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Thursday, May 22, 2014

Hospital medicine: Driving the future of health care

Hospital medicine has rapidly become one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 30,000 mark and healthcare reform takes hold, the specialty finds itself at the forefront of American medicine. And for good reason. It is a young, dynamic, varied and flexible specialty that can be practiced in a number of different settings. Hospital medicine doctors are no longer just the “stand-in” for the patient’s primary care physician. Hospitals all over the country are increasingly looking to hospitalists to drive quality improvement forward. Having been in practice for over 5 years, I feel that the best and most committed hospital medicine doctors (that I myself have used as role models) have been the ones who enjoy patient care above all else, and then find a particular niche that they become expert in.

I have had the opportunity to work in a number of different hospitals up and down the East Coast, ranging from large urban medical centers, to more rural community hospitals. The challenges faced in many of these places are almost identical. I would like to identify 5 areas to focus that will take our specialty to the next level:

1. Rounding models

Currently, most hospitalists typically have patients scattered around the hospital on different floors. Their patients will be seen at completely random times. One may be seen at 7:30 a.m. and another at 3 p.m., often with no rhyme or reason behind the times. The solution to this problem is to institute good old-fashioned ward rounds, ideally multidisciplinary rounding within the patient’s room. This should be accomplished on all the patients by mid/late morning, with a definitive plan in place that is clear and succinct. Such a system works best when all patients are kept on one floor, in a geographical rounding model. This has a whole host of additional benefits, including vastly improving efficiency and reducing the volume of pages.

2. Program organization

Unfortunately most hospitalists work in a system of “hospital medicine chaos.” I use the term endearingly, because it’s not the fault of any doctor or even hospital. It’s the fact that our specialty is still new and largely disorganized. Hospitalists need to be able to focus on each patient, and not be multitasking to an unsafe degree. As well as more organized rounding models, programs can do this with other techniques such as utilizing a dedicated “admitter” in the emergency room and making sure that any additional call coverage is manageable. This will enable a better focus on metrics such as early discharges, reducing length of stay, and higher patient satisfaction.

3. Transitions of care

Two particular problems are admission medication reconciliation and the discharge process. The former has been a problem in every hospital I’ve worked in. It often seems impossible to get a complete and accurate medication list. There are a number of reasons why this eludes us, including the patient themselves not knowing what they are taking, and the admitting doctor having several different lists available to them! We need to get a “no ifs, ands, or buts medication list.” Studies are increasingly proving the value of pharmacists stationed in the emergency room to hand hospitalists this list when patients are admitted. Think this is expensive? Consider the reduced medication errors and improved patient safety.

The discharge process is another big area for improvement. By its nature a risky process and fraught with potential problems, we need to make every hospital discharge as thorough and seamless as possible. The role of the hospitalist is invaluable in making this happen.

4. Focusing on the patient

The drive to enhance patient satisfaction and improve the healthcare experience is really not rocket science. We need to listen to patients and take on board their concerns. The most common complaints I hear from my patients are usually quite straightforward, and I’m sure similar to what other doctors hear up and down the country—among them are a good night’s sleep and better hospital food! Not far behind is patients simply wanting more time with their doctors and nurses. We need to get back to the fundamentals of good medicine in a comfortable, healing environment.

5. Integrating health care IT with frontline hospital medicine

Meaningful use implementation has meant that hospitalists are having to work more than ever with information technology. This will only increase with time. Unfortunately, most of the current IT solutions are slow, inefficient, and cumbersome. They take time away from our patients. Hospital doctors should insist on IT that is optimized to our unique workflow. Rapid order entry (ideally using mobile technology) and efficient EMRs are the way of the future.

Ahead lies enormous opportunities for process improvement and making a real difference in our patients’ lives. We must remain fully engaged and more importantly lead in these hospital processes. The old attitude of many administrators that “hospitalists don’t make any money for the hospital” is rapidly turning into “hospitalists are crucial for our organization’s success.” The first few years have been a bit of a rocky road, and most programs around the country are still disorganized and can’t achieve the metrics that are needed to take things to the next level. Once we organize the specialty better, there’s no limit to high hospital care can soar.

This is a tremendously rewarding career. There are very few specialties left where you are the “captain of the ship”, guiding patients through their illness, forming strong relationships with both them and their families. Being a good old-fashioned doc with solid clinical and reasoning skills that are applied on a daily basis. Hospital medicine is one of them, and I feel blessed to be practicing it.

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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
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.

And Thus, It Begins
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.

Auscultation
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
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.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

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.

DrDialogue
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.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
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.

Gut Check
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.

I'm dok
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.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
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.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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