May 27, 2010

USA: New Breed of Specialist Steps In for Family Doctor

NEW YORK, NY / The New York Times / US / May 27, 2010

Dr. Subha Airan-Javia lowered the steroid dosage for Marilyn Lopp, 72,
who has chronic pulmonary disease.  James Estrin/The New York Times

By Jane Gross
PHILADELPHIA — By the time Djigui Keita left the hospital for home, his follow-up appointment had been scheduled. Emergency health insurance was arranged until he could apply for public assistance. He knew about changes in his medication — his doctor had found less expensive brands at local pharmacy chains. And Mr. Keita, 35, who had passed out from dehydration, was cautioned to carry spare water bottles in the taxi he drove for a living.

The hourlong briefing the home-bound patient received here at the Hospital of the University of Pennsylvania was orchestrated by a hospitalist, a member of America’s fastest-growing medical specialty. Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.

Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association. 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, to be phased in by 2014.

The New Old Age Blog: In Hospitals, New Fingers on the Pulse (May 26, 2010)
A Busy Schedule Is Never Boring (May 27, 2010)

Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.

Dr. Subha Airan-Javia is a hospitalist, or physician-administrator, at the Hospital of the University of Pennsylvania in Philadelphia.
James Estrin/The New York Times

Dr. Subha Airan-Javia, Mr. Keita’s hospitalist, splits her time between clinical care and designing computer programs to contain costs and manage staff workflow. The discharge process she walked Mr. Keita and his wife through can work well, or badly, with very different results. Do it safely and the patient gets better. Do it wrong, and he’s back on the hospital doorstep — with a second set of bills.

Dr. Subha Airan-Javia spoke with a patient, Djigui Keita, and handled many details of his care, relieving the burden on family doctors who are pressed for time.
James Estrin/The New York Times

“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun. These young doctors, coming into a highly dysfunctional environment, had an affinity for working on processes and redesigning systems.”

But hospitalists are not a panacea. Some have made mistakes when they sent their short-term charges home, failing to pass along necessary information to the regular doctor and family. Another concern is that patients will balk at an unfamiliar doctor at the scariest of times.

Carol Levine, in charge of family caregiving at the United Hospital Fund of New York, remains skeptical that hospitalists will completely smooth the process. “The patient,” she said, “is still expecting a doctor-doctor, when ‘Wait a minute I don’t know you’ is going to take care of them.”

The hospitalist appeared in the early 1990s, before the primary care situation was the crisis it is now. Today’s private internist may carry a roster of more than 2,000 patients, older and sicker than ever before, and the workload is expected to increase 29 percent by 2025. 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. (Physicians also earn 40 percent less for time spent with a hospitalized patient than one in the office, according to a report in the journal Health Affairs. )

Mort Miller, 84, of Chicago, was hospitalized eight years ago for a broken hip. He already had congestive heart failure and diabetes and was on dialysis. He died after four weeks.

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,” Mr. Miller said. “I guess he didn’t have time.”

Mr. Miller left his business to help run the hospitalists’ professional group, the Society of Hospital Medicine, a career change inspired by his father’s experience.

The most compelling argument in favor of hospitalists, who are now in 5,000 institutions, from academic giants like the Hospital of the University of Pennsylvania to small community hospitals to innovators like the Mayo and Cleveland Clinics — is that they are there all the time. Another is that they are more comfortable than their predecessors with technology and cost-cutting decision-making. One day in April, Dr. Airan-Javia was in and out of the rooms of a dozen patients, toggling between clinical work and designing a computer system for the safe handoff of patients between residents whose hours are now limited by law.

Bad discharges generally result from hurried instructions to patients and families and little thought to where they are headed. One such situation was the centerpiece of a class taught for doctors at Mount Sinai Medical Center in New York. The patient, an elderly woman in the hospital for scoliosis, a spinal condition, was discharged by a hospitalist on a Friday night, with a prescription for a narcotic pain reliever that her pharmacy, as it turned out, did not stock. No one explained how her new medication differed from the old, or gave her a contact number for help. Without medication, by Tuesday, her ankles swollen and her breathing irregular, the woman was back in the hospital.

In 2008, the hospitalists’ organization decided to invent better discharge systems rather than respond defensively to criticism, not unlike the simple operating room checklist, made famous by the physician and author Atul Gawande, which reduced accidents and deaths.

In 65 participating hospitals around the country, the Society of Hospital Medicine identifies patients at high risk for readmission, provides staff mentoring, and designs user-friendly discharge forms listing follow-up appointments, potential signs of trouble and phone numbers for the hospital team. Peer-reviewed research on the reforms in the system is expected in a year or two.

Even experts who were initially skeptical agree that the hospitalists’ skill set is timely. They are young and thus not entrenched in the current order. They enjoy working in teams, when older doctors tend to be hierarchical. And, like Dr. Airan-Javia, who has a 16-month-old baby, they appreciate the regular hours and a paycheck of, say, $190,000 — higher by $30,000 than community-based peers.

Dr. Airan-Javia says she made an inspired career choice. Forty percent of her time is spent on the floor, treating diseases and helping patients and families though complex life events, like deciding when it is time to suspend medical care and let life end. Sixty percent of the time she is designing systems to improve workflow and advising the hospital’s chief medical officer. At meetings with her fellow hospitalists, phrases seldom spoken by most doctors, like “cost-effective delivery of care,” and “preventable adverse events,” flow off everyone’s tongue: The language of health care reform.

“The tools have never been better,” she said, “for finally getting all of this right."

Copyright 2010 The New York Times Company