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:
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.”