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The Times Hits the Right Notes on Hospitalists

You probably saw yesterday’s hospitalist piece in the New York Times, arguably the best lay article on the movement to date. It hit all the right notes, and did so with uncommon grace and fairness.

The piece, written by the Times’ Jane Gross, profiled Dr. Subha Airan-Javia, a young hospitalist at the Hospital of the University of Pennsylvania. While Dr. Airan-Javia spends about half of her time in administrative, largely IT-related roles (like many of my faculty), the article (and an accompanying profile) gave us a day in her life on the wards:
seeing patients, collaborating with consultants, talking to families, and orchestrating discharges. The fundamental advantages of the hospitalist model – tremendous availability, markedly improved efficiency, and a unique focus on systems improvement – came through unambiguously. For example, regarding availability, there was this:

Because she was on the floor all day, [she] was able to schedule a long meeting with a man who held power of attorney for a patient who was close to death and incompetent to make decisions… Expansive and gentle, the doctor discussed why she would recommend a transfusion but not a feeding tube.

As for efficiency, Gross cited my 2002 JAMA review, which found that hospitalist care was associated with an approximately 15% reduction in hospital costs and length of stay.

Finally, turning to the hospitalist as systems improver:

As their numbers have grown, from 800 in the 1990s to 30,000 today, medical experts have come to see hospitalists as potential leaders in the transition to the Obama administration’s health care reforms… Under the new legislation, hospitals will be penalized for readmissions, medical errors, and inefficient operating systems.

And PJ Brennan, Penn’s CMO, is quoted: “These young doctors, coming into a highly dysfunctional environment, had an affinity for working on processes and redesigning systems.”

The article even went on to discuss Project BOOST, lauding the Society for Hospital Medicine and the field more generally for proactively rolling up its sleeves to “invent better discharge systems rather than respond defensively to criticism.”

After reading many lay articles on hospitalists over the years, I have learned to gird myself for the inevitable one-sided zinger regarding the patient’s experience. But Gross, to her great credit, lays out both sides of this issue. On the one hand, there was Carol Levine, a patient advocate for the United Hospital Fund of New York, lamenting:

“The patient is still expecting a doctor-doctor, when ‘wait a minute I don’t know you’ is going to take care of them.”

(I understand the sentiment, Carol, but hospitalists really are “doctor-doctors.”)

In any case, there it was. But Gross counters with the story of Mort Miller, the late father of SHM quality director Joe Miller. When Mort was 84, he was hospitalized for a broken hip, on top of his multiple comorbidities of CHF, diabetes, and renal failure.

His son, Joseph, said that he did not once communicate with the family doctor. “He rounded in the morning when I wasn’t there and never returned my phone calls. I guess he didn’t have time.”

Even more impressively, the article doesn’t romanticize the primary care doctor’s time in the hospital as some Marcus Welbyian chance to hang out with patient and family, schmooze with colleagues, and carefully consider all the diagnostic and management choices. Instead, we get this realistic portrayal of many PCPs’ hospital rounds under the old system:

To keep tabs on hospitalized patients, the doctor generally races in, white coat flying, at 7 a.m., when the patient is asleep and the family is not there.

In contrast, Gross ends with a charming vignette regarding the Penn hospitalist, one that vividly highlights the advantage of on-site presence:

[Dr. Airan-Javia]
was with each patient for far longer than the usual doctor’s visit and saw them throughout the day as their test results landed.


“You again?” Mrs. Huff [one of her inpatients] joked, when the doctor poked her head back in Room 1103.

Congratulations to the Times and Jane Gross on taking the time to explore all sides of the hospitalist issue, and to Dr. Airan-Javia for being such a terrific exemplar of what we’re trying to achieve.

I’ll end with a brief personal reflection: This was one of the first lay-oriented hospitalist articles I can recall that didn’t harken back to the early days of the field and cite my coining of the term “hospitalist”, an omission that several of my old friends (gleefully) pointed out. My feelings about this surprised me.

Now don’t get me wrong: I certainly like being quoted in the paper, and when I am, it delights me to give the folks in Boca something to talk about over Mahjong and tennis.

But the best way I can describe my feeling is that it resembled the one I have when my kids do something terrific and the kudos are all about them – they aren’t Bob’s kids, they are mature young men who are being judged on their own merits.

As any parent can tell you, that feels just great.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

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Joeline WebberGreg PawelskitsurisDr. Janet Parker DVMbev M.D. Recent comment authors
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Greg Pawelski
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Greg Pawelski

To keep tabs on hospitalized patients, the PCP generally races in at 7 a.m., when the patient is asleep and the family is not there? Same thing happens with a Hospitalist. He/she is there when the family is not. Have you ever tried to track down a Hospitalist in a hospital? Time consuming! I’ve noticed recently, what Dr. Weinstein had stated about the change in economic incentives of Hospitalists. The longer the patient is in the hospital, the more they make, ordering more tests and (really) asking for more consults toward the end of a hospitalization. Didn’t know that it… Read more »

tsuris
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tsuris

Hospitalists are agents for hospital administrators. Administrators have as their goal, first, their compensation, then hospital profits, and then notariety and infamy. Patients are nothing but grist for their cash registers and most hospitalists are the executioners for the corner suite inhabitants. The articel was PR for the hospitals and Hospital Society who planted the story.

Dr. Janet Parker DVM
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Join our Medical Whistleblower Advocacy Network http://www.change.org/medicalwhistleblower/petitions Sign our petition to Protect Medical Whistleblowers Remember that all licensed medical professionals are the Mandated Reporters on the health and safety of the patients and the public. Even clinical psychologists and therapists are mandated reporters. Many doctors and nurses do not know that they are covered under international law and the Defenders of Human Rights Mandate. Please support us in getting proper protection for human rights defenders and mandated reporters. http://www.change.org/medicalwhistleblower/petitions/view/protect_our_medical_whistleblowers Persons who are medical whistleblowers are by definition Defenders of Human Rights because they are persons who have stepped forward to… Read more »

bev M.D.
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bev M.D.

primarycaredoc;
I didn’t find the results of the NEJM study particularly positive! But I understand what you are saying. But are you jumping to conclusions about why it was not published? Is there any public statement available? You could write AHRQ and complain your taxpayer dollars were wasted. I wrote them once (about something else) and actually got a reply……

primarycaredoc
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primarycaredoc

BevMD—it is important to recognize that the NEJM study you cite is a retrospective, nonrandomized study, with all the many biases entailed by that design. The unpublished randomized trial was designed specifically to address those biases. It is clearly a superior study, and it showed absolutely no difference between hospitaiist care and usual care across a wide range of measures. it is kind of disappointing that several of the authors of the NEJM paper were also coinvestigators on the randomized study that was funded to be definitive. Our knowledge about how to structure hospital care to improve the well being… Read more »

bev M.D.
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bev M.D.

primarycardoc:
Your referenced study may not have been published, but there are other similar ones reaching similar conclusions.See:
http://content.nejm.org/cgi/content/full/357/25/2589
I think for or agin, hospitalists are here to stay. The challenge now is to make the best use of them to improve care. As for their supposed obesiance to hospital administrations, this charge has been leveled at every other hospital based specialty too over the years; rads, paths, anesthesia, etc. As one of them(pathology); while administrations can try to apply pressure, one’s support from the medical staff is usually enough to thwart it. So the medical staff should be supporting, not criticizing…..

Sheryl Kurland
Guest

While there are many pros and cons to “hospitalists,” it is a fact that a hospitalist is in one way or another connected with the hospital. A patient benefits most from an an INDEPENDENT PATIENT ADVOCATE, whose ONLY interests are SOLELY those of the respective patient. An independent Patient Advocate’s pay is attached to nothing except for the time dedicated to the respective patient, helping to guide him/her through the medical maze and achieve an optimum outcome. Period.
Sheryl Kurland
Patient Advocates Of Orlando
http://www.patientadvocatesfl.com

primarycaredoc
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primarycaredoc

It is important to keep in mind that most of the studies of hospitalists are heavily biased. They are either nonrandomized, or use noncomparable randomized groups. (ie, the hospitalists are highly selected, and what is portrayed as a study of hospitalists versus usual care is really a study of average doctors to great doctors) To address whether hospitalists really improve outcomes, AHRQ paid millions of dollars to support a multicenter randomized study comparing hospitalists to usual care. Everyone agreed this was to be the definitive study of the effect of hospitalists. The results were presented at SGIM several years ago.… Read more »

MD as HELL
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MD as HELL

Hospitalists are not good for overall results. Their patients are discharged without the primary care doc knowing a flippin’ thing. Then before the patient can see their primary they are sick again and back in the hospital. In the pre-hospitalist days the primary care doc was aware of their status at discharge and could tweek their care more readily than can a hospitalist. The patient can not even contact their hospitalist except to come back through the ED. Hospitalists will be forced to become primary docs because their patients cannot be abandoned to the void of no follow-up. The circle… Read more »

Joeline Webber
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Joeline Webber

MM hmmm…. A huge problem that will only worsen. Example: Today my landlady was told she would need to see her Primary Care Physician within a week of discharge from the hospital for a percutaneous wrist pinning. Her PCP won’t have had time to get any copies of reports in his office before she gets there so he won’t be absolutely certain what has been done (we’ve short-circuited this issue by insisting on copies of everything in her record which we will pick up in a couple of days and take with us to the appointment. So here we have… Read more »

Carla Kakutani MD
Guest

This article was very odd, starting with the title. Aren’t hospitalists of different stripes covering inpatients for all sorts of outpatient based physicians, including internists and pediatricians? Why insinuate that family doctors are somehow lacking in skills or the get up and go to follow their patients in the hospital? It certainly gave a “best case” picture of how hospitalists are supposed to work, but based on the comments attached to the article on the NYT website, patient and family experiences are anything but. I appreciate the help of hospitalists at my hospital but continue to try to manage as… Read more »

Margalit Gur-Arie
Guest

Interesting article. IPC (NASDAQ:IPCM), probably the largest hospitalist company in the US, states in their 10-Q, that the company is “highly dependent on patient encounters and the productivity of our affiliated hospitalists to sustain profitability”. On top of the base physician salary, they also seem to offer “Productivity Based Incentive Bonus (No Cap On Earnings)”. Doesn’t sound to me like “The language of health care reform”. No doubt that hospitalists provide a useful service in a highly dysfunctional system and bring us one step closer to industrialized medicine. I just wonder how this concept fits in with Medical Homes and… Read more »

Andrew Weinstein, MD
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Andrew Weinstein, MD

“As for efficiency, Gross cited my 2002 JAMA review, which found that hospitalist care was associated with an approximately 15% reduction in hospital costs and length of stay.” Much has changed since 2002. Speaking from my personal experience, in 2002 most hospitalists were employed by the hospital and there econmiic incentives were exactly in synch with the hospital and predictably, length of stay was decreased. Now, most hospitalists are employed by a hospitalist company (the largest being publicly traded) and their economic incentives are the same as any internist’s in a FFS setting…the longer the patient is in the hospital,… Read more »