance of the hospitalist function.
Impact on Resident Education
As the director of residency training at UCSF, Dr. Pletcher strongly advocates for the inclusion of resident education as a core component of the hospitalist’s responsibilities. Alexandra Bourdillon, MD, an otolaryngology resident at UCSF, shared her perspective on the benefits of the three-hospitalist coverage model for trainees. She noted that this system reduces the burden on residents to locate attending physicians for guidance and minimizes the need to negotiate schedules around attending physicians’ outpatient commitments.
Dr. Bourdillon further elaborated on the cohesive nature of the hospitalist team at UCSF. She described how the three hospitalists sign out to each other and engage in collaborative discussions, which streamlines patient care and ensures a consistent approach to management. This unified approach, she stated, is highly beneficial for resident education and provides a stable learning environment. The hospitalist role, she concluded, is ideal for individuals dedicated to fostering resident development.
Beyond the satisfaction of working closely with residents, Dr. Pletcher identified other attractive aspects of the hospitalist role, including a more predictable schedule and the opportunity to engage with complex patients, often those arriving via emergency department transfers. He acknowledged that, like any profession, the hospitalist role presents both advantages and disadvantages, and its suitability depends on an individual’s career goals and work-life balance preferences.
Diverse Models, Shared Goals: Experiences from Emory and Houston Methodist
Elizabeth S. Willingham, MD, Associate Professor at Emory University School of Medicine, recounted her experience as the inaugural otolaryngology hospitalist at Emory in 2014. Similar to UCSF, Emory’s hospital system is geographically dispersed, and the otolaryngology department’s relocation from the main campus necessitated a consistent presence at the satellite location.
During her initial year, Dr. Willingham established the hospitalist paradigm at Emory, drawing inspiration from successful programs at UCSF and Louisiana State University. She and another faculty member initially shared coverage from 8 a.m. to 5 p.m., Monday through Friday. Their responsibilities encompassed all hospital consults, ED cases requiring otolaryngologic expertise, acute OR consultations for airway bleeding or difficult intubations, head and neck infections, and general otolaryngology issues across various hospital settings, including the ICU and ED.
To manage the increasing demand, Emory hired an advanced practice provider (APP) after two years. Over a four-year period, the service documented an average of nearly 1,000 evaluation and management (E&M) encounters annually, alongside approximately 450 procedures performed each year. Dr. Willingham advocated for this hybrid model, comprising a hospitalist and an APP, as a means to mitigate burnout, ensure seamless outpatient follow-up, and maintain clinical skills.
In 2016, the Emory otolaryngology hospitalist model evolved into a formal consult service with the addition of an APP and a PGY-1 otolaryngology resident. This resident rotation offers invaluable one-on-one teaching, equipping new interns with critical otolaryngologic skills, effective consultation strategies, and the ability to manage emergency ENT procedures. It has consistently been a highly rated rotation among residents.
Dr. Willingham noted that a review of presentations from five established hospitalist programs revealed commonalities in the types of consults handled (e.g., airway evaluations, epistaxis, sinusitis, dysphonia, tracheotomies, head and neck infections, neck masses, and ear complaints) and the procedures performed (e.g., direct laryngoscopy, epistaxis control, incision and drainage, sinus surgery, tonsillectomy, tracheotomies, vocal cord injection, and biopsies).
The overarching sentiment among hospitalists is a strong preference for working with complex patients requiring innovative solutions, engaging in multidisciplinary collaboration, and contributing to the care of critically ill individuals within structured workday hours. Dissatisfactions often stem from a lack of control over daily workflow variability, a lack of understanding from colleagues about the role’s scope, and coverage challenges when the hospitalist is unavailable.
Ran Wang, MD, an otolaryngologist at Houston Methodist, became the institution’s first otolaryngology hospitalist in 2023. Her practice is structured as a solo general ENT role with access to subspecialty colleagues, operating between 6 a.m. and 3 p.m., Monday through Friday. She performs consultations, surgeries, and resident education, mirroring the responsibilities of her counterparts.
Dr. Wang highlighted the significant benefit of enhancing patient-focused care for both inpatients and outpatients, thereby strengthening the department’s overall service. She explained that the hospitalist role allows for flexibility in addressing urgent inpatient and outpatient needs simultaneously, freeing up her partners to focus on their scheduled outpatient activities. This division of labor optimizes departmental efficiency.
The hospitalist role also provides the surgery service with greater flexibility in scheduling inpatient surgeries, which benefits patients and their families by enabling more predictable surgical timing. Dr. Wang’s forthcoming study on her single-site practice is expected to quantify these benefits. Preliminary data indicate an improvement in the rate of bedside tracheotomies performed within three working days of consult, increasing from 75% to 85%, and a reduction in the rescheduling rate for tracheotomies from one in three to fewer than one in eight.
She also emphasized the collaborative advantages, particularly the strong relationships forged with the ICU and gastrointestinal (GI) service lines. Joint bedside tracheostomies and percutaneous endoscopic gastrostomy (PEG) procedures, coordinated with the GI team, minimize the need for multiple anesthesia sessions, thereby improving service line efficiency for all involved departments. For Dr. Wang, the hospitalist’s consistent presence and effective collaboration with colleagues are paramount to positively impacting patient care within the hospital.
A Varied Approach at Montefiore Einstein
Richard Vance Smith, MD, Professor and Chair of the Department of Otorhinolaryngology—Head and Neck Surgery at Montefiore Einstein, described a distinct hospitalist model implemented in 2021. Their program features one dedicated otolaryngology hospitalist who provides consulting services four days a week, from 8 a.m. to 5 p.m. Consultations occurring outside these hours are handled by the on-call physician. The hospitalist typically engages in consultations for half of their days and performs surgeries as needed, often with residents seeing consults first. The hospitalist then reviews cases with residents in the afternoons, while mornings may involve work with ambulatory patients in the office. The hospitalist also maintains an active subspecialty practice.
Montefiore Einstein is currently on its second otolaryngology hospitalist in this role. Dr. Smith noted that physicians taking on this position often leverage it as a stepping stone to developing a robust subspecialty practice. The role allows them to build their reputation and referral network within the medical community, with an expected tenure of three to five years.
Echoing the sentiments of other panelists, Dr. Smith underscored the critical advantage of having an on-site hospitalist who significantly enhances and expedites attending physician oversight of consultations, leading to improved inpatient care quality.
A notable difference in Montefiore Einstein’s model is that the hospitalist does not perform inpatient bedside tracheotomies, as this procedure is already managed by a long-standing, specialized service. The hospitalist operates independently of this established service.
The Crucial Issue of Payment
A recurring theme throughout discussions on the otolaryngology hospitalist role is the challenge of securing adequate and sustainable reimbursement. Panelists universally acknowledged that financial considerations are paramount in establishing and maintaining these positions.
At UCSF, reimbursement for the hospitalist role is managed through a "Tier 4" payment structure, which involves a fixed salary paid by the health system to the department, which in turn compensates the hospitalist. Dr. Murr characterized this as a "staffing payment paradigm," asserting that reimbursement is not a significant issue due to UCSF’s established history of supporting hospitalists, influenced by the model pioneered in internal medicine. However, he cautioned that not all institutions readily recognize the value of such positions, and persuading hospital leadership may be necessary.
Dr. Pletcher concurred, noting that despite demonstrable efficiency benefits to the hospital, securing dedicated funding for a hospitalist position can be challenging. He explained that the flow of funds varies across hospital systems, with some relying on RVU-based models and others on collections-based systems. These financial structures can influence the institutional and departmental risk associated with creating a funding line for an otolaryngology hospitalist.
Reimbursement models differ; some medical centers generate revenue through surgeries that produce relative value units (RVUs), while others allocate funds and transfers to departments, with hospitalists receiving a portion, and the remainder supporting departmental operations and physician salaries. Dr. Pletcher highlighted the critical role of insurance status, as patients in inpatient settings often have less favorable insurance, which can impact hospital administrators’ enthusiasm for funding such roles.
Dr. Willingham emphasized that the precedent for hospital systems to support hospitalists is well-established in hospital medicine, with hospitals subsidizing these roles due to their significant benefits. She pointed out that a hospitalist’s compensation cannot solely rely on traditional RVU-based reimbursement, as their patient volume is not entirely controllable. A substantial portion of a hospitalist’s value lies in their ability to enhance hospital efficiency, such as reducing ED wait times and expediting the transition from consultation to surgical intervention. Therefore, she argued, the value of the role must be recognized beyond RVU generation.
Dr. Wang stated that her compensation comprises a base salary with potential RVU bonuses, disbursed by a physician specialty group within which the otolaryngology department operates. She acknowledged that reimbursement contracts are highly individualized.
The evolution of the otolaryngology hospitalist role signifies a commitment to optimizing inpatient care, enhancing resident training, and fostering interdisciplinary collaboration. While challenges related to funding and widespread understanding persist, the demonstrated benefits in efficiency, quality of care, and patient outcomes continue to drive the adoption and refinement of this vital position within academic medical centers.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.
