Daniel J. Brotman, M.D. - Understanding where patient load meets personal responsibility

For the last 8 years, Dr. Daniel J. Brotman has been the director of the hospitalist program at Johns Hopkins Hospital in Baltimore. In that role, he’s expanded the program to include 24/7 coverage of the hospital, deployed a bedside procedure service, and developed formal comanagement services with colleagues in gastroenterology and hematology. And he still finds time to mentor residents, fellows, and faculty members in their research interests.

Dr. Brotman, who has been hailed as a pioneer in building the academic credentials of the hospitalist field, recently collaborated with Dr. Henry Michtalik, a hospitalist and assistant professor of medicine at Johns Hopkins, on the impact of physician workload on safety. The striking results – that 40% of hospitalists think their workload exceeds what they can safely handle – were published in the March 11 issue of JAMA Internal Medicine (2013;173:375-7).

In an interview with Hospitalist News, Dr. Brotman explained why the results are important and how the Affordable Care Act may affect workload pressures.

Question: The survey results that you and your colleagues published back in March reflect physician perceptions, but do we know for sure if safety has been compromised because of high patient loads?

Dr. Brotman: The fact that these are self-reported data is fundamentally important. We did not measure specific outcomes. But it’s important to recognize that in the safety literature, not just in medicine but across the board, the impressions of front-line providers are very important. When you’re dealing with front-line providers who feel like what they’re doing is potentially unsafe, that is an important indicator that in fact there are real safety risks.

The extent to which system redundancies and smartly designed back-up systems can prevent actual harm from reaching the patient is going to obviously vary from place to place. But there is nobody, aside from the front-line provider, who is in a better position to judge near-misses. This is a real issue.

Question: How can hospitalists and administrators work together to create a safer environment?

Dr. Brotman: What isn’t going to work is simply cutting patient loads for the sake of cutting patient loads. There are differing personal standards that people expect from themselves.

Hospitalists are human. It’s only natural that some folks will decide, if they have a lower load, that they’d rather go home early and spend time with their children than spend that extra time to communicate better with the referring provider or go back and see that quasi-stable patient that made them a little nervous in the morning. [But] there are some physicians who just do that stuff, and they do it ... because they feel like they have to or they won’t sleep well at night.

Ultimately, you cannot make a direct connection between lightening patient load and improving quality of care unless you are holding people accountable for the quality of care they are providing at the same time.

Question: Speaking of accountability, how is the Affordable Care Act likely to have an impact on this issue?

Dr. Brotman: I am personally delighted that our health care system is being forced through legislation to think about the value proposition as opposed to the quantity proposition. It forces providers and institutions to be accountable to patient health, not only when the patient is under their care directly but also throughout the continuum of care.

The Affordable Care Act is not a panacea for fixing our health care challenges in this country, but it is a good start. There will be more and more legislation coming down the pike and more and more investment in concepts like accountable care that will fundamentally change the incentive structure within our health care system.

The Affordable Care Act is a landmark piece of legislation and a wake-up call to our health care system that we need to be thinking about patients across the whole continuum of care, paying attention to the quality and efficiency of what we’re doing, not just the quantity.

Question: Will you be continuing your research in this area?

Dr. Brotman: There’s another piece of work I did recently with Dr. Lenny Feldman in our group looking at the impact of cost transparency on the ordering provider on how we order diagnostic tests (JAMA Intern. Med. 2013;173:903-8). That’s an important angle to bending the cost curve.

In terms of the work in the area of staffing levels, we would like to connect staffing levels to outcomes using a broader sample and extend this from a self-report study to something that has more teeth. One of the ways to do that is to capitalize on the fact that there are actual variations at any given institution in the total workload imposed on hospitalists.