By BOB WACHTER, MD
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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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 disjointed care again… the Hospitalist system is to the benefit of the Hospital, the Hospitalist, and any organization for whom the Hospitalist works. The patient is way down the list in terms of it being in his/her best interests..
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 often resulted in lengthening the stay. Good point!
As a caretaker, I’ve experienced the “flippin’ thing” consequences as Madder states. The PCP is virtually clueless about what went on with the patient’s hospital stay. I certainly wished that my dad’s PCP was aware of his status at discharge and tweeked his care. It couldn’t have helped, tremendously!
The studies that arn’t published (as primarycaredoc states), is a drawback. Studies with positive findings are more likely to be published than studies with negative results. Even negative results can provide useful information about the effectiveness of care. Any tendency to put negative results into a file drawer and forget them can bias review of care reported in medical literature, making them look more effective than they really are.
The Hopitalist maybe here to stay, but care is still often isn’t well co-ordinated (and that’s after what, ten or so years?). And two of the hospitalists that I’ve dealt with recently for my mother, readingly admit it. But some good Hospitalists are making a difference.
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.
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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……
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 of our patients will not successfully advance if leaders in the field choose to only publish results that confirm their point of view, and bury studies that may cause some to reconsider this point of view. It is time for these leaders to do the right thing and publish the results of their randomized study.
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…..
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
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.
The result: Across multiple outcomes, hospitalists had no beneficial effect on outcomes. None. No benefit on health outcomes. No benefit on utilization.
The reason you have not heard of this study is that it was never published. It is a very unfortunate example of publication bias, in which negative results which disappoint the investigators do not get published.
Some info on the trial can be found at the online registry of clinical trials:
http://clinicaltrials.gov/ct2/show/NCT00204048
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 will complete itself, but there will be no long-term relationship that has always made for better care and cost effective care.
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 many of my own patients there as possible. I believe that the slight loss of efficiency is balanced out by the benefits of planning out their work up, treatment and discharge in the context of our long relationship. Unfortunately, even when the primary care doctor has priveleges and wants to be called, nobody thinks to do it.
In the days before E&M codes were so devalued, when you could see a reasonable number of patients a day and still make overhead, there was time to round at the hospital. Worsening economics pushed many primary care doctors to give up this part of their professional life and the end result is less continuity for patients and an insidious loss of prestige and influence for primary care.
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 their 24×7 access to one’s doctor. Maybe that access is only good when you’re healthy or at least not sick enough to require hospitalization….
“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, the more they make (up to a point…if their numbers start looking bad they get heat from the hospital). The result is that hospitalist no longer cut costs or lengths of stay. In fact, I often see them ordering more tests and asking for more consults toward the end of a hospitalization because it often results in lengthening the stay. I would bet serious money that if you repeated your review in 2010 you would get very different results.
“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.”
A dedicated physician is a dedicated physician, regardless of their specialty. But to imply that this is the usual and customary behavior of a hospitalist (which the article does) is a farce. Countless patients have complained to me about getting bills from a physician they never saw in the hospital except at admission. They were complaining about hospitalists.
Hospitalists do bring something to the table but this (the NYT article) was a puff piece at its worst.