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Time for hospitalists to act

September 2009

Obama’s speech last night to a joint session of Congress was a call to action for lawmakers buried under a morass of organized, polarizing opposition to health care reform. The speech provided the specifics that both critics and backers of change wanted, and should help assuage those who think the president wants to enact a complete government take-over of the health care industry.

But the speech should also serve as a call to action to hospitalists across the country. The president expects to pay for his reform agenda by establishing a commission of doctors and health experts to establish “common-sense best practices … everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.” Citing health systems like Intermountain Healthcare in Utah and Geisinger in rural Pennsylvania, Obama wants us to implement best, evidence-based practices to deliver quality while reducing costs.

We face these challenges every day. Hospitalists, in particular, not only see a lot of waste, redundancy, and not-evidence-based practice (and sometimes a bit of quackery), but we also have the opportunity to modify care, establish better communication among providers and protect the system from waste. Hospitalists will have a seat at the reform table, and it is our time to act.

Which brings me to a little article that didn’t seem to generate a lot of interest. The title is “Hospitalists and the Quality of Care in Hospitals,” and it was published n the August 10/24 issue of Archives of Internal Medicine. The study compared outcome measures between hospitals that had hospitalists and those that didn’t. The study concluded that hospitals with hospitalists performed better in Hospital Quality Alliance (HQA) measures for acute myocardial infarction, congestive heart failure and pneumonia.

Actually, what grabbed my attention was not the study, but the accompanying editorial, written by Drs. Robert Centor and Benjamin Taylor from the department of internal medicine at the University of Alabama.

In their essay, the authors discuss the importance of the word “quality,” its nebulous context as it applies to health care, and the purported difference between quality and safety. Centor and Taylor write that, like many similar studies, this one focuses on “performance measurement rather than quality” and that “attempts to simplify quality into scorecards or checklists may seem attractive, but those attempts may well mislead and negatively affect patient care.”

In other words, hospital medicine has fully matured. We should stop trying to justify the existence of hospitalist programs and focus on how hospitalists truly impact care by comparing different hospital systems, acquiring evidence to define best practices and helping adopt those across the spectrum.

We should investigate what organizational structures make one hospitalist group better than another. The editorial authors write, “Lumping hospitalists without a consideration of organizational differences could hide the promise of excellent hospitalist groups.” We know hospitals with hospitalists are better than those without them, but it’s time to compare hospitalist groups to one another. To do so, we must move beyond performance metrics and focus more on standardized quality measures.

Toward the end of the president’s speech, he echoed comments by the late Sen. Ted Kennedy, calling health care a “moral issue.” The morality of this issue is the necessity to ensure access to excellent health care to everyone in this country.

This is not a political imperative. It is one framed by the Hippocratic oath, which exhorts doctors to hold to this pledge: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice”. Comparative analysis and evidence-based medicine are the cornerstones of excellence in medical care. Through those, we can help diminish the intentional injustice of our present health care system.