BOSTON, Ma. — It was Christmas Day. I was on call at the hospital and was waiting for my wife and 6-week-old son to come so we could eat lunch together. She was bringing kimbap, sweet potatoes, and avocados. But then my pager buzzed.
On the phone was a hospitalist physician.
“Is this ID? We have a new consult for you,” she said. “This man has a history of dementia. For some reason he has a urinary catheter to empty his bladder. We gave him an antibiotic, but now his urine is growing a resistant bacteria.”
I sighed. Yet another catheter associated urinary tract infection.
I walked up the stairs to his hospital room. He was bald, thin, and sitting alone in bed. The peas and fish on his tray were untouched. There were no gifts or tree in his room. I washed my hands, put on gloves and a yellow isolation gown, and introduced myself.
“How are you?”
“Ok, I guess,” he replied.
“Do you know where you are?”
“I’m not sure.”
“You are in the hospital. Do you know what day today is?”
Dr. Gregory House hung up his stethoscope and cane for the last time last night and shuffled off into eternal life in the Land of Reruns. House — the brilliant, misanthropic, drug addicted, my-way-or-the-highway physician — has been an entertaining presence on FOX television for the past eight years. I enjoyed the series and even learned a little medicine. I also took some pride in the show, since House was television’s first hospitalist, a term I helped coin and now the fastest-growing specialty in modern medicine.
But as entertaining as he was, House was a throwback to an era in which the antisocial tendencies of some physicians were seen as irrelevant to their doctoring. As medical leaders strive to redefine “the great doctor” of today, House’s departure is both timely and welcome.
When I went to medical school in the 1980s, many of us valued nothing more than our autonomy. We saw medicine as an individual, not a team, sport, and interpreted professionalism as unwavering advocacy for our patients. While this was often healthy and noble, in some cases it crossed the line into obnoxiousness, even rage. (Today, we call doctors who cross this line “disruptive physicians.” Dr. House would certainly qualify.)
In this month’s Archives of Internal Medicine, my colleagues and I report the results of our early experience with hospitalist co-management of neurosurgery patients. We found stratospheric satisfaction among neurosurgeons and nurses, as well as impressive cost reductions ($1400/admission). At the same time, there was no impact on quality or safety, at least as judged by hard end-points such as mortality and readmission rates.
While these results might seem like a mixed bag, I believe that the overall impact of this service has been fantastic, for patients, surgeons, and our own hospitalists. Let me explain, beginning with a brief history of hospitalist co-management, folding in the history of our neurosurgery co-management effort (which we call the “Co-Management with Neurosurgery Service”, or CNS), and ending with some of the more subtle outcomes that lead me to feel that this is one of the most important things our hospitalist program has done since its inception in 1995.
A Brief History of Co-Management
When the hospitalist field took off in the mid-1990s, we projected that its growth would largely reflect the degree to which hospitalists assumed the care of inpatient internal medicine (and later, pediatrics) patients: those with pneumonia, heart failure, sepsis, GI bleed, and the like. Sure, I recognized that there would be increased opportunities for traditional medical consultation – we come when you call us – but I completely underestimated the siren call of co-management.
It turns out that once there are hospitalists in the house, the notion of having them actively co-manage surgical patients is hard to resist, for several reasons. First, many of the problems such patients experience before and after surgery are really medical, not surgical. Secondly, just as a hospitalist can provide on-site availability that the primary care physician can’t match for medical patients, he or she can do the same for surgical patients. (In this case, it’s not that the primary care doc is stuck in the office, but rather the surgeon is stuck in the OR.) Third, in an era of more widespread quality measurement and reporting, it seems likely that a hospitalist will improve quality measures such as DVT prophylaxis and evidence-based management of CHF more than a surgeon, flying solo, would be able to.
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.