Chapter 13: Emergency Medicine and the Hospitalist Service
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Description
In this chapter, Dr. Tweardy talks about a major initiative he undertook on becoming division head: building the institution’s emergency medicine readiness and hospitalist service. He begins by explaining that the medical management of acutely ill patients is a challenge and that when he arrived in 2014, the institution was not addressing this as effectively as it should be, even though the emergency center was established in 2012. Dr. Tweardy explains that he wanted to institution to deliver not only the best cancer care, but the best onco-medical care then talks about developing hospitalist and emergency services.
Next, Dr. Tweardy comments on the resistance to emergency services and instances of the institution’s conservative thinking about the treatment of acute patients. He observes that it can be helpful to have an outsider bring in a new perspective and a new way of organizing functions.
Identifier
TweardyDJ_03_20190418_C13
Publication Date
4-18-2019
City
Houston, Texas
Interview Session
David J. Tweardy, MD, Oral History Interview, April 18, 2019
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Leadership; On Leadership; Working Environment; Building/Transforming the Institution; Growth and/or Change; Obstacles, Challenges; Institutional Politics; Definitions, Explanations, Translations; Overview; Survivors, Survivorship; Patients, Treatment, Survivors; Cancer and Disease; MD Anderson Culture; The History of Health Care, Patient Care; Understanding Cancer, the History of Science, Cancer Research
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey. A. Rosolowski, PhD:
Absolutely. Well, before we turned the recorder on you said that a lot of what had been set in place during this transition period created a framework in which you, within the division, could move ahead with certain projects, so maybe you want to talk about some of those.
David Tweardy, MD:
Yeah. I mean, I was very fortunate to inherit a division, as I already told you, that had great leadership, and that’s at the department chair level, super-section level. And that is a testament and a shout-out, really, to my predecessor, Dr. Bob Gagel. He left the division in great shape. But clearly healthcare is dynamic, and the one thing about medical care at MD Anderson that is, in a way, different, or less than optimum, is the management of acutely ill patients --and both in the outpatient setting, frankly, and in the inpatient setting. As an intensivist—as infectious disease physicians are generally intensivists, particularly me-- I did a bit of outpatient medicine, but all of my medical care is really delivered in the inpatient setting. So I’m used to patients being very sick, needing care literally within minutes, if not hours, of their arrival at the hospital, in order to have the best outcomes. So I’m very attuned to the type of conditions that lead to patients need to come into the hospital, which is acute deteriorations in their health. I think that we were not at the highest level or standard of care in certain aspects of how we managed those acutely ill patients. So I essentially wanted to make certain we moved in the direction of being the best place, not only to get your cancer care but also to get your onco-medicine care in all sort of—across the full spectrum of that, be it optimization of your medical condition before you have surgery, radiation therapy, or chemotherapy, managing those complications during therapeutic period, managing the patient beyond that, and managing complications that are immediate, intermediate, in terms of timing, and then long-term around those cancer care procedures and interventions that happen. One of the things that happens very commonly in the acute phase is those patients decompensate and need to be managed in the inpatient setting. Many times they have complications that are not as familiar to oncologists, to surgeons, or the radiation therapists, as they are to internists, particularly internists who basically specialize in hospital-based medicine, and they’re called hospitalists. So the two major initiatives that I wanted to support here—and they had already started—one was the building of a hospitalist service in the Division of Internal Medicine that basically specialized in onco hospital medicine; that is, the care of the cancer patient when they’re in the hospital. And the second was further grow the emergency medicine effort to really become as effective as it could be, and supported by the institution, and recognized, because the one thing that the Emergency Medicine Department was started … So I’ll maybe start with the Emergency Medicine Department and then go to the hospitalists, in that order, because in a way it’s a natural thing to talk about in that way because patients come in. They actually—50% of the patients that get admitted to this hospital are admitted through the Emergency Center, and so that’s a good place to start. One of the things that’s interesting around MD Anderson is people filter much of their thinking around how does our competition do X? That’s often very helpful, but in the case of Emergency Medicine care it was a distorting factor, because when they—people who knew or trained there at Memorial Sloan Kettering, they don’t have an emergency center. And so some faculty, and not a small number here, will always wonder, why do we have an Emergency Medicine Center? Memorial Sloan Kettering doesn’t. Well, (laughs) the thing they fail to mention, or don’t know, is right across the street is the Emergency Center for Cornell. And so if you’re really sick, you go to Cornell’s Emergency Center. If you’re maybe urgent-care level sick, you’d come into the Urgent Care Center at Memorial Sloan Kettering. And the nearest emergency center here, maybe Ben Taub, might be Houston Methodist. Do you want to send your patients to those two hospitals instead of having a full-scaled developed emergency center? So you can (overlapping dialogue; inaudible).
Tacey. A. Rosolowski, PhD:
Does Cornell have the capabilities to deal very effectively with cancer patients?
David Tweardy, MD:
They are not as good as we are. So, in fact, they are sub—in my mind, they’re sub—if I were a cancer patient in emergency problem, I’d come to our Emergency Center over Cornell’s Emergency Center, or Memorial Sloan Kettering’s Urgent Care Center.
Tacey. A. Rosolowski, PhD:
So tell me about the process of setting this all up.
David Tweardy, MD:
Well, again, I was fortunate that that had started before I came here, but I needed to help … The first was Knox Todd, who was the chairman of the department, and who oversaw the Emergency Center, and then it was Kumar Alagapan, who’s the current chair. He came into the system within a year of my arrival as the permanent chair, as it turns out, because Knox decided to retire pretty much within the first year that I came. But what I needed to do is support their efforts to make this emergency room and the staffing be the best it could be. So part of my mission was to sell what they did to the rest of my colleagues in the division head level, often, and elsewhere. And to basically allow the Emergency Medicine Department to evolve as emergency centers elsewhere had evolved almost a decade before, which is … One of the things about medicine that has transpired over the 50 or 60 years that I’ve been either in medical school or training is something you are very well aware of, which is the increasing specialization of medicine. Well, emergency medicine became its own specialty in the ’60s, ’70s, really, in the ’70s, when a very straightforward phenomenon, that you’re going to understand, happened, which is back in the ’50s, ’60s, if you were sick, acutely sick, you went to your GP. Then the GP realized I really don’t have the capabilities to manage your case, so we’ll then divert the patient to the hospital and see them in the hospital. Well, it turns out emergency medicine became the place you went when you knew, or your doctor, --when you called your doctor and say, “Hey, I got this, this, and this,” and he said, “Don’t come see me in my clinic; go to the emergency center, or to the hospital.” Well, the hospital then needed a place to manage patients in the outpatient setting. Some of them would go home, but some of them would be really sick and need immediate intervention; otherwise, they wouldn’t do well. And that’s what the birth of the emergency center was. Then it was hospital-based, because all of the other resources you needed to manage a patient that was acutely ill were there in the hospital, not in the GP’s office, so— And then the specialty grew from that, and it grew out of general internal medicine, or surgery. And it’s interesting: some hospitals or trauma centers, like University of Maryland, Ben Taub, those hospitals would have surgery run their emergency centers. Yeah. But most other places would have internal medicine run their emergency centers. And then—
Tacey. A. Rosolowski, PhD:
I was going to say, surgery would seem like an interesting lens to put everybody through.
David Tweardy, MD:
Well, and it was the trauma part. If a good fraction of the sickest patients needed lines, needed surgical—you needed to be stabilized in the EC, then rushed to the ER to have all their wounds sewn up, etc., then surgery made sense. So Ben Taub was a perfect example. University of Pittsburgh Medical Center, where I started, was medicine. But then they became their own subspecialty, and then ECs were no longer within the parent department of either Medicine or Surgery, but their own department of Emergency Medicine, and so that was what was created here. And, again, it took our … But it occurred here in 2012, whereas it occurred in the rest of the world, or certainly the rest of the United States, back in 1990. So we were about 20 years behind the curve in providing the best in acute care to the sickest patients in this hospital.
Tacey. A. Rosolowski, PhD:
What was the resistance, do you think?
David Tweardy, MD:
It was kind of just—I think it was—it was somewhat—emerged from that Memorial Sloan Kettering memory that many people had. It emerged from a sense that, well, if we’re truly an emergency center then we’ll have to take patients that don’t have cancer. That turned out to be a very small problem. The Memorial Sloan Kettering issue became really a moot point once you realize the EC for those cancer patients actually was across the street. That’s where they’d go to start before they’d be transferred over to Memorial Sloan Kettering. The other—it was just a lack of information about how medicine was evolving outside of a cancer center, okay. So, think about it: the number one and number two cancer center that are dedicated to cancer, one of them doesn’t still have an emergency center and the other took a long time to develop it. So it was kind of just this concept: cancer patients, they don’t have emergencies. But then you tell, oh, by the way, 50% of patients admitted to this hospital come through the EC. So a lot of it was just lack of knowledge, so lack of knowledge or misinformation. And so part of my mission in this area was to educate. And then there was the—and then the second phase of inpatient care. So Emergency Center would admit many patients, and then they could admit them to two places, and that second place became available in 2014, which is the CDU.
Tacey. A. Rosolowski, PhD:
The CDU?
David Tweardy, MD:
The CDU, the Clinical—this is a real terrible abbreviation—Clinical Decision Unit.
Tacey. A. Rosolowski, PhD:
Oh, dear.
David Tweardy, MD:
I know. They’re often called observation wards elsewhere, where you can bring a patient in, observe them up to 48 hours, and then make a decision whether they need to be admitted or could go home, delay it for 48 hours. A lot of patients come in, need stabilization, need a few interventions, but they don’t need a full hospital admission. And, actually, the CMS encoding changed for that particular type of admission, that short admission. And so we … When that became separately billed and based on, really, a need—you could just have made them short admissions, but there was a billing difference between the short, 48-hour, less-than-48-hour admission, and an admission for 50 hours. There actually is a difference. And so our institution—that is, MD Anderson—decided, okay, let’s do what, again, the rest of the country had done probably five years before: create an observation unit, call it a CDU, but—(laughs) and this is really right after I got here—but do the very strange thing of having the physicians of record of those patients admitted be the last MD Anderson doctor that saw the patient. So, radiation therapy patient comes in, had lung cancer, radiated, now comes in with post-obstructive pneumonia. Okay, Dr. Herman, you’re the physician of record. You saw the patient six months ago. You gave the patient radiation. Dr. Herman: “Wait a minute, I’m in Europe at a radiation oncology conference. How can I be the physician of record? (laughs) I can’t see the patient in the obligatory eight hours that I’m supposed to be doing.” So, crazy idea. So what happened over the next four years is that I, with the help of Kumar and the wisdom of the organization, we changed the ownership of the patient, and we changed the oversight of that unit to the Emergency Center.
Tacey. A. Rosolowski, PhD:
Interesting, yeah. Oh, yeah.
David Tweardy, MD:
So that continuum, if you’re in the emergency room, can’t decide whether you can go home, we’re going to watch you, rather than leave you in the emergency room for eight to 12, whatever hours, we’re going to bring you into the CDU and then take care of your problem and have time to evaluate whether you really need to be admission longer than 48. So one of the major accomplishments I think I had made is I changed the structure of the CDU with the leadership of Kumar, and that makes certain that patients actually get seen in a timely manner. The most important patients to see within hours of their arrival are the patients coming into the EC, or who have to be observed into the CDU. And it was interesting: that concept wasn’t integrated into the thinking and the DNA of this institution. So that’s one of the things that I helped to develop, that thinking about how do you do the best of acute care in the real world, and bring the best practices of the world into this cancer center, which is so well-renowned for everything else it does.
Tacey. A. Rosolowski, PhD:
It’s really, obviously, a really important story in terms of a significant piece that’s been added to patient care here, but it is also, at a different level, just this interesting observation about how the culture of an institution can become really ossified and resistant—
David Tweardy, MD:
Oh, yes. Yep, yep.
Tacey. A. Rosolowski, PhD:
—and how hard it is to change people’s perspectives and paradigms.
David Tweardy, MD:
Yeah. And the leadership here had … One of the ways you do that is you bring somebody in who hasn’t lived, breathed, and eaten everything here at MD Anderson in their careers, and just knows what acute care medicine is like, and how it’s evolved over the time, and bring that person in to be an agent of change. And Kumar, by the way, fits that description perfectly well, as well. He was head of Emergency Medicine and the CDU at North Shore—or at Long Island Jewish for ten years before Knox recruited him. Actually, he went to Ben Taub and then Knox recruited him here to join the faculty, and within a month he became the interim chair of the department. And, again, this is that outside thinking about how emergency medicine and observation care is provided. So that was, I think, one of my and Kumar’s—totally to Kumar’s credit—changes that I implemented with his leadership that I think was impactful in a major way, and I think will have impact for the rest of the history of the organization. The other is once you do come in for a true admission, who should care for you? Should it be the oncologist who last did internal medicine training 20 years ago, or 15 years ago, even five years ago? Or should it be people who did their training and really care for inpatients as what they do for a living? And the answer, frankly, is the latter. And so when I first came here there were two models of hospital care—actually three, and two of those models still exist, but one of them is actually have the team that’s caring for that patient for the cancer also care for them while they’re in the hospital. That model still exists for surgery, and still exists for some departments in cancer medicine. But what we have argued successfully, and shown that we can deliver, is basically say, no, when the patient’s in the outpatient setting and getting their chemotherapy or radiation therapy, or needs their surgery—and surgery still stays with their own model, but then they get to chemotherapy and radiation therapy, you are the experts. You’re the experts at radiation therapy. You’re the experts at chemotherapy. But when they need a doctor, a physician, you’re not the experts. The experts are in internal medicine. You need an internist to manage you. And not just an internist: you need a hospitalist, an expert in the inpatient management of medical problems for patients. And so when I came here we had six hospitalists, and they were competing with in-department hospitalists: Cancer Medicine departments like Leukemia, GU-Medical oncology, and even, I think, Stem Cell. They had, particularly Leukemia, two docs who their job was to care for the patients in the house, as their primary hospitalist, if you will. The retention and burnout there was phenomenal. Those people didn’t last very long. In GU Medical Oncology, similar. And so when I came, I said, “Let’s blow up and expand our hospitals group. I think we’ll be able to convince the cancer medicine physicians that it’s a better way to proceed.” Because hospitalists, especially now with, in General Internal Medicine. In fact, there is even a sub-subspecialty of hospitalists called onco-hospitalists. These are hospitalists that care for the medical care of acutely-ill inpatient who has cancer, and that’s really what we do in our division. And now we’ve grown up to be 21 hospitalists in the last four years. We actually are the largest inpatient service now in the hospital, in the aggregate. And I don’t say that because, a-ha, we did it. It’s just, actually, if you want to have those patients managed optimally --bring them in, get them cared for, and discharge them so you can have the bed available for the next sick patient-- you want your hospitalists to manage them, because they know how to do it. They can get the patient in, get them diagnosed, get them managed, get them out of the hospital in the most timely fashion. They don’t have any other clinical responsibilities, like your oncologist did, who’s also doing clinic, or … And they don’t have to look in the book of how do you manage hyperkalemia, community-acquired pneumonia, or hospital-acquired pneumonia, or hyper—etc., etc. So the good news here, I think, the reason we’ve been able to grow, it’s really in the wisdom of the institution to sort of say, okay, if you have three models of care, having them be provided by the service that takes care of them through their outpatient service, as well as inpatient, or embedded hospital types who are in their cancer medicine, or a group of dedicated onco-hospitalists … The institution has really said, yeah, I think Tweardy’s right: let’s go with the embedded—let’s go with the hospitalist group that’s specializing in onco-hospital medicine. We’ll be able to achieve a whole lot of other key indicators of care with that group than disparately trying to do it in implementing it across the heterogeneity of the other types of models that we had or that were in existence. So, in my mind, this is the other perhaps, long-lasting and impactful intervention or development, I think, that I was able to grow. I didn’t create it; I just grew it, and convinced the institution—and it wasn’t hard. And a fortunate thing about having Steve Hahn as the COO is he came from Penn, and he understood how you do this in other places, and that this was the better model to pursue. And, of course, we have a great inter—we have a super-section Chief, Josiah Halm, H-A-L-M, who is just—led that super-section since it was six faculty. And Carmen Escalante [oral history interview], his Chair, who has really been amazingly interested and completely aligned—in fact, I should say I aligned with her vision, but we aligned brilliantly in terms of trying to have this happen within our division.
Tacey. A. Rosolowski, PhD:
Interesting. Yeah, the value of the fresh face, the new perspective, new way of communicating, and there’s also this thing about how you’re never a hero in your own land—
David Tweardy, MD:
That’s right.
Tacey. A. Rosolowski, PhD:
—and so you can come in as a different hero, (laughs) to champion something.
David Tweardy, MD:
That’s right. Nobody’s a prophet in their own land. That’s exactly right.
Tacey. A. Rosolowski, PhD:
Right, that’s it, that’s it, the prophet in your own land, yeah.
David Tweardy, MD:
Yeah, and I—well, in a way it’s interesting. Here, the one thing that I did encounter was the sense that you’ve been just here, what do you know? Kind of: I’ve been here 20 years; I know how this place works. So it cuts both ways, in some respects. I think certain folks here are really interested in how it’s done elsewhere, and how to bring in best practices, but there is a segment of the institution that doesn’t want to change, and is very happy with the way things are, and thank you very much for your suggestion but we’ll continue doing things the way we have. It’s worked so far.
Tacey. A. Rosolowski, PhD:
Yeah, it’s interesting. I mean, I’m working on a project right now with Charles Balch on the history of Surgery, and what’s coming out of those stories is a parallel story in the early years of traditions of surgery based on the Sloan Kettering model, and then how kind of some isolation in the institution from other institutions created a track that was not aligned with best practices that were evolving elsewhere, and so it really did take a new person, new recruits—
David Tweardy, MD:
A new face to come, yeah.
Tacey. A. Rosolowski, PhD:
—to come in and change that.
David Tweardy, MD:
Well, and I would say the second piece is almost as important, if not more important, is that the new vision, but then the ability to recruit and dilute. Recruit and dilute.
Recommended Citation
Tweardy, David J. MD and Rosolowski, Tacey A. PhD, "Chapter 13: Emergency Medicine and the Hospitalist Service" (2019). Interview Chapters. 1395.
https://openworks.mdanderson.org/mchv_interviewchapters/1395
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