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The growth of the hospitalist model across modern medical centers is well documented and has given patients, as well as physicians, a triad of access, flexibility and a new definition of continuity in their care. Numerous systems have seen the consistency of this model as improving outcomes through removing unnecessary variation and allowing surgeons to be dedicated to care episodes unique to inpatient procedures. Such immersive ventures outside of internal medicine has come from neurologists as well, whose ability to provide continuous coverage for systems which support advanced stroke care center certifications is necessary for their sustainability. These niche systems have even established societies which become advocates for members, as in the case of neurohospitalists whose membership is in excess of 1,500. For systems which inherently require time-dependent therapies like tPA administration or endovascular interventions, such models are leveraging the demand for in-hospital personnel traditionally staffed with on-call community models.
Translation of the hospitalist model into surgery has had similar beginnings, with initial progress in general surgery under their designation as “surgicalists.” This model has also similarly grown, offering both surgeons and hospital systems novel opportunities for meeting their evolving needs, or the so called ‘call dilemma’. Individual companies, with similar infrastructures to locum tenens providers, have grown into this novel space, offering flexibility, evidence-based advantages and outcomes-driven methods with growth trajectory into new markets and subspecialties. Facility administrators also see the surgicalist model as a way to reduce the expensive call stipends traditionally associated with subspecialty care as discussed in Today’s Hospitalist. These systems have the strength of consistent presence and segmental delegation of care streams outside legacy systems.
The surgicalist model is proving to be a hybrid solution between the needs of hospital administrators and surgeon opportunities for those not interested in the traditional locum tenens model, which can add cost and have reduced community engagement. The growth of surgicalist companies to bring value through the objective benefits seen is attractive to bridging the needs for continuous coverage, and this has further diversified into models which support subspecialists, including orthopedics, neurosurgery and others. The predictability elements of these models offer novel ways for mid-career surgeon transitions to a care model where neurosurgeons have a greater level of control over their day-to-day routine by deconflicting the demand for elective productivity. In this way, the neurosurgicalist model opens new options for ensuring efficient productivity tied to subspecialty care. The published gains in quality with such systems has been widely applauded as a motive force for adoption of these models.
Not all systems are looking for consultancy-based arrangements; however, with some neurosurgery departments looking internally to their own partners to take on these novel roles. One example is a medical center in the Northeast, where the ‘neurosurgicalist’ is the designated call responder from 6 am – 4 pm Monday through Friday and performs all operative care for patients admitted overnight who need intervention. Emergent cases are accomplished by the night call provider, and the call structure for the department is partitioned into subspecialty service lines for spine, tumor and cerebrovascular. The single neurosurgicalist is a department salaried position commensurate with the ability to sustain work product essentially generated from within an intradepartmental referral system, allowing for department specialty care elective service lines to remain mostly undisturbed.
As hospitals strive to lower cost by altering their acute coverage structures, the neurosurgicalist option may further evolve to provide advantages for continuous off-hours coverage supported by outcomes data, reimbursement levelling and novel practice opportunities for broadly trained neurosurgeons who desire the predictability of time-bracketed workload. As these care streams are developed and tested, additional study should be supported to provide data necessary to prove their value for implementation.
