The Role of a Hospitalist in Oncology Care

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:05provided by Smilow Cancer Hospital.
00:05 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:09with Doctor Anees Chagpar.
00:09 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:14care by welcoming oncologists and
00:14 --> 00:17specialists who are on the forefront
00:17 --> 00:18of the battle to fight cancer.
00:18 --> 00:20This week, it's a conversation
00:20 --> 00:22about the role of a hospitalist
00:22 --> 00:23in oncology care with doctors
00:23 --> 00:26Jensa Morris and Sarah Schellhorn.
00:26 --> 00:28Dr. Morris is director of the
00:28 --> 00:29Smilow Hospitalist Service and Dr.
00:29 --> 00:31Schellhorn is an associate professor
00:31 --> 00:33of medicine and medical oncology at
00:33 --> 00:36the Yale School of Medicine, where Dr.
00:36 --> 00:38Chagpar is a professor of surgical oncology.
00:39 --> 00:42So maybe we can start off with both
00:42 --> 00:44of you telling us a little bit more
00:44 --> 00:46about yourselves and what it is you do.
00:46 --> 00:47Jensa, maybe we'll start
00:47 --> 00:50with you.
00:50 --> 00:54So I'm a hospitalist at Yale New Haven.
00:54 --> 00:57I came to Yale a long time ago,
00:57 --> 00:59in 2002, directly out of my training,
00:59 --> 01:02when hospitalist wasn't really even a word.
01:02 --> 01:05It was a new field. There were
01:05 --> 01:09just 2-3 doctors and about 5
01:09 --> 01:13or 6 physician assistants when we started,
01:13 --> 01:17and the field has grown dramatically.
01:17 --> 01:18It's now an enormous,
01:18 --> 01:20enormous group of hospitals,
01:20 --> 01:21about 100 of us at Yale,
01:21 --> 01:24taking care of
01:24 --> 01:25hospitalized patients.
01:25 --> 01:28And as you're going to learn tonight,
01:28 --> 01:30we've gone from taking care of
01:30 --> 01:32general medicine patients now to
01:32 --> 01:33subspecialties and in particular,
01:33 --> 01:35we're caring for oncology patients
01:35 --> 01:37with our oncology colleagues like Dr.
01:37 --> 01:37Schellhorn.
01:40 --> 01:41Sarah, maybe you
01:41 --> 01:43can tell us a bit more
01:43 --> 01:44about yourself and
01:44 --> 01:46what you do. NOTE Confidence: 0.9353995
01:46 --> 01:48I am a medical oncologist specializing
01:48 --> 01:50in the treatment of breast cancer.
01:50 --> 01:53So breast cancer has several different
01:53 --> 01:56specialties involved in its treatment
01:56 --> 01:59and I'm the medication piece of that.
01:59 --> 02:02I treat, as I said, exclusively breast
02:02 --> 02:04cancer practicing both at Yale
02:04 --> 02:07New Haven Hospital as well as one of
02:07 --> 02:11our outlying Smilow sites in Guilford.
02:11 --> 02:13And I attend on the medical oncology
02:13 --> 02:15service taking care of patients
02:15 --> 02:17who've been hospitalized with cancer
02:17 --> 02:19and complications from cancer
02:19 --> 02:22and its treatment and work closely
02:22 --> 02:24with the oncology hospitalists
02:24 --> 02:27like Doctor Morris to provide the
02:27 --> 02:29subspecialty piece of hospital care.
02:31 --> 02:33So Jensa to go back to what
02:33 --> 02:36you were talking about at the top,
02:36 --> 02:39it might be somewhat of a foreign concept,
02:39 --> 02:41this idea of a hospitalist.
02:41 --> 02:43I mean, many people may understand
02:43 --> 02:45the concept of having a doctor.
02:45 --> 02:47And if you're a cancer patient,
02:47 --> 02:50you likely have an oncologist
02:50 --> 02:52or a team of oncologists.
02:52 --> 02:55And for many, they may think,
02:55 --> 02:58my doctor is going to take care
02:58 --> 03:01of me whether I'm in the hospital
03:01 --> 03:04or whether I'm an outpatient or
03:04 --> 03:06sometimes even when I'm at home.
03:06 --> 03:08Has that concept changed and can
03:08 --> 03:11you talk a little bit more about
03:11 --> 03:13how a hospitalist fits into that?
03:14 --> 03:17Yes, there's a little bit of
03:17 --> 03:19history that's important here.
03:19 --> 03:22So to take you back and it's
03:22 --> 03:24really not in the distant past,
03:25 --> 03:28but the model used to be that a primary
03:28 --> 03:31care doctor would come into the
03:31 --> 03:32hospital in early morning round
03:32 --> 03:34on his or her patients and then
03:34 --> 03:36go back to their clinic and see
03:36 --> 03:38all their patients all day long
03:38 --> 03:39in their office and then perhaps
03:39 --> 03:42come back at the end of the day to
03:42 --> 03:44see their hospitalized patients.
03:44 --> 03:48And that became absolutely unmanageable.
03:48 --> 03:52The pace of care in the hospital ramped
03:52 --> 03:55up, the number of tests and treatments,
03:55 --> 03:57that amount of communication
03:57 --> 03:58required with patients, families,
03:58 --> 03:59with subspecialists.
03:59 --> 04:02It just couldn't be managed in
04:02 --> 04:03half an hour in the morning and
04:03 --> 04:05half an hour in the evening.
04:05 --> 04:06And that's sort of how the
04:06 --> 04:08hospitalists as a field developed.
04:08 --> 04:10We are physicians who live and
04:10 --> 04:12work exclusively in the hospital,
04:12 --> 04:14provide all that complex inpatient
04:14 --> 04:15care and work really,
04:15 --> 04:17really closely with the
04:17 --> 04:19docs who know the patients best.
04:19 --> 04:21They're outpatient doctors.
04:21 --> 04:23That's how it developed in
04:23 --> 04:25a general medicine setting.
04:25 --> 04:27But of course,
04:27 --> 04:31it quickly became obvious that this could
04:31 --> 04:33be applied in subspecialty settings.
04:33 --> 04:37Most large cancer centers now have
04:37 --> 04:40oncology hospitalists who are internal
04:40 --> 04:42medicine doctors generally who really
04:42 --> 04:45have an interest in oncology care
04:45 --> 04:47and spend all their time caring
04:47 --> 04:49for the patients who are admitted
04:49 --> 04:52with complications of their cancer
04:52 --> 04:54or the treatment for their cancer.
04:54 --> 04:56And in our case,
04:56 --> 04:59we are there all day long at the
04:59 --> 05:01bedside from 7:00 AM to 7:00 PM
05:01 --> 05:04working extremely closely with
05:04 --> 05:06the patient's primary oncologist.
05:06 --> 05:07But the primary oncologist simply
05:07 --> 05:09can't be there all day long.
05:09 --> 05:11They have patients to care for in clinic.
05:11 --> 05:12They have labs to run,
05:12 --> 05:13research to do,
05:13 --> 05:17to continue to push the field forward.
05:17 --> 05:19Sarah, what do you have to add there?
05:21 --> 05:23I can add to that a little bit.
05:23 --> 05:27I think there's a lot that
05:27 --> 05:29can happen in the hospital,
05:29 --> 05:31some of which is related to cancer,
05:31 --> 05:33some of which is related to the cancer
05:33 --> 05:35treatment and some of which is unrelated.
05:35 --> 05:39And the pace of the field has rapidly
05:39 --> 05:42picked up over the last decade such
05:42 --> 05:45that there are a lot of complicated
05:45 --> 05:47medical issues happening
05:47 --> 05:48in the hospital
05:48 --> 05:51and to our patients who are living
05:51 --> 05:54longer and longer with cancer that the
05:54 --> 05:57oncologists simply can't keep up with
05:57 --> 05:59because it's a field outside of oncology.
05:59 --> 06:02So you think about cardiac complications.
06:02 --> 06:05Well, it's been now more than 15 years since
06:05 --> 06:08I cared for somebody with a cardiologic
06:08 --> 06:11issue in the hospital or
06:11 --> 06:12endocrinology type problems
06:12 --> 06:15that require really dedicated
06:15 --> 06:17endocrinologists to be involved.
06:17 --> 06:19I haven't cared for someone like
06:19 --> 06:20that in in a very long time.
06:20 --> 06:23So the benefit in my
06:23 --> 06:26mind is not only
06:26 --> 06:27the ability of the hospital
06:27 --> 06:29to be present for the patient and
06:29 --> 06:31their families and to communicate
06:31 --> 06:32closely with us as oncologists,
06:32 --> 06:35but to really be much more in tune with
06:35 --> 06:38all of the medical issues that a
06:38 --> 06:40patient might be facing and being able
06:40 --> 06:43to provide a more comprehensive big
06:43 --> 06:46picture view of what's happening and
06:46 --> 06:48keeping the patient in the hospital.
06:50 --> 06:52Yeah, I think medicine is catching
06:52 --> 06:54up to the rest of the world and
06:54 --> 06:56understanding that team based approach
06:56 --> 06:59is the way to go, that we
06:59 --> 07:00can't know everything and we
07:00 --> 07:03need each other to provide the best
07:03 --> 07:05possible care for our patients.
07:06 --> 07:07So Sarah,
07:07 --> 07:09when we think about oncologists
07:09 --> 07:12and the relationship that patients
07:12 --> 07:14have with their oncologist,
07:14 --> 07:18it tends to be a very close relationship.
07:18 --> 07:22And so how do you find patients
07:22 --> 07:24adjust to this idea?
07:24 --> 07:26I mean, it sounds like you're very
07:26 --> 07:29happy with the idea that
07:29 --> 07:33you've got a partner in the hospital
07:33 --> 07:35as a hospitalist who's taking care
07:35 --> 07:38of these myriad of other issues
07:38 --> 07:41that can affect cancer patients.
07:41 --> 07:43Do patients see it the same way?
07:43 --> 07:46Do they appreciate the fact that
07:46 --> 07:47when they're in the hospital,
07:47 --> 07:49Jensa is going to be taking care of them,
07:49 --> 07:52but when they get out of the hospital,
07:52 --> 07:55they can have you continue to care for them.
07:55 --> 07:58I think patients really do
07:58 --> 08:00appreciate it once it's explained.
08:00 --> 08:02It's not that I'm no longer their doctor,
08:02 --> 08:04it's that I'm not the doctor
08:04 --> 08:05responsible for all of their care
08:05 --> 08:08that's keeping them or their care
08:08 --> 08:09that's going on in the hospital.
08:09 --> 08:14So it's a matter
08:14 --> 08:17of explanation and I like to go in
08:17 --> 08:19and see patients with the hospitalist
08:19 --> 08:21and we kind of introduce it as
08:21 --> 08:23I'm still your oncologist and I'm
08:23 --> 08:25responsible for your cancer treatment.
08:25 --> 08:29But the reason that you are in the
08:29 --> 08:32hospital is XY and Z and Doctor Morris
08:32 --> 08:35or another doctor
08:35 --> 08:37who are many of our hospitalists is
08:37 --> 08:39going to be the person who's going
08:39 --> 08:41to touch base with you every day,
08:41 --> 08:42who's going to be examining you,
08:42 --> 08:44is going to be reviewing every
08:44 --> 08:46single thing that happens to you in
08:46 --> 08:48the hospital and is responsible for
08:48 --> 08:51getting this acute issue dealt with
08:51 --> 08:54and then planning for your discharge.
08:54 --> 08:56Patients I think really understand
08:56 --> 08:58that and they understand the complexity
08:58 --> 08:59of medical care in general.
09:02 --> 09:03And Jensa,
09:03 --> 09:06the flip side of that too is that
09:06 --> 09:09while you may be caring for that
09:09 --> 09:10patient while they're in the
09:10 --> 09:12hospital with the myriad of medical
09:12 --> 09:14problems that they may face,
09:14 --> 09:16ultimately that patient is going to
09:16 --> 09:19be discharged and when they come back,
09:19 --> 09:21if they come back,
09:21 --> 09:25they may have a different hospitalist.
09:25 --> 09:29And when they leave the hospital,
09:29 --> 09:32there's a lot of coordination that needs to
09:32 --> 09:35happen both with their oncologist as well as,
09:35 --> 09:37for example, their cardiologist,
09:37 --> 09:38their nephrologist,
09:38 --> 09:40their endocrinologist to take care
09:40 --> 09:42of that whole myriad of problems
09:42 --> 09:44that Sarah was talking about.
09:44 --> 09:47How does it feel from a hospitalist
09:47 --> 09:48standpoint in terms of
09:49 --> 09:51not being involved in the longterm
09:51 --> 09:53care of that patient and what
09:53 --> 09:55are the complexities of really
09:55 --> 09:57coordinating care with all of
09:57 --> 09:59these other physicians who will
09:59 --> 10:02have to carry the baton after the
10:02 --> 10:04patient's hospitalization is over?
10:05 --> 10:08So I think there are two parts to that
10:08 --> 10:10and one part is the question that a
10:10 --> 10:13lot of physicians ask,
10:13 --> 10:16what is the satisfaction in that
10:16 --> 10:18curtailed relationship when it's
10:18 --> 10:21not a longitudinal relationship.
10:21 --> 10:22And I think the satisfaction is
10:22 --> 10:24being there for someone in the real
10:24 --> 10:26time of crisis because when you're
10:26 --> 10:28hospitalized that is really the worst,
10:28 --> 10:29the most challenging time.
10:29 --> 10:31And there's a lot of satisfaction
10:31 --> 10:33to truly being at the bedside in
10:33 --> 10:36that worst possible time and really
10:36 --> 10:38having the conversations and making it
10:38 --> 10:40just a little bit easier for people.
10:40 --> 10:42And then when things are really bad and
10:42 --> 10:45we have to have the conversations about
10:45 --> 10:48prognosis and how much time
10:48 --> 10:51is left and to be able to work with
10:51 --> 10:55patients and families and give the gift
10:55 --> 10:58of honesty and kindness and empathy,
10:58 --> 11:00that's really important to me and
11:00 --> 11:02that makes the job very fulfilling.
11:02 --> 11:05The other part is you're absolutely right.
11:05 --> 11:08There sure is a lot of coordination
11:08 --> 11:08and communication.
11:08 --> 11:10I mean I spend my entire day
11:12 --> 11:14talking to other physicians,
11:14 --> 11:16talking to the patients,
11:16 --> 11:17triangulating with the nurse and
11:17 --> 11:19the family members and all day
11:19 --> 11:22long is spent on the phone and at
11:22 --> 11:26late hours of the night
11:26 --> 11:28I'm talking to the oncologists who
11:28 --> 11:30are still working and still in clinic
11:30 --> 11:32and we're at the bedside and
11:32 --> 11:34sometimes we're bringing the oncologist
11:34 --> 11:36into the conversation at the bedside
11:36 --> 11:38either by FaceTime or by other means.
11:38 --> 11:39And so yes,
11:39 --> 11:42that is a key part of our job is all
11:42 --> 11:44that interdisciplinary communication.
11:45 --> 11:48Our hospitals are really a special group.
11:48 --> 11:51They have tremendous skill in communication,
11:51 --> 11:52not just with patients but
11:52 --> 11:53with other clinicians.
11:53 --> 11:56They have an ability to see the big
11:56 --> 11:58picture which sometimes gets lost when
11:58 --> 12:01we think about a single specialty.
12:01 --> 12:03They're tremendously organized which
12:03 --> 12:07you kind of have to be in order to
12:07 --> 12:10to take care of all of these various
12:10 --> 12:13issues and they're incredibly
12:13 --> 12:17empathetic and spend time and love
12:17 --> 12:20talking to patients and their family
12:20 --> 12:22members and help with transitions
12:22 --> 12:24of care at whatever point the
12:24 --> 12:26patient is along the cancer journey.
12:27 --> 12:30And we couldn't do it without you
12:30 --> 12:32helping us along and reminding us of
12:32 --> 12:34all the things we may have forgotten.
12:36 --> 12:37So Jensa, you know,
12:37 --> 12:39one of the things that you mentioned is
12:39 --> 12:42that you spend all day, every day in
12:42 --> 12:46the hospital from 7:00 AM to 7:00 PM.
12:46 --> 12:48But one of the questions that our
12:48 --> 12:50listeners might have is, well,
12:50 --> 12:51who's looking after them the
12:51 --> 12:54other 12 hours of the day,
12:54 --> 12:56the 7:00 PM to 7:00 AM?
12:56 --> 12:59Do they have a different hospitalist
12:59 --> 13:02or is that really the purview of the
13:02 --> 13:05nursing staff and the house staff
13:05 --> 13:08or do they call you after hours?
13:08 --> 13:09How does that work?
13:11 --> 13:14So we do have night hospitalists as
13:14 --> 13:16well and they would be taking care
13:16 --> 13:19of the patients taking over the
13:19 --> 13:22baton pass off from 7:00 PM to 7:00
13:22 --> 13:24AM and they're following up on things
13:24 --> 13:26that have happened during the day.
13:26 --> 13:28They're following up on any
13:28 --> 13:30recommendations that may have
13:30 --> 13:32been placed by other teams.
13:32 --> 13:34They're handling urgent situations
13:34 --> 13:36that may happen overnight.
13:36 --> 13:37They're continuing
13:37 --> 13:38to communicate with families.
13:38 --> 13:40There really is just a
13:40 --> 13:42continuity of that same care that's
13:42 --> 13:44provided during the day.
13:44 --> 13:44Terrific.
13:45 --> 13:46Well, we're going to take a short
13:46 --> 13:48break for a medical minute.
13:48 --> 13:50Please stay tuned to learn more about the
13:50 --> 13:52role of a hospitalist with my guests, Dr.
13:52 --> 13:55Jensa Morris and Sarah Schellhorn.
13:55 --> 13:57Funding for Yale Cancer Answers
13:57 --> 13:59comes from Smilow Cancer Hospital,
13:59 --> 14:01where their hematology program
14:01 --> 14:03offers diagnosis and treatment of
14:03 --> 14:05blood cancers including lymphoma,
14:05 --> 14:07leukemia, and myeloma.
14:09 --> 14:10More at smilowcancerhospital.org or
14:10 --> 14:13e-mail Cancer Answers at yale.edu
14:15 --> 14:18The American Cancer Society estimates
14:18 --> 14:21that nearly 150,000 people in the US
14:21 --> 14:23will be diagnosed with colorectal cancer
14:23 --> 14:25this year alone. When detected early,
14:25 --> 14:27colorectal cancer is easily
14:27 --> 14:29treated and highly curable,
14:29 --> 14:31and men and women over the age of
14:31 --> 14:3345 should have regular colonoscopies
14:33 --> 14:35to screen for the disease.
14:35 --> 14:37Patients with colorectal cancer have
14:37 --> 14:39more hope than ever before thanks
14:39 --> 14:41to increased access to advanced
14:41 --> 14:43therapies and specialized care.
14:43 --> 14:45Clinical trials are currently
14:45 --> 14:47underway at federally designated
14:47 --> 14:49comprehensive cancer centers such
14:49 --> 14:51at Yale Cancer Center and Smilow
14:51 --> 14:53Cancer Hospital to test innovative
14:53 --> 14:55new treatments for colorectal cancer.
14:55 --> 14:58Tumor gene analysis has helped improve
14:58 --> 15:01management of colorectal cancer by
15:01 --> 15:03identifying the patients most likely
15:03 --> 15:05to benefit from chemotherapy and
15:05 --> 15:07newer targeted agents resulting in
15:07 --> 15:09more patient specific treatment.
15:09 --> 15:12More information is available
15:12 --> 15:13at yalecancercenter.org.
15:13 --> 15:15You're listening to Connecticut Public Radio.
15:16 --> 15:18Welcome back to Yale Cancer Answers.
15:18 --> 15:20This is Doctor Anees Chagpar,
15:20 --> 15:23and I'm joined tonight by my guests, Dr.
15:23 --> 15:25Jensa Morris and Sarah Schellhorn.
15:25 --> 15:27We're talking about the role
15:27 --> 15:29of an inpatient hospitalist.
15:29 --> 15:32And right before the break, Jensa,
15:32 --> 15:35you were talking about the idea that,
15:35 --> 15:37you know, hospitalists are really there
15:37 --> 15:42to be kind of the extension of the
15:42 --> 15:45patient's oncologist and their internist,
15:45 --> 15:47their cardiologist,
15:47 --> 15:48their endocrinologist.
15:48 --> 15:51They're really there to help these
15:51 --> 15:53patients at a time when they are
15:53 --> 15:56in the most need of this kind of
15:56 --> 15:59coordinated care and provide them
15:59 --> 16:02that care in that hour of need.
16:02 --> 16:06And it really seems to me that
16:06 --> 16:09the hospitalist really is at the
16:09 --> 16:11center of coordinating this and
16:11 --> 16:14not only communicating back to the
16:14 --> 16:17patient's regular oncologist and
16:17 --> 16:18other healthcare professionals,
16:18 --> 16:21but then there's also a
16:21 --> 16:21nighttime hospitalist.
16:21 --> 16:24So can you talk a little bit about the
16:24 --> 16:26handoff that occurs between the daytime
16:26 --> 16:28hospitalist and the nighttime hospitalist?
16:28 --> 16:31I mean, do patients feel like,
16:31 --> 16:33you know, I'm kind of
16:33 --> 16:35I don't know who my doctor is because
16:35 --> 16:37at 7:00 AM my doctor might be doctor X,
16:37 --> 16:39but at 7:00 PM,
16:39 --> 16:41my doctor might be doctor Y.
16:41 --> 16:43And then when I get out of the hospital,
16:43 --> 16:44my doctor is doctor Z?
16:46 --> 16:49I think you bring up a
16:49 --> 16:50really important point.
16:50 --> 16:54I worry the most about fragmentation of care.
16:54 --> 16:59I think that is the highest risk for
16:59 --> 17:04poor quality safety outcomes.
17:04 --> 17:07It's certainly alienating for the
17:07 --> 17:10patient to not know who is my doctor
17:10 --> 17:14and can I trust them that I think
17:14 --> 17:16that's definitely the biggest concern
17:16 --> 17:19in how we practice medicine is yes,
17:19 --> 17:20we absolutely need the expertise
17:20 --> 17:22of all these different people who
17:22 --> 17:24have different knowledge and skills.
17:24 --> 17:26And yes, we need to work as a team.
17:26 --> 17:28But how confusing is that for the patient
17:28 --> 17:30when there are different physicians
17:30 --> 17:32coming in and out all day long,
17:32 --> 17:34day and night?
17:34 --> 17:40Hopefully we can do some things to ease that.
17:40 --> 17:44One is that our doctors work 12 hours.
17:44 --> 17:45They work seven days straight.
17:45 --> 17:47Yes, it's extremely demanding
17:47 --> 17:48for the physicians,
17:48 --> 17:50but it means that there's great
17:50 --> 17:52continuity with the patients.
17:52 --> 17:53They are there and they're
17:53 --> 17:55truly there day in and
17:55 --> 17:56day out. And in all fairness,
17:56 --> 17:57then they have seven days off.
17:59 --> 18:00Yes, indeed. And
18:00 --> 18:03so they work 80 hours and
18:03 --> 18:05we call it a compressed workweek.
18:05 --> 18:07But I think it benefits the patient
18:07 --> 18:09that kind of compressed workweek because
18:09 --> 18:11there are fewer comings and goings.
18:11 --> 18:13And the same applies to the
18:13 --> 18:14nighttime hospitalists that are
18:14 --> 18:16there for that full 12 hour time.
18:17 --> 18:20Often times the hospitalists kind of
18:20 --> 18:22alternate. So it might be a pair of
18:22 --> 18:24hospitalists 1 takes the first week,
18:24 --> 18:26the second takes the second week and then
18:26 --> 18:27back to the first one for the third week.
18:27 --> 18:29So for someone who has a prolonged
18:29 --> 18:31hospitalization, they'll often see
18:31 --> 18:33the same people time and time again.
18:33 --> 18:34And there are a limited
18:34 --> 18:35number of hospitalists.
18:35 --> 18:37So for people that are
18:37 --> 18:39admitted multiple times,
18:39 --> 18:42they can end up seeing the same doctor.
18:45 --> 18:48I'd love to ask Jensa a question,
18:48 --> 18:51the hospitalists have been
18:51 --> 18:53around now for a couple of years.
18:53 --> 18:57What changes have we seen in the care of
18:57 --> 19:00our patients and are we improving
19:00 --> 19:03on anything for those patients who are
19:03 --> 19:04in the hospital with cancer related issues?
19:04 --> 19:06The program was developed
19:06 --> 19:10with a few goals in mind and one
19:10 --> 19:12of the goals was certainly that
19:12 --> 19:14nobody wants to be in the hospital.
19:14 --> 19:16The hospital is
19:16 --> 19:17the absolute worst place to be.
19:17 --> 19:19As much as we try to make it a
19:19 --> 19:21kind and welcoming environment,
19:21 --> 19:23nobody wants to be here and
19:23 --> 19:24certainly nobody wants to be here
19:24 --> 19:26any longer than they have to be.
19:26 --> 19:29And so one of the goals was
19:29 --> 19:30to expedite patients care,
19:30 --> 19:33how to get the work done,
19:33 --> 19:36get the tests done, intervene,
19:36 --> 19:38get patients better so that
19:38 --> 19:39they can get home.
19:39 --> 19:41And you know in medical terms
19:41 --> 19:43we call that length of stay,
19:43 --> 19:45how can we reduce the time patients
19:45 --> 19:46are spending in the hospital.
19:46 --> 19:47And the flip side, of course,
19:47 --> 19:49is to increase the time that
19:49 --> 19:50they're spending at home.
19:50 --> 19:52And we did see significant reductions
19:52 --> 19:54in length of stay with hospitalists.
19:54 --> 19:55And it makes perfect sense.
19:55 --> 19:57If you're there all day long,
19:57 --> 19:59you can keep pushing the care forward.
19:59 --> 20:01You get a result at noon.
20:01 --> 20:03You can order the next test or get
20:03 --> 20:05the consultant in by 2:00 PM and you
20:05 --> 20:07can keep moving things forward and
20:07 --> 20:10perhaps the patient can go home by 6:00 PM.
20:10 --> 20:13So that's sort of the natural
20:13 --> 20:15effect of having hospitalists.
20:15 --> 20:17There was another effect
20:17 --> 20:20that we hadn't anticipated.
20:20 --> 20:23And that was that hospitalists
20:23 --> 20:25were able to work really closely
20:25 --> 20:27with the patients and
20:27 --> 20:28sometimes have some difficult
20:28 --> 20:30conversations in the hospital,
20:30 --> 20:31conversations that really require
20:31 --> 20:33a lot of time.
20:33 --> 20:36Really the whole family needs to be
20:36 --> 20:38present to talk about end of life care,
20:38 --> 20:41about how people want to spend
20:41 --> 20:42their remaining time.
20:42 --> 20:44Sometimes those conversations either
20:44 --> 20:46aren't appropriate in the outpatient
20:46 --> 20:48setting because patients are doing great,
20:48 --> 20:50we don't need to have this
20:50 --> 20:51conversation or perhaps there
20:51 --> 20:53just isn't time because we've got
20:53 --> 20:54to talk about chemotherapy,
20:54 --> 20:55we've got to sign a consent.
20:55 --> 20:57And there's so many other things that
20:57 --> 21:00have to be done in that brief 30 minute,
21:00 --> 21:0215 minute appointment as an outpatient
21:02 --> 21:05that we can do on the inpatient
21:05 --> 21:07side that because we have the time.
21:07 --> 21:10And what we found as a result was
21:10 --> 21:13patients were opting at much higher
21:13 --> 21:15rate to choose less aggressive care,
21:15 --> 21:18to choose palliative care and
21:18 --> 21:21sometimes to choose to discontinue
21:21 --> 21:23care and pursue Hospice.
21:23 --> 21:24And we actually perceive that to
21:24 --> 21:26be a good effect of the hospitalist
21:26 --> 21:28program because
21:28 --> 21:30we're allowing patients to choose
21:30 --> 21:32how they will spend their time.
21:33 --> 21:35And oftentimes especially near
21:35 --> 21:39the end of life in someone with
21:39 --> 21:42an aggressive Stage 4 cancer,
21:42 --> 21:45spending time and discussing what's
21:45 --> 21:47the likely benefit of therapy or
21:47 --> 21:50what are the likely harms of therapy
21:50 --> 21:52and what's important to a patient.
21:52 --> 21:56And really spending that time discussing
21:56 --> 21:59all possible potential therapeutic
21:59 --> 22:02options including Hospice is as Jensa
22:02 --> 22:05said time consuming but so valuable.
22:05 --> 22:07And once those
22:07 --> 22:08conversations can happen,
22:08 --> 22:11oftentimes patients make very personal,
22:11 --> 22:14very difficult decisions.
22:16 --> 22:18The oncology group also feels that
22:18 --> 22:20not only is decreasing length
22:20 --> 22:22of stay incredibly important,
22:22 --> 22:23we want patients to spend time where
22:23 --> 22:25they want to spend time and most of
22:25 --> 22:27the time that's not in the hospital.
22:27 --> 22:28And
22:30 --> 22:35improving the numbers of patients
22:35 --> 22:37who may or increasing the number of
22:37 --> 22:40patients who may choose less aggressive
22:40 --> 22:42options makes it so that patients
22:42 --> 22:43aren't faced with really difficult
22:43 --> 22:45decisions while being in the hospital.
22:45 --> 22:49I mean we never want anybody to die
22:49 --> 22:51in the hospital getting chemotherapy if
22:51 --> 22:54that's not consistent with their wishes.
22:54 --> 22:55We want their wishes to be
22:55 --> 22:57honored as much as possible.
22:57 --> 23:00So these are both really important
23:00 --> 23:01improvements that the hospitalist
23:01 --> 23:04program has given to our Cancer Center.
23:05 --> 23:07And certainly,
23:07 --> 23:09it sounds like especially
23:09 --> 23:12reducing the length of stay would
23:12 --> 23:15improve patients quality of life.
23:15 --> 23:18I mean, have you gotten feedback
23:18 --> 23:21from patients either in a rigorous
23:21 --> 23:24study where you've actually looked at
23:24 --> 23:27quality of life before and after an
23:27 --> 23:31intervention with a hospitalist or even
23:31 --> 23:34anecdotal data from patients about
23:34 --> 23:38how they perceive their quality of
23:38 --> 23:41life to have improved or not so much?
23:42 --> 23:44I don't think that there have
23:44 --> 23:46been any truly robust scientific
23:46 --> 23:47randomized trials looking at
23:47 --> 23:50quality of life before and after the
23:50 --> 23:52implementation of a hospitals program.
23:52 --> 23:54But I think that the length of stay
23:54 --> 23:56data speaks for itself because one's
23:56 --> 23:58own bed is more more comfortable than
23:58 --> 24:01a hospital bed any day of the week.
24:01 --> 24:04And one's own home environment
24:04 --> 24:07with their own TV and their own cable
24:07 --> 24:10and their sole control of the remote
24:10 --> 24:12is far more comfortable than having
24:12 --> 24:16to watch QVC in the hospital or
24:16 --> 24:19whatever else is on and
24:19 --> 24:22being able to be visited by whomever,
24:22 --> 24:24whenever at whatever time and not
24:24 --> 24:27limited to the restrictions of visitor
24:27 --> 24:28policies especially now coming out
24:28 --> 24:31of a three-year long pandemic where
24:31 --> 24:33there were pretty stringent visitor
24:33 --> 24:35policies is far more comfortable
24:35 --> 24:37than than the alternate.
24:37 --> 24:40So I don't think that there's any doubt
24:40 --> 24:42that this has improved patients lives.
24:42 --> 24:44I think that's a very difficult
24:44 --> 24:45metric to capture.
24:47 --> 24:50And certainly you know
24:50 --> 24:53the flip side of having too many
24:53 --> 24:55visitors in hospital with the nursing
24:55 --> 24:57staff coming in every four hours
24:57 --> 24:58to do vitals and so on and so forth
24:59 --> 25:01and bells and whistles and sounds.
25:01 --> 25:04And yes, it's just not a pleasant
25:04 --> 25:07place to to have to spend time,
25:07 --> 25:09especially when the amount of time
25:09 --> 25:11that one might have left is limited.
25:12 --> 25:16Have either of you had patients
25:16 --> 25:19tell you stories about their experiences
25:19 --> 25:21with hospitalists that you might
25:21 --> 25:23want to share with our audience to
25:23 --> 25:25kind of give us a flavor of what a
25:25 --> 25:27patient's experience might be like?
25:27 --> 25:29I've already alluded to to one of
25:29 --> 25:31my dear patients that I've cared for
25:31 --> 25:33for many years who's been in and out
25:33 --> 25:35of the hospital over the last year,
25:35 --> 25:40who's had the same hospitalist and who I
25:40 --> 25:44think basically trusts that hospitalist
25:44 --> 25:49more than she trusts most of her doctors
25:49 --> 25:54and really raves about that hospitalist.
25:54 --> 25:57I will share another anecdote.
25:57 --> 25:59I spoke to one of the hospitalists,
25:59 --> 26:02Doctor Parker, this morning about a patient
26:02 --> 26:04of mine who's currently hospitalized
26:04 --> 26:07with a complication of her treatment.
26:07 --> 26:11And we quickly reviewed all of the damaging
26:11 --> 26:13that had been done over the last day or two.
26:13 --> 26:15We reviewed all of the testing and the
26:15 --> 26:17plan for getting the patient out of the
26:17 --> 26:19hospital and then I was able to go talk
26:19 --> 26:21to the patient specifically about it
26:21 --> 26:22sounds like things are getting better.
26:23 --> 26:25Here's the plan from a hospitalist
26:25 --> 26:27standpoint or from a what's keeping
26:27 --> 26:29you in the hospital standpoint.
26:29 --> 26:33And and here's the plan for when you come
26:33 --> 26:36see me in the clinic to talk about how
26:36 --> 26:38we're going to adjust your treatment.
26:38 --> 26:42And she is certainly not happy
26:42 --> 26:43to still be in the hospital,
26:43 --> 26:45but she really appreciates how
26:45 --> 26:46things were expedited.
26:46 --> 26:50And I know Doctor Parker did
26:50 --> 26:52a tremendous job to move up one of
26:52 --> 26:54the tests to get it done quickly
26:54 --> 26:55and we were able to review it.
26:55 --> 26:58And so her care has been pushed
26:58 --> 27:01forward as as Doctor Morris indicated,
27:01 --> 27:04we're able to move things every,
27:05 --> 27:07you know every hour the care is
27:07 --> 27:08moving toward getting the patient
27:08 --> 27:10out of the hospital.
27:10 --> 27:12It's really a tremendous
27:12 --> 27:14add to the hospital care of
27:14 --> 27:16our patients with cancer.
27:16 --> 27:19And I'm so grateful to have the
27:19 --> 27:21opportunity to get to know Doctor
27:21 --> 27:23Morris and her colleagues and
27:23 --> 27:25to have them care for my patients.
27:25 --> 27:26They're getting fantastic care.
27:28 --> 27:29You know, Jensa,
27:29 --> 27:31to Sarah's point though,
27:31 --> 27:33with that patient who has
27:33 --> 27:35her favorite hospitalist,
27:35 --> 27:37it's fortunate that she was able to
27:37 --> 27:40see the same hospitalist on the two
27:40 --> 27:41occasions that she was in hospital.
27:41 --> 27:44But at the beginning of the show,
27:44 --> 27:45you had mentioned that there
27:45 --> 27:47are so many hospitalists now,
27:47 --> 27:49one would think that that
27:49 --> 27:50would be a rarity, right?
27:50 --> 27:52So we were lucky.
27:52 --> 27:55The general medicine hospital program
27:55 --> 27:58by necessity had to expand very fast.
27:58 --> 28:02We were able to build a small niche
28:02 --> 28:05boutique hospitalist firm over in Smilow.
28:05 --> 28:08And because we're small,
28:08 --> 28:12we have about 12 hospitalists now
28:12 --> 28:15and working every other week.
28:15 --> 28:17So really it's six hospitals a day,
28:17 --> 28:20five to six hospitalists a day who are working.
28:20 --> 28:21And because of that,
28:21 --> 28:23it is actually quite likely that
28:23 --> 28:26we will see a lot of the same patients
28:26 --> 28:28and the same patients will see us.
28:28 --> 28:31Doctor Jensa Morris is director of
28:31 --> 28:32the Smilow Hospitalist Service and
28:32 --> 28:35Doctor Sarah Schellhorn is an associate
28:35 --> 28:36professor of medicine and Medical
28:36 --> 28:39oncology at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

Information

The Role of a Hospitalist in Oncology Care with guests Drs. Jensa Morris and Sarah Schellhorn September 3, 2023 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095