Hospital medicine has become rapidly one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 44,000 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 five 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 for hospitalists 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 Healthcare IT with Frontline Hospital Medicine
Meaningful Use implementation has meant that hospitalists are obliged 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 lie 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 changes to 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 how high hospital care can soar.
Hospital Medicine 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 those specialties, and I feel blessed to be practicing it.
Dr. Suneel Dhand MD
Dr. Suneel Dhand is board-certified in internal medicine. He was born in London and grew up in Berkshire, England. Suneel went to medical school at Cardiff University and then moved across the pond, completing his internal medicine residency in Baltimore, Maryland. He currently lives in Boston, and practices as a hospital medicine physician.
Suneel’s clinical interests include frontline healthcare quality improvement, improving hospital processes, enhancing patient experience, and healthcare information technology development and integration. He regularly writes and speaks about these topics. As well as his clinical duties as a frontline doctor (which he enjoys the most), Suneel has experience in the implementation of hospital IT systems, and was the lead hospital physician for the successful implementation of a Computerized Physician Order Entry (CPOE) system in Worcester, Massachusetts. Suneel also has experience in a number of different healthcare environments and systems. In addition to practicing as a physician up and down the East coast, including in Florida, he previously worked in the United Kingdom’s National Health Service, and undertook an elective experience in Australia, where he worked with the Royal Flying Doctor Service.
Suneel held a faculty position with the University of Massachusetts Medical School as an Assistant Professor of Clinical Medicine, regularly teaching medical residents and students. He has authored numerous articles in clinical medicine that have been published in leading medical journals, covering a wide range of specialty areas. He has also authored chapters in the “5-Minute Clinical Consult” medical textbook. His other main area of interest is preventive medicine and wellness, and he is the author of two well-being books; High Percentage Wellness Steps, and the historical fiction book, Thomas Jefferson: Lessons from a Secret Buddha.
When he is not working in the hospital or on healthcare-related projects, Suneel enjoys running, cycling, playing tennis and golf, traveling (he tries to visit a different country every year), and getting back to London as often as possible!
Suneel blogs at: www.suneeldhand.com and www.HealthcareImprove.com.
Follow Suneel on twitter: @SuneelDhand
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