“We are playing the same sport, but a different game,” the wise, thoughtful emergency medicine attending physician once told me. “I am playing speed chess – I need to make a move quickly, or I lose – no matter what. My moves have to be right, but they don’t always necessarily need to be the optimal one. I am not always thinking five moves ahead. You guys [in internal medicine] are playing master chess. You have more time, but that means you are trying to always think about the whole game and make the best move possible.”
In recent years, the drive toward “efficiency” has intensified on the wards. I am seeing much more speed chess played by us hospitalists, and I don’t think that is a good thing.
The pendulum has swung quickly from, “problem #7, chronic anemia: stable but I am not sure it has been worked up before, so I ordered a smear, retic count, and iron panel,” to “problem #1, acute blood loss anemia: now stable after transfusion, seems safe for discharge and GI follow-up.” (NOTE: “acute blood loss anemia” is a phrase I learned from our “clinical documentation integrity specialist” – I think it gets me “50 CDI points” or something).
Our job is not merely to work shifts and stabilize patients – there already is a specialty for that, and it is not the one we chose.
Clearly the correct balance is somewhere between the two extremes of “working up everything” and “deferring (nearly) everything to the outpatient setting.”
There are many forces that are contributing to current hospitalist work styles. As the work continues to become more exhaustingly intense and the average number of patients seen by a hospitalist grows impossibly upward, the duration of on-service stints has shortened. In most settings, long gone are the days of the month-long teaching attending rotation. By day 12, I feel worn and ragged. For “non-teaching” services, hospitalists seem to increasingly treat each day as a separate shift to be covered, oftentimes handing the service back-and-forth every few days, or a week at most. With this structure, who can possibly think about the “whole patient”? Whose patient is this anyways?
In many groups, metrics are focused at the individual hospitalist level and only capture processes or outcomes that occur within the hospital encounter. Worse than that, in most hospitals, the metrics and attribution are widely inaccurate. These sorts of problems greatly diminish the usefulness of these measures. No insights can be gained. No accountability fostered. Nonetheless, there is a relentless focus and messaging about length of stay and utilization measures.
There is a lot at stake if we allow our chosen profession to be defined by shift-work and “speed chess.” The hospital medicine movement was built on the promise of both safer and more efficient care. However, recent studies have not looked good for us. When comparing hospitalized patients cared for by a hospitalist versus their own primary care physician (PCP), those cared for by a hospitalist had a shorter length of stay (we win the efficiency game!). But, wait, there is an outcome that EVERYBODY cares about more than length of stay. The patients cared for by PCPs had lower 30-day mortality rates. They also were more likely to be discharged home. Maybe that is some time well spent in the hospital.
Furthermore, another study suggests that with the decreased length of stay and utilization in hospitals, we are simply shifting costs and utilization to post-discharge settings. In the grand scheme of things, this does not count as “improvement.”
All things considered, I am resolutely proud to be a hospitalist. Our profession has led the advancement of quality improvement, patient safety, and clinical education for the rest of the medical world. I count some of the most inspiring and innovative clinicians in the history of modern medicine as hospitalist colleagues. I go to many different conferences each year, but when I go to SHM’s annual conference, I unambiguously feel like I am with my people.
I believe though we need to redirect our current trajectory. Rather than narrow the scope of our responsibility, we should seek to widen the clinical footprint of hospitalists. We should consider moving from narrow hospital-centric metrics like length of stay and advocate for measuring more holistic patient-centered outcomes, like “home-to-home time.” We need to take more team-based responsibility for patient outcomes, including those that happen on days when we are not the attending physician, and even those that happen outside the walls of our hospital. It will be tricky to do this in ways that rather than diminishing individual accountability for outcomes, will instead foster shared accountability that encourages teamwork.
These sorts of shifts, I believe, will further compel current innovative efforts by some hospitalist groups to improve handoffs at all levels, to work in high-functioning teams, and to better coordinate and provide high-quality care in post-acute settings. For the selected few patients who need the benefit of true longitudinal and coordinated care, we should embrace and encourage “comprehensivist” physician models. For all other hospitalized patients, we must develop innovative ways to foster better communication and coordination with PCPs – in the age of countless communication platforms, we cannot accept still being tied to faxes and phone trees. Hospitalists are innovators. Somebody please fix this!
We need to double-down on enhancing our unique skillsets to be master chess players – working in multidisciplinary teams – who truly improve care, rather than risk being seen as interchangeable physician cogs moving patients in and out of the hospital as quickly as possible.