`14 September 2018
Dear Interested Readers
There Are No “Do Overs” in Life, But Continuous Improvement Is Always An Option
Sometimes it feels like my wife and I are running a B and B. The last of our summertime visitors, or the first of our fall guests, left mid week. Before leaving, “the guy” in the couple contributed to my thinking and this “Musing.” Unlike me, he is an avid golfer. The last time I played golf, about four years ago, I played with him and his son who is also a good golfer. It was a humiliating experience for me that only got worse the longer it lasted. During this visit things were quite pleasant until the subject of golf came up.
While I was trying to watch the Red Sox beat the Astros my guest, who was tired of making excuses for his Orioles, began to talk about golf and how hot it had been this summer, especially over the last few weeks. It was so hot that he cancelled a tee time. He briefly mentioned how much fun he had playing golf with me the last time I was down his way. I grunted that I was glad that he had enjoyed the day. I added that I had been afraid that I had been a drag that day since I was always off in the woods looking for my ball.
He quickly reassured me that he really did enjoy the day, and then for a bonus started talking about “Mulligans.” I did not immediate get the connection as he began to describe how his golf league raised money for charities. One of the ways they make money for good causes is to sell Mulligans. If you don’t like your putt or your drive, you can buy a Mulligan, the chance to repeat the shot. It seems that terrible golfers like me usually buy Mulligans so that they can take a second, maybe better, shot from the tee. Better golfers, like my guest, buy Mulligans to repeat putts. According to my guest, the best golfers buy Mulligans to repeat “approach shots.” If their shot to the green left them a long putt, they buy a Mulligan and on the second shot they put the ball near the pin. I told him that was interesting, and then I tried to shift the conversation back to baseball while I continued to think about “do overs.”
I frequently have “do over” dreams. They are not usually “sweet dreams,” and I rarely do better in dreams than the first time around, even though I have a veteran’s experience. I have the same do over experience in golf. “My rules” allow a second tee shot, if desired, on the first hole. If I take a second shot from the first tee because I “topped the ball” on the first drive and watched it dribble forward 20 feet, the second shot is likely to be not much better, or it “slices” or “hooks” into the woods along the fairway. Every time that I have played golf I resolve that it will be the last time that I will play golf.
As I continued my musing about golf, Mulligans, and the fantasy of “do overs” in life, I began to think about “continuous improvement” and Lean. Lean depends on a series of “do overs” guided by reasoning, scientific method, and an analysis of the results of the current state or the last effort. Continuous improvement science has so much to offer us, but it is the rare organization that uses it effectively. Many organizations that do use Lean, and think that they are Lean organizations, do use it for incremental improvements in established processes, but they do not use the philosophy or the tools either for organizational transformation or to support innovation.
Lately, as I have watched my father become more and more debilitated following multiple hospitalizations, I have had good personal reason to consider some of the larger issues in healthcare that I would like to see get a “do over.” I had many of the same concerns with my mother’s care six years ago before she accepted hospice care. I do not think that I can cover all that seems to be in need of a “do over” in one letter, so I will begin in this note with my concern about the way we use “hospitalists.” I do not think what my family has witnessed and endured is unique.
As far as I am concerned, from the point of view of families, patients, and perhaps a significant number of PCPs, the use of hospitalists should be reconsidered. Perhaps as a society and profession we should take a “Mulligan” on the concept of “hospitalist.” As a minimum I feel we should consider what we have lost and what we have gained. There are several advantages that I am sure we would like to retain, but what we may think yields short term gains could be the origin of long term losses. I will begin by briefly describing my professional experience with the concept, and then I will cross over to touch on the experience and concerns of patients and families.
The concern about hospitalists is not new. In an editorial in the New England Journal of Medicine in December 2007 entitled “The Hospitalist Movement-Time to Move On,” Lawrence McMahon, MD wrote:
The hospitalist movement has arrived, and it has transformed the care of hospitalized patients. Investigations similar to the early studies of hospitalist practice, which were focused on cost and comparing outcomes with those of other providers, should begin to wane. New investigations should focus on quality improvement, comparative effectiveness, clinical informatics, the safety of patients, and the translation of new medical advances to clinical practice.
Reading Dr. McMahon’s editorial eleven years later, it is clear that although there were financial benefits, and we thought there might be clinical benefits, there were some concerns then about this new specialty and the dramatic changes in practice that were rapidly occurring. There is also a suggestion in the editorial that we should be concerned about whether, or how, hospitalists should be folded into the staffs of academic medical centers. I would add that the issues and benefits of hospitalists might vary across many different environments. Does a hospitalist in a small community hospital work in the same way that a hospitalist performs in a suburban hospital in a large metropolitan area with some house staff?
Our organization moved into the use of hospitalists in a gradual fashion. In retrospect the movement was driven almost completely by financial considerations. I remember the arguments that were presented to justify the shift. As our revenues transitioned from risk based capitation to more and more activity based fee for service income, it became obvious that revenue was maximized by keeping the PCPs in the office for the entire day. It was inefficient financially for everyone to see their own patients in the hospital and then go to the office. The billings from hospital rounding were smaller than the RVU based revenue from the same time spent in the hospital.
We started slowly. The first step was that each week one PCP would have his/her office schedule cancelled and then round at the hospital on all the patients of his/her colleagues who were in the hospital. One would work six or seven weeks in the office and then a week in the hospital. PCPs were initially concerned about losing their hospital skills.
The next step was to hire hospitalists. They were our colleagues. We paid them. They worked within the hospital to direct the care in a way that that was consistent with our philosophy of management and resource utilization. In time the connection to our practice was lost, and we used the hospitalists employed by the hospital.
In retrospect even if the finances appeared favorable for the event of the hospitalization much may have been lost if an entire episode of care was considered. There were other real losses and real gains to consider in the overall analysis from the perspective of our practice. In retrospect what was least considered were the losses and gains that accrued to patients and families.
Ironically through it all, I was able to see many of my own primary care patients when I was rounding in the hospital for our cardiology service. In a way I was doing a side by side study. If I was able to see my patient in the hospital, I could block the wasteful practice of repeating tests that had already been done as an outpatient, or I could discharge a patient to have a test or procedure done as an outpatient after the hospitalization. I was able to review meds, answer questions, and facilitate the follow up in my office at the most appropriate time. I could manage referrals to ensure that the patient stayed within our practice where the consulting physician had easy access to all the accumulated medical records and easier access to me, a referring colleague. Transitions of care have become vulnerable periods where waste occurs and outcomes become vulnerable to lapses in communications.
Over the years I relished my on call weekends in the hospital. The pace in any hospital slows down on Saturdays, Sundays, and holidays. There is time to sit down in a patient’s room and have meaningful conversations that can run a little longer than usual if warranted. Family members are often visiting and connections can be made that facilitate better care after discharge. Trust can be built or repaired. Even a long post hospitalization visit with the PCP often can’t accomplish what a good discharge visit with the same PCP could accomplish before the advent of the “hospitalist.”
Those patients that circumstances prohibited me from seeing in the hospital often vocalized a sense of abandonment. I would frequently hear, “I was hoping that you would be able to see me. I kept seeing a different doctor every day. It was so confusing. I don’t really know what happened to me.” As they described their confusion and the dysfunction that they often experienced, I would feel guilty. There were no Mulligans, or “do overs,” on their hospitalization.
Another NEJM article, written by Richard Gunderman, MD in September 2016, says nicely what I have tried to describe from my own perspective from practice:
The hospitalist model has provided such putative benefits as reductions in length of stay, cost of hospitalization, and readmission rates — but these metrics are all defined by the boundaries of the hospital. What we don’t yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians. The increasing number of hospitalists cannot, in and of itself, be taken as conclusive evidence of benefit. Such increases can be driven by a variety of perverse incentives, such as low payment rates for primary care that place a premium on maximizing the number of patients a physician sees in a day and therefore militate against taking the extra time required to see inpatients.
Dr Gunderman gets more specific and hits some of the points to which I have referred:
Practically speaking, increasing the number of physicians involved in a patient’s care creates opportunities for miscommunication and discoordination, particularly at admission and discharge. Gaps between community physicians and hospitalists may result in failures to follow up on test results and treatment recommendations. Moreover, the acute care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion. Studies are under way to see whether these pitfalls can be mitigated, but I suspect the inherent tensions will remain fundamentally irresolvable.
Dr Gunderman tries to be balanced and does not forget patients and families:
…increasing reliance on hospitalists entails a number of risks and costs for everyone involved in the health care system — most critically, for the patients that system is meant to serve. As the number of physicians caring for a patient increases, the depth of the relationship between patient and physician tends to diminish — a phenomenon of particular concern to those who regard the patient–physician relationship as the core of good medical care…
From the patient’s point of view, it can be highly disconcerting to discover that the physician who knows you best will not even see you at your moment of greatest need — when you are in the hospital, facing serious illness or injury. Who is better equipped to abide by an incapacitated patient’s preferences or offer counseling on end-of-life care: a physician with whom the patient is well acquainted or one the patient has only just met? The patient–physician relationship is built largely on trust, and levels of trust are usually lower among strangers.
Dr. Gunderman’s analysis speaks to the centrality that hospitals represent in today’s medicine and the role of the hospitalist that has emerged from that reality. He speaks for me in his closing paragraph:
The true core of good medicine is not an institution but a relationship — a relationship between two human beings. And the better those two human beings know one another, the greater the potential that their relationship will prove effective and fulfilling for both. Models of medicine that ensconce physicians more deeply in spatial and temporal silos only make the prospects for such relationships even dimmer.
It is difficult to hold a whole movement to blame for what in retrospect were defects in the care that my father may have experienced in his multiple hospitalizations over the last year under the care of many different hospitalists, often several on the same admission. Perhaps his steady downhill slide is just a function of disease and his advanced age, but it would have been better for him, better for his wife, and better for his children if his physician of many years had been a guiding influence within the process of his care rather than someone who was forced to try to catch up by reading very good notes in Epic between each complicated and unnecessarily prolonged hospitalization. His knowledge may have been useful in avoiding many of the procedures that were done and may have made sense in a patient of my age, but not for one who was 97.
It is frustrating to realize that like it or not, and I don’t like it, we are “stuck” with the concept of hospitalists. Many PCPs, and certainly those who entered practice after the mid nineties, have lost many of the skills that are required to practice effectively in the hospital. We probably can’t go back and use a Mulligan on the move to hospitalists. The future will be about realizing that we must improve what we have adopted. We need to structure those improvements using patient and family concerns, not finance, as the primary driver for reform. Dr. Anthony DiGioia at the Center for Patient and Family Centered Care at UPMC has shown that making the patient and family experience our primary concern also produces a better financial outcome.
There is another important NEJM article about hospitalists, “Zero to 50,000 — The 20th Anniversary of the Hospitalist.” It appears in the same September issue in which Gunderman’s article appears and was written by Robert Wachter, MD, whom some call the father of “hospitalists” and Lee Goldman, MD who was Wachter’s colleague at UCSF and is now dean of the school of medicine at Columbia University and the CEO of the Columbia Medical Center. Their article reviews much of the history of the hospitalist specialty in a way that is compatible with my experience. They are objective about the pros, cons, knowns, and unknowns of the hospitalist movement. Their article suggests the reality that hospitalists are here to stay. They admit that there is room for improvement:
Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specialization and full-time hospital presence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing systems (e.g., handoff protocols and post-discharge phone calls to patients) to mitigate harm from discontinuity, it remains the model’s Achilles’ heel.
As they concede that there are some problems with the move to use hospitalists, they make some suggestions for improvement:
Although we continue to believe that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it’s clear that today’s pressures require innovative approaches around this core. In addition to following patients in post–acute care facilities, another modified approach is to have a subgroup of hospitalists function as “comprehensivist” physicians who care for a small panel of the highest-risk, most frequently admitted outpatients and remain involved when hospitalization is required. This model aims to blend the advantages of the hospitalist model for the vast majority (>95%) of inpatients with the potential advantages of continuity for a small group of patients who are admitted repeatedly.
We can’t ask for a “Mulligan” on the introduction of hospitalists. They are now one of our largest group of specialists. As Wachter and Goldman demonstrate, the growth has been exponential. “Do overs” aren’t possible, but continuous improvement is. The whole analysis changes if healthcare finance shifts from fee for service to value based reimbursement for population management. The approach would have to change, even if just to modify current hospitalist programs toward an emphasis on improved communications, if patient centeredness became a driving concern. For those who are brave enough to take on the challenge of continuously improving the hospitalist role for all parties, hospitalists, PCPs, families, patients, and CFOs, I would suggest that we not jump to solutions, but rather restructure the analysis and proposed solutions along the lines of the six domains of quality: patient centeredness, safety, efficiency, effectiveness, timeliness, and equity. After considering the issues of quality we can secondarily look at the issues from the perspective of hospitals and professionals. I wish “a better lie” was as easy as taking a Mulligan.
The Milky Way Courtesy of An Interested Reader
I have been to Maine many times, but I have never been to Great Pond in Belgrade. I think that I will stop by Great Pond on a trip that we have planned to Ogunquit in mid October. Joanne Cascella is an Interested Reader who spends a lot of time at Great Pond. She regularly responds to these notes. After I had used a picture of “our” loons as a header back in July, she sent me a fantastic picture taken by a friend of two of “her” loons on Great Pond. In response to the “sunset” picture from Little Lake Sunapee that I used as the header for last week’s note, Joanne sent me another of her friend’s photos that is showcased in this week’s header. I believe that the desire to share what we love is fundamental to building the relationships that form effective coalitions.
Joanne’s picture took my breath away and my immediate response was, “Wow, I need to share this picture with the other “Interested Readers.” I asked Joanne if it would be OK to share the picture with you. She conferred with the photographer, Barbara Johnstone. It was a go.
It occurred to me that posting your great pictures that mean something to you is better than forcing you to see the pictures that I like. So, I hope that you will accept my invitation to share your pictures with me like Joanne has done so that other Interested Readers can see them right here. Only one photo can make the header each week, but I will try to work any picture I receive into the note somewhere, or put it in a queue for a later week. I think it will be fun for me to “riff” on the pictures you send. Autumn is a great time to start because autumn is heaven for photographers. Try taking a walk with your smartphone camera intent on capturing something beautiful, and I will assure you that you will enjoy the walk more.
I could write volumes about the picture that Joanne sent me. It reminds me most of spending hours on a summer night lying on cool grass and getting lost in the stars. One of the reasons I have moved from Eastern Massachusetts with its 4.5 million people to New London, New Hampshire that has a population of 4,500 is light pollution. It’s never really dark in the city. The ambient light makes seeing the Milky Way almost impossible. Belgrade, population 3,189 in 2010, is north and west of Augusta, Maine and is the center of a region of lakes. Great Pond is the largest “pond” in Maine and the largest lake in the region. The “pond” is over 8,500 acres and is seven miles long and is four miles wide at its widest point. The acreage makes it about 20 times larger than my “little lake.” I guess it’s all a matter of perspective.
I hope that you will follow Joanne’s example and send me your favorite pictures!
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
