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The best of times?
That depends on where you work
by Erik DeLue, MD, MBA



Published in the September 2010 issue of Today's Hospitalist

"It was the best of times, it was the worst of times ... " I couldn't help but think of Dickens' classic introduction to "A Tale of Two Cities" when reading the May 26 New York Times article that the hospitalist world promptly began buzzing about.

In the article, hospital medicine is shown in an exceptionally positive light— well-deserved, of course. Subha Airan-Javia, MD, the hospitalist featured in the article who works at the Hospital of the University of Pennsylvania in Philadelphia, is a renaissance doctor, saving lives in a dysfunctional
In some hospitals, we drive both clinical care and administration. In others, we remain a concierge service for consultants.

system with both her clinical acumen and her technological expertise. Hospitalists are portrayed as the saviors of a health care system that is in crisis and heading toward many more unknowns in a reformed environment.

Why the worst of times? Admittedly, that is a bit strong. In the writing business, we call the opening line the "hook," so sometimes hyperbole is needed. Perhaps more accurately stated: "Hospital medicine: It was the best of times, it was a time where things could be much worse—but certainly they could be better."

Revenue, quality, autonomy
Why the qualifier? Let's start with programs that see more than 20 patients a day. There is a point on the x/y intercept (where x is revenue and y is quality) where the two cross, and this is the sweet spot: Optimal quality matched with reasonable revenue.

But move further to the right and revenue increases, only to have quality plunge. We all know this, yet there are more than a few programs out there that continue to drive their hospitalists to see too many patients at the expense of quality (not to mention the hospitalists' sanity). The sweet spot has been debated at length, but depending on your program, I believe it is between 15 and 18 patients per day.

And if expectations of too much productivity aren't enough, think about all the differentials in hospitalist autonomy. In one program, a hospitalist may work in the ICU and treat complex infections without calling on an army of consultants. In another program, hospitalists treating a patient with a similar illness may find that their only responsibility is ensuring that morning labs have been ordered.

Our own égalité
In a number of hospitals, we are the drivers of the hospital, both clinically and administratively. In others, we remain a concierge service for consultants, allowing them additional time to see and intervene on more patients, now that they are relieved of admitting orders, H&Ps, discharge instructions and the like.

I know of places where the hospitalist cannot order stress tests; if you need one, a cardiology consult is mandatory. Stroke in a 95-year-old? Mandatory neurology involvement. And OK, I understand closed ICUs, sort of, but when you realize that so many hospitalists manage so many ICU patients exceedingly well, I will never be a fan of excluding us from certain sections of the hospital. (That doesn't include labor and delivery. I'm happy never to go there again.)

Toward consistency
Our field still has so far to go despite the fact that such challenged hospitalist programs are increasingly a minority. Here's the familiar saying: "If you know one hospitalist program, you know one hospitalist program."

Not good enough. While we will never (and should never) be absolutely homogenous given our many diverse and distinct responsibilities, we do need more consistency in how we all practice.

To my mind, accomplishing this standardization is critical to the future of both our profession and the delivery of health care. After all, who else is so poised to do so much with so much less in the era of post-peak Medicare? I define peak Medicare as the point when the maximum rate of extracting funds to pay for health care is exhausted, followed by an inexorable, futile exploration for more money. In fact, I would submit we have reached that point.

Hospitalists are hardly the demoralized French peasantry of the 18th century as told in Dickens' classic tale. And I will leave it to you to draw parallels between the French aristocracy of the same period and all the forces preventing hospitalist programs from reaching their potential.

But the French Revolution was fueled by the Enlightenment, "an era in Western philosophy and intellectual, scientific and cultural life in which reason was advocated as the primary source for legitimacy and authority," or so says Wikipedia. The day when all hospitals are filled with autonomous hospitalists who can dedicate themselves exclusively to improving the quality of care would certainly be not only the "best of times," but a new age of enlightened health care indeed.

Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial in Mt. Holly, N.J. Check out Dr. DeLue's blog and others on the Today's Hospitalist Web site.
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