Tuesday, January 28, 2014
It's time to establish order amid this hospital medicine chaos
Following rapid growth in the last couple of decades, hospital medicine is set to become the largest specialty in American health care. Hospitalists work in almost every hospital across the country. Being in the field myself, I know that we are uniquely placed to get a complete view of the system from admission to discharge and to lead quality improvement initiatives. We treat a full range of medical illnesses, often coordinating care between a number of specialists as the “captain of the ship”. The close bonds that are formed with patients and their families make the job very unique and special. Hospital doctors are truly practicing frontline medicine in the purest form. At its best, this is one of the most rewarding professions anyone can ever hope to have.
Given this, members of our specialty have to ask ourselves why the job is not as popular as it should be? Most programs around the country are struggling to hire hospitalists, and those programs that are well established suffer high rates of turnover, as much as 20% to 30% per year. No organization can succeed with such high rates of attrition.
A friend once remarked to me, “In my hospital, it always seems like the hospitalists really hate their job”. As someone who had been in practice several years, this observation really made me think. I know that a lot of hospital doctors don’t like their jobs, have plans for fellowship, or view it as a temporary career move. But why? Many hospitals take it as a given that their programs will see a “revolving door” of staff turnover. This is an incredible shame and I don’t think it’s the job per say that is making this happen. It is actually the way programs are set up and the circumstances that hospitalists are expected to work under. Poor organization and inattention to optimal workflow basically ensure that the doctor will be subjected to complete chaos during the typical work day. Why should we assume hospital medicine has to be like this?
Fortunately, I have worked in the better programs which are well ahead, but it’s obvious to me from looking around and talking to other colleagues what the issues are. Here is the typical scenario for a significant proportion of hospitalists. The doctor will start the day with a list of patients to see. As they diligently get to work, they will simultaneously be getting paged with questions from nurses about their patients. Some urgent, some not so urgent.
In between, the doctor will be taking calls from the emergency room for new admissions and other hospital floors for new consults. The pager will be going off constantly. Trying to spend a few minutes talking to patients and their families, the precious time will regularly be interrupted. There is simply no rhyme or reason to the day. One patient may get seen at 7 am and another 3 pm. The new admission from the ER that was taken at 8 am may not be seen until 4 pm. The patient that was waiting to go home all morning is finally discharged at 5 pm. Sounds crazy? These scenarios play out in most hospitals on a daily basis.
The job of a hospitalist is one that requires significant multitasking. However, lack of organization makes the typical workday for a lot of jobs out there intolerable. No wonder there’s so much burnout. Nobody—not anyone—who is diligent, thorough and wants to do a good job, could work like this.
Moreover, it’s also dangerous for patients. At a time of increased focus on quality and safety, the hospital medicine doctor needs to work in an environment that affords time for focus and high quality care. Take even the best job in the world and make it completely unorganized and chaotic—people will soon dislike it. Of course being a doctor in most specialties is anything but predictable, but the situation is made much worse than it should be.
What we need to do is to create a defined framework to the day. The workflow of a hospital medicine doctor is actually one that can be somewhat planned (it’s very different for example from that of an ER doctor, which has a continuous workflow of “one patient after another” not knowing what’s arriving through the door next). In many respects, the day should be more similar to a primary care or office-based physician who will attempt to have a set clinic schedule. In these settings it wouldn’t be acceptable to have the patients coming in at random times and to also keep slotting in extra patients during the day. The same goes for a surgery schedule too. Yet this is what happens every day in hospital medicine.
Here’s the broad strategy that every hospitalist program needs:
• The doctor has their list of patients to see in the morning;
• Have expectations for rounding on patients before a certain time utilizing a full multidisciplinary rounding model;
• Institute a system of geographical rounding, which means that the hospital doctor is always near their patients and spends less time walking between floors. This also reduces the frequency of paging the doctor;
• Nurses and Case Managers should know approximately what time they will be able to convey their concerns and questions to the doctor;
• A focus on discharging patients as early as possible;
• Afternoons should be spent on reviewing patients, documentation, and family meetings; and
• An on-call doctor should be based in the Emergency Room, tasked with seeing all new admissions. The same applies to any new medical consults.
Standardizing systems isn’t designed to take away individuality, but rather to establish order to what is now chaos. Working in an organized fashion will also mean more emphasis can be put on important metrics such as reducing length of stay, earlier discharge times, and improving patient satisfaction. We already have some excellent programs across the country that are leading the way. In addition, to avoid monotony, variety can be added to the program by having doctors rotate around different floors and the Emergency Room every several weeks.
The success of a hospital medicine program can make or break the institution—it’s vital we get this right. Hospital leaders should be putting their heads together and working out how to make this the best job in medicine (it’s already shaping up to be one of the most important). Put more order into the day and watch hospital medicine doctors and our health care system flourish. And ultimately, happier patients will be the real winners.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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