Each year in the United States, about five million adults with cancer are admitted to hospitals. Given our aging population, this trend will increase, putting added stress on the oncology community, which is already dealing with an impending workforce shortage. Although physician extenders, such nurse practitioners, can help bolster the workforce, they may be somewhat limited, especially in the palliative setting, by prescriptive authority, which varies by the schedule of the drug in question. Hospitalists are increasingly providing care to hospitalized patients with cancer, providing a much-needed addition to the overstressed workforce.
To shed light on the working relationship between hospitalists and oncologists, The ASCO Post spoke with Kathleen R. Atlas, MD, a hospitalist at Memorial Sloan Kettering Cancer Center (MSK), New York, who has studied the issue. Employed at MSK for more than 9 years and currently Deputy Service Chief for night shifts, Dr. Atlas is an internist who is not formally trained in oncology.
Kathleen R. Atlas, MD
Experience With Oncology Patients
Please tell us about your experience as a hospitalist at a comprehensive cancer center.
I generally work at night, and it is extremely rewarding. Patients with cancer who come into the hospital usually have complicated clinical issues that allow me to practice at the peak of my training. Moreover, many of the patients with cancer whom I admit are approaching the end of life, so that is the kind of care I deliver, helping both patients and their loved ones and family through this difficult period. I work in close collaboration with the multidisciplinary oncology care teams, so over the years, I’ve learned a lot about oncology and managing the multiple issues that occur over the continuum of care. I’ve also learned a lot about palliative care medicine, which helps in these difficult clinical settings. Many hospitalized patients with cancer have pancytopenia, infections and sepsis, cytokine-release syndrome, as well as other toxicities from immune effector cell therapy. So, the nights in a cancer center are filled with a broad range of potential clinical scenarios.
Please describe the design and goals of the survey study you conducted at MSK.
Our goal was to determine the perceptions of oncologists about inpatient cancer care delivery and the care provided by hospitalists. We conducted a cross-sectional survey of all oncologists practicing at MSK who admit patients with cancer to our main hospital.1 In short, we wanted to know whether they believed that internal medicine–trained hospitalists were capable of managing their patients. We determined that 206 oncologists were eligible for the survey, and 102 oncologists responded, which was about 50%. A total of 67 respondents were solid tumor oncologists, and 35 were hematologic malignancy oncologists.
You found that solid tumor oncologists were significantly more likely than hematologic specialists to believe hospitalists were capable of performing necessary inpatient cancer care. Please expand on that interesting finding.
Correct. Although there was a significant difference between the two specialties about hospitalists’ capability with their patients with cancer, we are not exactly sure why, as it wasn’t something built into the survey. My personal hypothesis is that patients with hematologic cancer are receiving highly complex management strategies—intensive chemotherapy regimens, bone marrow transplants, and other therapies that an internist generally has not had a lot of exposure to during their training. In contrast, the reasons patients with solid tumors are admitted to the hospital are often within the scope of care of an internist. We found that many solid tumor oncologists did not believe that the care of inpatients was an efficient use of their time and that many would give up more inpatient service time if given the opportunity.
In addition, at MSK, many of the solid tumor services already had hospitalists taking care of their patients at the time of the study. Thus, over time, they were integrated into the care model, and oncologists learned to trust the care they were giving their patients with cancer. In contrast, there is just not as much experience with hospitalists on the hematologic services clinic. Nevertheless, there may be a valuable co-management role for hospitalists on hematologic and bone marrow transplant services, as attested to in the pediatric literature.
What was the reaction among the oncologists at MSK when you initiated the survey, and where are we now in the use of hospitalists nationwide?
All the participating oncologists were very gracious and thoughtful and took their time in answering the questions. Even if it is still a relatively new field, hospital medicine is the fastest growing specialty in the country. In fact, in 2016, Robert Wachter, MD, and Lee Goldman, MD, MPH, wrote a perspective for The New England Journal of Medicine in which he noted that, over the past 20 years, the number of hospitalists in the United States has grown from a few 100 to more than 50,000.2
Implications of Survey Findings
Please describe the overall survey results and how they may translate into the cancer care system.
Cancer care is increasingly being delivered in the outpatient setting, and many of the oncologists in our survey reported that, if possible, they would prefer not to be on in-patient services. Given that trend, it makes sense that much of the inpatient care could be shifted toward hospitalists. Moreover, given the knowledge hospitalists have in negotiating the entire hospital setting, it adds one more layer of responsibility they can assume, which relieves pressure on the cancer clinic. So, the hospitalist discipline within cancer care will continue to grow and help improve outcomes for patients with cancer.
DISCLOSURE: Dr. Atlas reported no conflicts of interest.
1. Atlas KR, Egan BC, Novak CJ, et al: Oncologist. August 3, 2020 (early release online).
2. Wachter RM, Goldman L: N Engl J Med 375:1009-1011, 2016.