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.

5 Responses to “The Times Hits the Right Notes on Hospitalists”

  1. Jack Percelay May 28, 2010 at 6:26 pm #

    Bob,
    The SHM Public Policy Committee was actually had our Capitol Hill visits on Wednesday of this week, so the article was just a day late for some of the younger staffers to be able to answer, “Of course, I know what a hospitalist is. I read all about you’all in today’s New York Times.”

    While the article was quite laudatory, blog posted feedback on the article was running 3:1 negative this morning. There were reports from many people whose experience or family member’s experience with hospitalists had been negative. Not surprisingly, the bulk of these complaints centered around transitions of care–either on admission, from one shift to another, or most commonly at discharge. While we can take pride in the wonderful work we have done and continue to do, and can celebrate that we are being recognized in DC and at CMS, we need to remember some of the basics. So, in addition to good, effective, evidence-based medicine, when asked about key aspects of hospital medicine, paraphrase the words of the US President when the term “hospitalist” was coined andremember, “It’s the transition, stupid.”

  2. menoalittle May 29, 2010 at 6:14 pm #

    Bob,

    Commentary is well said. It behooves you and the Society to take heed of the criticism which has as its focus, neglect of the patient. There is not a hospitalist I have met who does not believe he/she has provided excellent care, and as hospital employees, they carry out hospital missions and feed in to churning beds and adopting the computer as the patient.

    Hospitals missed unread echocardiograms stored in hidden silos on electronic record systems at the Harlem Hospital for years: http://www.nytimes.com/2010/05/29/nyregion/29harlem.html
    They should not be blamed for failure in a inferior system of devices, but what were these hospital doctors thinking?

    Were they bewildered by the complexly flawed electronic record systems? One can only imagine what these quasi HIT experts were thinking since they were getting paid well as long as they did not upset the administration.

    These real sick patients did not have advocates.

    Best regards,

    Menoalittle

  3. a hospitalist June 2, 2010 at 2:07 am #

    Most of the comments on this article have been negative and many are unfortunately correct.

    I’ll list some of the problems with my profession.

    It is near impossible for a hospitalist to provide excellent care to All of his/her patients All of the time when the patient census is high. Colleagues then turn to ” dispo mode” or “how can I discharge or transfer” the patient in order to lower the census size. There is often a sense of relief when able to transfer a patient to another service or if the family agrees to make the patient DNR.

    There often isn’t a sense of ownership of the patient especially with our younger colleagues. Many do not care what happens to the patient after discharge. I have heard many times that ” the patient is no longer my problem”.

    There is much complaining about” difficult patients and families” rather than working on how to improve communication.

    We should not tolerate this sort of behavior. We need to model professionalism.

  4. Anti - Hospitalist! June 22, 2010 at 5:33 pm #

    I do not appreciate this entire movement, nor will I ever be convinced that utilization of “hospitalists” in lieu of your private phsyician, who knows you and your conditions is an improvement in te Medical Field!

    So we are being told – Select your doctor and have faith in their ability – then when you are really sick and need them – they are not there – Use a stranger!

    Somehow I have to beleive that this movement is only about the financial benefits and really has nothing to do with improving the care of the patients! Anyone believing anything to the contrary really has to question their own intelligence!

  5. Anne from Texas June 29, 2010 at 8:23 pm #

    I have to agree with the reservations about hospitalists. One put a sick geriatric friend of mine through many stressful tests unrelated to the cause of her hospitalization. It was very hard on her and I believe contributed to her decline which resulted in death shortly post-hospitalization.

    I’m sure his intentions were good, and I’m also sure there are genuine points in favor of hospitalists in some circumstances; but I’m uncomfortable with the conflict of interest inherent in procedures and tests being profitable to the hospital.

    My brother (a very medically complex case as he’s been sick for decades with multiple ailments) is currently in the hospital in very dire shape and although I am not in that city, it is reported to me that the hospitalist was extremely defensive when his caretaker suggested he speak with his physician of thirty years, and unwilling to do so (the doctor does not have privileges at the hospital that the ambulance insisted on dumping my brother at).

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