Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Soccer, Seven-On-Seven-Off, and Saving Lives: Inside a Hospitalist's World
The modern hospital experience has dramatically transformed over recent decades, and few understand this evolution better than hospitalists - physicians who specialize exclusively in caring for hospitalized patients. Dr. Lin Liu, head of internal medicine at St. Luke's Hospital, takes us behind the scenes of this relatively young medical specialty that emerged around 1996.
"Hospitalists are the unsung heroes of acute care," Dr. Liu explains, describing how these physicians navigate increasingly complex cases in today's healthcare landscape. While patients once followed their primary care doctors into hospital settings, the hospitalist model has created specialists who excel at managing acute conditions efficiently and safely. This shift hasn't been without challenges - patients initially resisted the change, but the benefits have become increasingly apparent.
What's particularly fascinating is how hospitalized patient demographics have shifted. At Dr. Liu's facility, the median patient age ranges from 75-80 years old, reflecting both improved healthcare access and longevity. These older patients present unique challenges, often carrying multiple chronic conditions alongside acute issues. Modern medicine has created a situation where "somebody who may have died from heart failure in 1985 at the age of 65 is living to 85" while accumulating additional medical concerns.
Dr. Liu offers valuable insights into why length of stay matters as a quality measure, not merely a financial consideration. Each day in the hospital exposes patients to risks including delirium, falls, infections, and deconditioning - studies show patients can lose 10% of their strength daily. The seven-on, seven-off schedule common among hospitalists provides continuity of care while preventing physician burnout, creating a system that benefits both providers and patients.
Beyond clinical care, we discover Dr. Liu's passion for building community through a hospital soccer club that brings together healthcare workers across disciplines. The conversation concludes with a thoughtful examination of medical orthodoxy and the importance of questioning established practices. Whether you're a healthcare professional or simply curious about what happens behind hospital walls, this episode offers rare insight into the specialized world of hospital medicine.
Listen now to understand why hospitalists play such a crucial role in modern healthcare and how they're working to improve patient outcomes while navigating the complex challenges of today's medical landscape.
Hello, this is Jason Edwards and this is Doc Discussions. I'm here with Lin Liu, the head of our internal medicine program. Lin, how are you doing today? Good, how are you? Yeah, I'm doing very well. Thank you for joining us. Well, absolutely, Thank you for inviting me. So you are a hospitalist? Can you explain to people what a hospitalist is?
Speaker 2:Well per chat. Gbd hospitalist is the unsung hero of acute care. Wte hospitalist is the unsung hero of acute care. But yes, so hospitalists are internists who work exclusively in the hospital, taking care of acutely ill patients.
Speaker 1:And this is a in the past, you know, 20 years or so. This is a newer concept, correct?
Speaker 2:Yes, so this was born roughly 1996, roughly in University of San Francisco. The two founders are Dr Watcher and Dr Goldman.
Speaker 1:Okay, so a little historical context. Yeah, I remember people when I was younger being upset when the hospitalists kind of became a new thing, because they were used to seeing their primary care doc in an outpatient facility and then if they got sick, their doctor would come to the hospital, and so when they saw that that wasn't the case anymore, it was upsetting to them. And thinking back to that, that seems extraordinarily cumbersome on the doctor's side of things side of things. And with the specialization of medicine it makes sense that you have. You know, there's a lot of things that people are admitted to the hospital for, but in general there are, you know, probably five or six main things that people are admitted for, and it would be good to have people who take care of those things all the time for better care all the time for better care.
Speaker 2:So yeah, so we do have common acute problems that we treat all the time. But these days, of course, we're seeing very complicated patients, people coming with all different situations, so we've got to be keen on all different differential diagnosis and be able to treat all of them. If we cannot, then we will need our consultant to help.
Speaker 1:And is this because the health of the general public has decreased over the past several decades and so their medical conditions have become more complicated? Is that what's going on?
Speaker 2:I don't think that's the trend, that the overall health of our population is getting worse. I think it's just what we admit to the hospital might be different from years ago, where our ER is functioning, I would say, more efficiently to get not that sick patients back to home or maybe not admit patients who are not really ill to the hospital.
Speaker 1:Okay okay, patients who are not really ill to the hospital, okay okay. So the ER kind of sorts things out and people who maybe in 1985 would have been admitted to the hospital, they are taken care of in the ER and sent back home.
Speaker 2:I think so. I think that's part of the story. The other is, of course, we have an aging population, so we all know that.
Speaker 1:Yeah, okay.
Speaker 2:And so, as people… and modern medicine is helping our people to live longer and with longevity you come with different chronic conditions. When you come in, you have acute illnesses as well. So on top of those chronic illnesses, it just makes the whole picture more complicated.
Speaker 1:Got it. So somebody who may have died from heart failure in 1985 at the age of 65 is living to 85 and they still have their heart failure, but then they accumulate more illnesses and that has led to the increased complexity of the admitted patient.
Speaker 2:Absolutely, and if you look at our patient population, our medium age is actually 75 to 80 years old At our hospital. That's our peak, and then we have 80 to 85, and then followed by 70 to 75. So I think that's our biggest patient population here.
Speaker 1:Yeah, and that age is probably a fair amount older than the country average right Absolutely than the country average right, Just because, A we live in an area where people are probably healthier and live longer and have more access to care, and so that's why our average ages are higher. And so, yeah, these are really complex cases and it takes oftentimes several days to kind of figure out what's going on and address the issue and then send people either back home or to a skilled nursing facility, correct? Yes, what percentage of patients go to a skilled nursing facility instead of going home?
Speaker 2:Well, I think I'm probably not the best person to answer this Our case managers and utilization management. They may know better.
Speaker 1:But what's like a rough estimate.
Speaker 2:Roughly probably 30 to 40% here in this hospital, I think, which is higher than many other hospitals. Yeah.
Speaker 1:But our patients are older, so that kind of makes sense. And is the issue that? So if you're a little bit older and you have kind of you're not as strong as you were when you were younger and you're in the hospital bed for several days, you get weaker very quickly and your strength and stamina has taken a big hit just in a few short days, and there's good data on this that it's like you lose 10% of your strength in a day, based off hand grip analysis, which is a proxy for just generalized strength. And so, even though you were just in the hospital for a few days, you were sick and you didn't move very much and you've lost your strength and stamina. So you need to go to a facility where they can exercise you every day to get your strength and stamina back up. Is that the general idea?
Speaker 2:Yes, so, yeah, the longer our patients stay in the hospital, in general they got weaker. Yeah, so, especially given our geriatric population, they come yeah so, especially given our geriatric population becoming even for minor illnesses like a UTI. They ended up cannot get up from the bed no-transcript.
Speaker 1:And so if you can build the thigh muscles and the buttocks and you're strong even if you get sick, you still have enough strength to be able to go home and not to a skilled nursing facility.
Speaker 2:That's great If we can do that to everybody in the hospital. I think that would be helpful.
Speaker 1:Yeah, To be honest, I've been preaching it for years and then I just saw, like a few months ago AARP had an article on recommending that. But you know, you see with your own eyes patients and you see what happens first, and even the 50-year-olds I say, if you're 55, you're not going to be a strong 75-year-old if you're a weak 55-year-old. So you need to build up that strength and stamina now.
Speaker 2:Yeah, I absolutely agree. Unfortunately, the reality is, in the hospital, I think over 95% of the time patients are like lying in bed. Yeah, even though we kind of put in order saying ambulate or ambulate with assistance, the reality is, you know, there's just not as many people to help our patients get up and get around. Yeah, all of the workers here are dealing with illnesses and there's not enough workers to get patients to walk around, and that's probably a difference from a rehab hospital. We focus more on treating acute illnesses, stabilizing our patients and triage them with our physical therapy and occupational therapy service to see where they need to go for functional recovery.
Speaker 2:But, we're just not a functional recovery hospital.
Speaker 1:Yeah, yeah, yeah, that's certainly an issue. So what are the, if you kind of ranked, just roughly speaking, what are the most common diagnoses that patients are admitted to the hospital for?
Speaker 2:seen. A diagnosis will be chest pain, okay, heart failure, exacerbation, shortness of breath, even though some of these are not necessarily diagnosis. But this could be just coming in with this symptom, right, yeah yeah, shortness of breath um pneumonia, you know, fever, um things like that.
Speaker 1:So yeah, yeah yeah, and in different hospitals will have kind of a different array of diagnosis. Right when I worked at previously there was like a ton of liver failure. Like I don't think there's a lot of liver failure here at St Luke's or am I wrong?
Speaker 2:No, you're right, you're right.
Speaker 1:Yeah, but some areas you know, different communities have different challenges.
Speaker 2:Yeah, yeah, we have a lot of falls for our you know geriatric population.
Speaker 1:Yeah, yeah, yeah, we have a lot of falls for our geriatric population, gi bleed as well. So, yeah, patients, and so we want to treat patients effectively but not keep them in the hospital too long, otherwise the hospital will lose money, and you know, and and you know money is not the central goal of a hospital, it's to help people. But you do have to keep the lights on. You know, if there's there's no money, there's no mission, and so there's pressure to get that patients out of the hospital. And that sometimes competes with the goal of taking care of the patient and making sure that they're well taken care of. And those can be competing interests sometimes, and we always choose taking care of the patient over the financial interest, but that's a big deal. Patient over the financial interest, but that's a big deal. And with your work, with the program, we've been able to become more efficient in giving patients good care but also, kind of in a reasonable period of time, the length of stay. Can you tell us about the program and improving that?
Speaker 2:Well, absolutely, absolutely. So length of stay is actually a quality measure. It's not just a efficiency measure because, as we said, the longer the patient stays in the hospital, the more complications they may have. So I think if you go to CMS website, there are actually eight major categories of hospital card conditions. Some of the common ones in this hospital-acquired conditions. Some of the common ones in this hospital is definitely delirium Fals, of course, for geriatric population, hospital infection is another big one DVT, pe those are big ones. But our goal is definitely to first of all treat our patients, get them better and also, you know, discharge them safely and efficiently and so that they don't, you know, stay in the hospital unnecessarily and that will really expose them to, you know, all the hospital-acquired conditions and risks. That's why I think Lens of State itself is really a quality measure, not just an efficiency measure, and in this sense I think the interests of our patients and our hospitals are actually aligned very well.
Speaker 1:And so the hospital-acquired risks. So you're talking about, like hospital-acquired infections.
Speaker 2:Delirium, deconditioning, falls and DBTPs, all these kinds of things, okay so as patients are here, they get weaker.
Speaker 1:They're exposed to bacteria that aren't seen that often out in the community but are in hospitals and they're well-documented.
Speaker 2:Exactly, and it has been pointed out years ago that a hospital is a dangerous place and it still is. Yeah, yeah.
Speaker 1:Okay, so we're making some headway in that of minimizing patients' time within the hospital.
Speaker 2:Like really to avoiding unnecessary prolonged hospital stay. I personally have never seen anybody who is intentionally to be, you know, discharged out of the hospital prematurely or before they should be discharged. I think we see a lot of, you know, on the other end of the spectrum where you know patients are stable but somehow they don't have a bed in the facility. So we're waiting for a bed and that can delay discharge for another two, three days. So we see a lot of those. So it's a logistical issue.
Speaker 1:A lot of logistical issues, especially given our population. Here you have a place to send them, but there's no bed there, so they have to stay here.
Speaker 2:There's no bed or uh insurance, uh, is you know waiting for insurance authorization or I don't have a transport today. You know a lot of things like that.
Speaker 1:Yeah, and these are. These are real problems that happen. You know, it's easy for somebody to say like, oh, that should be fixed. Well, sure, I don't know if I should tell the story or not, but I previously worked somewhere where the patients very much wanted to stay in the hospital, and I don't think that's very common here, or as common.
Speaker 2:Well, we got again. We got you know, it's just like a normal distribution. We've got, you know, people from both ends, right? Yeah, some people really don't want to stay here. Some people really want to stay here, really don't want to stay here. Some people really want to stay here. So, um, and then we, we need to kind of find the happy middle where you know they, you know, really need to stay here as long as they need to be Right, yeah, so yeah, for sure, and there and there can be for the people not in the medical community.
Speaker 1:There can be a lot of reasons why a person would want to stay in the hospital. Some of them not super logical and so a lot of challenges, true.
Speaker 1:Yeah and so. So this is a story I don't know if I should tell or not. It was not at this hospital, but a patient would like not leave the room. They would not leave the room and you know you don't want to like have security come grab that. That's a bad look. And so the surgeon I was working with put a nursing order in and it said discontinue bed from room. So they moved the bed out of the room. Anyway, kind of a crazy story. Anyway, not at St Luke's for sure, but no. And so what made you want to become a hospitalist? What attracted you to it? Tell people about the schedule and how that works.
Speaker 2:So for a regular day hospitalist we usually work seven days on and seven days off, and on days the responsibility time is 7 am to 7 pm and this is kind of the norm for most places. And during this 7 am to 7 pm time you're expected to be in the hospital 8 am to 5 pm and that's also kind of standard for a lot of places. So you usually come in, you get a list of patients you see and then you kind of round on patients, either newly admitted patients or your patients from yesterday, and then you make plans with a care team, discharge patients accordingly and then you do some admissions in between and then that's pretty much the day. We also have a night team where the nocturnal is what we call the night doctors, who cover 7 pm to 7 am.
Speaker 1:So they mostly do admissions and cross-coverages here, and so a patient comes into the ER. If they're good enough to get sent home with some medication, that happens. If not, they call your team, they bring them up to the floor and then you address whatever issues need to be addressed. And then you call specialists if they need to get involved, whether it's a cardiologist or an oncologist, and you're kind of the quarterback of the team, so to speak. Well, I appreciate that, right, right, and you're kind of the quarterback of the team.
Speaker 2:So to speak. Well, I appreciate that, so, yeah, so what made me want to do hospice is number one. During my residency, I really find myself joined to general internal medicine rather than any specific organ system. Yeah, so I want to be capable of, you know, treating all different internal medicine-related diseases rather than just focusing on one part of the body, intermesin-related diseases rather than just focusing on one part of the body. Of course, our specialists are treating patients as a whole, but they focus more on one system. But I just want to have that kind of general ability to deal with all different sorts of conditions and I enjoy hospital work more than office. I mean, this is just a personal preference. I just like the challenges, the pace in the hospital, but I also like the lifestyle where you can do seven on, seven off, where you can have more flexible schedules and you know to pursue like personal hobbies and stuff like that.
Speaker 1:And the seven on, seven off is good for patients too, because during your stay, you know you're probably, if you have a three-day stay or a two-day stay, which is kind of a common length you have the same doctor every day, instead of that doctor switching off, and you have a totally different doctor managing your case.
Speaker 2:Yeah, absolutely so. Continual care is very important for the quality and efficiency of patient care and that has been very comprehensively studied. So seven days is a good stretch because I think nationally the average length of stay is right now is roughly 4.5 days and here we brought that down from, I think, over 5.4 or two days to now roughly 4.8 days. So it's still, like a way you know, within that seven day range. So seven days should give a reasonable continuity of care but also maintain a good well-being of our physicians. Yeah, Because ideally for best continuity of care you want somebody to work 365, right, but that person will be burned out in probably two months.
Speaker 1:Yeah, yeah, yeah, that's a tough go, yeah, and it's good, you know it's more efficient from the doctor's standpoint too, because if you know the patient, you don't have to go read the whole chart again. You're, absolutely. You just did that yesterday, so you're, you know there's an efficiency with that as well, exactly. So tell me about yourself personally. You have a family.
Speaker 2:Well, yeah, I'm married happily. This year will be our 18th year. Congratulations, Thank you. And I have two kids. My son, Ryan, is a nine-year-old and my daughter, Camille is a four-year-old. So my son is in elementary and my daughter is in student daycare.
Speaker 1:Yeah, yeah, and she'll be in school soon enough. Yeah, and then, what hobbies do you have? What do you like to do for fun?
Speaker 2:Well, so I mean, I do have hobbies quite a few of them so I play soccer still, yeah. So actually we started a St Luke's Soccer Club Okay, starting, I think, roughly last year, and we got physicians, residents, nurses, pharmacists, and then we also welcome family members to join us. Yeah so we do catch-up games Ideally, if we can, if weather allows. We do every Sunday afternoon. That's great, but sometimes we just can't do it or we don't have enough people. But that's fine.
Speaker 1:Things like that are so good to get to know people outside of work.
Speaker 2:And.
Speaker 1:I think it makes actually care better the more people you know on a personal level. You and I know each other. If you had an issue, you could call me on my cell phone and say, jason, I need you to do this and you know it's a more efficient way if you know somebody personally.
Speaker 2:Right, right, right and I think it also helped to. You know, get our people get out of the building and hang out together with you know, same common interest and I almost feel that I'm running, a side way, a well-being program for Dr Pullman. You know this is definitely well-being. You know, password to wellness.
Speaker 1:Yeah for sure, Playing soccer with each other is healthier than drinking beer with each other Nothing against the beer drinkers out there but it's a good, healthy thing to do with each other. And actually, you know, thinking about the people in the hospital, there's probably a fair amount of pretty good soccer players.
Speaker 2:Yes, we do, and also we have people coming from all over the world. I know soccer traditionally is not a big game in the US, but St Louis is the capital of soccer right. So we've got a great team and people coming from all over the world joining us different culture, background and a lot of people play soccer growing up, so I'm glad to get to know all the people with common interest and, you know you know, have some fun together yeah and so, and you're originally from china.
Speaker 1:Is that correct? Yes, and so, uh, is it. Is it called soccer or football, or do they?
Speaker 2:yeah, we call football football and our football team sucks.
Speaker 1:I'm sorry yeah, very good. And then, do you like to read? Do you read any books?
Speaker 2:Yeah, I read a lot of different books.
Speaker 1:Yes, you probably read a lot of medical journals and things like that too. I'm sorry. You probably read a lot of medical journals and things like that as well.
Speaker 2:Yes, we do, we do, yes, and actually for us there's the Journal of Hospital Medicine and now there's the Hospitals. These are relatively young journals but they have great sessions in there and you know, one of them being things we do for no reasons and we have a lot of those actually in every hospital, things we do for no reasons, for example, daily AM labs, and they talk about a lot of these kind of things, and I think those are like valuable sources for me as well.
Speaker 1:Yeah, this is kind of like a first principles concept of like stop, rethink everything you do and ask is this necessary?
Speaker 1:Is it not necessary? And some things are just done through orthodoxy. It's just the way we've always done it, and you got to be careful with that, because there may be a really good reason that you're not aware of that we do it. You know why I got started. But well, lynn, I appreciate you coming on. It's always good to see you here. I'm thankful that you're running the Hospitalist Program, and I think you've done a really good job with it, and so thank you for your time.
Speaker 2:Well, thanks for having me and thank you for your kind words. Yeah,