The Rev. Dr. Mark LaRocca-Pitts on a model for chaplains working with local clergy

The Chaplain As Hospitalist

A new metaphor is available that communicates well the role and work of chaplains to healthcare professionals and that also sheds light on a problematic nexus facing the provision of spiritual care. This new metaphor is the “hospitalist."

Since Wachter and Goldman first coined the term “hospitalist” in 1996 [1], the hospitalist movement has grown significantly. Supported by research that proves the financial and medical benefits of using hospitalists [2], most healthcare systems now have hospitalists on staff. [3] Hospitalists are physicians, usually Internists, who are hospital-based and whose primary focus is managing the general medical care of inpatients. As opposed to primary care physicians (PCP), who are primarily office-based, hospitalists spend all of their time in the hospital. As a result, hospitalists provide a continuum of care from admission to discharge, and are available 24/7 for emergent care and for consultations. Hospitalists, due to continuous involvement in a variety of hospital-based conditions, are better equipped than PCPs to manage many medical conditions. Finally, as staff members, hospitalists provide teaching, research, and leadership within the hospital. When it comes to providing overall medical care for inpatients and leadership within the hospital context, the hospitalist program is exceptional. [4]

“Hospitalist” as a metaphor for chaplains communicates well with other healthcare professionals whose preconceived notions of chaplains may be influenced by parish-based models, or on chaplains as “harbingers of death.” As a metaphor, the hospitalist compares to the PCP as the chaplain compares to local clergy.[5] That is, among clergy, the chaplain is the “hospitalist.” For example, chaplains are thoroughly and specifically trained in hospital-based interventions. [6]  Unlike many local pastors, the in-house chaplain is available 24/7 for emergent care and for consultations and provides a continuum of spiritual care from admission through discharge. Chaplains, as healthcare insiders, can advocate effectively for the patients’ needs. Chaplains understand the spiritual effects of hospitalization in general and many medical conditions in particular. Finally, chaplains, like hospitalists, provide teaching, research, and leadership within the hospital. When it comes to providing overall spiritual care for inpatients and leadership within the hospital context, chaplains are exceptional. [7]

Problems encountered by the hospitalist movement are also informative for professional chaplaincy. For example, upon admission and discharge medical care is transferred between the PCP and the hospitalist. Patients dislike this transfer and the continuum of care may be disrupted. Education concerning the benefits of hospitalists helps facilitate this transfer of care, and good communication between hospitalists and PCPs insures a continuum of professional care. [8]

Complete transfer of spiritual care from local pastor to chaplain will never become standard practice, although it does occur in special circumstances, e.g., when local clergy are unavailable or in an emerging crisis. Yet, the hospitalist metaphor invites us to examine intentionally how spiritual care is shared among chaplains and local clergy. Formalizing and communicating a confidential and effective transfer or sharing of spiritual care will be difficult, but the hospitalist movement provides models that will help.

In summary, using “hospitalist” as a metaphor to describe chaplains has advantages and disadvantages. Within the context and culture of healthcare it is advantageous in providing a clinically based metaphor accessible to healthcare providers. Within the context and culture of faith communities, however, its disadvantage rests in suggesting a transfer of spiritual care between providers. Regardless of this disadvantage, the “hospitalist” metaphor highlights a problematic nexus where authorities, responsibilities and accountabilities overlap among spiritual care providers. Naming and examining this nexus can only enhance the overall provision of spiritual care.

 

[1] RM Wachter, L Goldman, “The emerging role of ‘hospitalists’ in the American health care system,” New England Journal of Medicine 335 (1996): 514-517.
[2] AN Amin, “Identifying strategies to improve outcomes and reduce costs—a role for the hospitalist,” Current Opinion in Pulmonary Medicine 10 (Nov. 2004): Suppl:S19-22; V Parekh, S Saint, S Furney, S Kaufman, L McMahon, “What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?” Journal of General Internal Medicine 19, 5.1 (May 2004): 395-401; RM Wachter, L Goldman, “The hospitalist movement 5 years later,” JAMA 287, 4 (Jan 23/30 2002): 487-494.
[3] P. Basaviah, L Goldman, “A new doctor in the house: Hospital medicine in the United States,” Schweizerische Arztezeitung 83, Nr39 (2002): 2045-2051; JL Exline, S Topping, C Baxter, “CEO's perceptions of hospitalists: diffusion of the Strategy,” Hospital Topics  82, 1 (Winter 2004):18-24.
[4] For a good overview of the Hospitalist Movement, see the Society of Hospital Medicine homepage at http://www.naiponline.org/presentation/default.asp?area=faqs&po=0#8.
[5] The author first used this metaphor in an interview with VHA. See, AF Victor, “Like a prayer,” Alliance (October 2004): 18-20.
[6] L Austin, “Hospitals are not houses of worship,” PlainViews 1, 18 (Oct. 20, 2004): http://www.plainviews.org/AR/c/v1n18/er.html.
[7] M LaRocca-Pitts, “Walking the wards as a spiritual specialist,” Harvard Divinity Bulletin 32, 3 (Summer 2004): 20, 29.
[8] SZ Pantilat, A Alpers, RM Wachter, “A new doctor in the house: Ethical issues in hospitalist systems,” JAMA 282, 2 (1999): 171-174.