Many physicians see being a hospitalist as an opportunity to focus on direct patient care. For Mary Ottolini, MD, it is a way to have it all. Every day, she cares for patients at Children’s National Medical Center in Washington, D.C., teaches at Children’s and at George Washington University School of Medicine in Washington, D.C., serves on a variety of committees and in numerous organizations, and works as a department head.
Early Start, Full Day
“It’s just another typical, crazy day,” says Dr. Ottolini, division chief of the hospitalist division and director of pediatric medical student education at Children’s National Medical Center and professor of pediatrics at George Washington, as she walks briskly down the hall at 9 a.m. on her way to radiology rounds. Her day actually starts at about 7 a.m., when she sees overnight admissions and addresses any urgent problems that require her attention. By 9 a.m., her day is in full swing.
During radiology rounds she and her team, which consists of residents, interns, and third-year medical students, review films from the previous day with the radiologist. The group addresses issues such as what additional tests might be useful. Sometimes they try to determine whether a condition is the result of an illness or injury.
Leaving radiology, Dr. Ottolini and her team head to the ward for patient rounds. As they walk to the first room, they pass cheerful murals featuring cartoon characters and several paintings and drawings created by children. A third-year resident leads the rounds, filling the group in on each patient’s condition and progress. Dr. Ottolini conducts the physical exams and talks to family members when they are present. When she offers her thoughts and comments to the group, the students listen attentively and take notes as she talks.
At one point, the team has to send for a translator for a non-English speaking family. Dr. Ottolini explains that this is common. In fact, Children’s has translators readily available who speak several common languages, including Spanish, French, and Japanese. Additionally, they have access to individuals who speak just about any language that arises.
Despite the ready availability of translators, these family discussions can be challenging. “When we have the translator, we are trying to balance efficiency with effective family communication,” explains Dr. Ottolini. “The translator adds a time factor because everything has to be repeated, and then there’s a lag time when we are looking at each other and waiting for the translation. It works, but it adds a layer of complexity to the situation, especially when you are trying to teach trainees while addressing parental concerns.”
—Mary Ottolini, MD, division chief, Hospitalist Division, and director of pediatric medical student education, Children’s National Medical Center, Washington, D.C.
Family communication is an important part of Dr. Ottolini’s daily activities. Because she doesn’t have a previous relationship with the patient or family, Dr. Ottolini faces the task of establishing rapport quickly—often in the midst of a crisis. “Especially when the child is seriously ill, it can be challenging to establish a level of trust,” she says. “For me, it’s a matter of trying to put myself in the parents’ shoes.”
Dr. Ottolini has also gained insights from being on the other side of the doctor-patient relationship. “I had an amazing relationship with a doctor who helped me tremendously, and I think of that,” she says. “Part of it is listening and trying to understand what is concerning the family the most. Sometimes, this is not what we think is the greatest concern. If we can get past what’s troubling them, it helps to move the care plan forward and establish a trusting relationship.
“There is no substitute for spending time with the family and getting to know them a little,” she continues. “It is important to understand how the illness is affecting the family’s routines, and helping to resolve these issues is useful as well.”
Dr. Ottolini’s concern for the family is evident in her interactions with them. She speaks with them gently, asks questions, and listens compassionately. Occasionally, Dr. Ottolini will schedule a family conference to address family concerns or other issues. “Family meetings are based on patient complexity—when there is multi-organ system involvement,” she says. “Sometimes, if the parents’ long-term expectations for their child’s prognosis are unrealistic, we want to have a meeting so that they can hear—from different sub-specialists involved—our rationale for what we are recommending— and [so that we can] clarify issues they don’t understand.”
Another level of concern involves families with limited resources. For example, “We have many recent immigrants for whom navigating the system is challenging,” says Dr. Ottolini. “We help them ensure that their child gets the best possible care, and we work to address work schedules and other issues.”
First and foremost, she and her team are patient and family advocates. “If we think it is important or necessary, we will keep a child here even if the insurance company says no,” she says.
Busy Afternoons, Late Days
By 1 p.m., Dr. Ottolini’s day is far from over. Her afternoon is filled with a variety of activities. In addition to seeing new patients, she spends time on billing and administrative activities, holds teaching sessions with medical students and residents at bedside and in the classroom, and writes notes.
“I still write my notes by hand,” she says. “However, this will be computerized in a year or so. When I finish with all of my clinical work and teaching responsibilities, I can catch up on administrative responsibilities or work on one of my research projects.”
Currently she is studying “ways to best conduct rounds and ensure that residents and students can take the information they get and put it all together to clinically problem solve and to see the big picture.”
Committee work is a big part of Dr. Ottolini’s work life. In addition to serving on several hospital committees, she also serves on the George Washington University faculty senate. Elsewhere, she is involved in several national organizations, including SHM.
Talking with families isn’t the only communication activity that takes Dr. Ottolini’s time. She works hard to keep referring physicians informed and to ensure they are involved in the patient’s care as necessary.
“We keep the patient’s pediatrician in the loop as much as possible. We make sure he or she understands how the disease process was managed, what new diagnoses arose, what prescription changes there were, and what follow-up is recommended,” Dr. Ottolini says. She especially wants to involve the pediatrician when a patient is critically ill or when the family is upset or in crisis. “Having a family voice to talk to helps the family feel as if they are getting support from someone they trust,” she explains. “This can be very reassuring for them.”
Dr. Ottolini encourages her students to appreciate the role and involvement of the pediatrician in a hospitalized patient’s care. “I try to make sure that residents and students have some sense of what it is like to be on the other side of things,” she offers. “I encourage them to think about how they would like to be treated if they were the pediatrician.”
Some physicians choose to become hospitalists because they want to spend the majority of their time on direct patient care. While Dr. Ottolini takes great satisfaction from this part of her work, it currently comprises only 30% of her professional time. Forty percent of her time involves medical education and research, which Dr. Ottolini greatly enjoys; administrative activities take up the remaining 30% of her time.
Many hospitalists appreciate the opportunities they have to teach, and Dr. Ottolini is no exception. She proudly observes that several physicians she has taught or mentored have become hospitalists: “For me, this is one of the most satisfying things.”
Admit and Discharge Issues
Dr. Ottolini has some involvement with admission and discharge issues. These decisions are simplified by the involvement of an expert team, however. For example, “We have case managers on rounds with us, and this helps them understand nuances of what we are doing that may not be exclusive in the notes and why it may be important for a patient to stay or appropriate for him or her to be discharged,” she says. “We look at patients’ criteria for discharge and anticipate, [on] the day before, any potential delays that could affect their release—such as getting tests performed and results back.”
Discharge planning is key. “We plan ahead for discharge and communicate goals to the family—such as getting the child off oxygen, getting cultures finalized, and so on,” says Dr. Ottolini. “We assign a discharge time the day before and make sure that the discharge summary, all necessary paperwork, and prescriptions are ready to go.”
For Dr. Ottolini, involvement in admission is limited. “The majority of our patients come through the emergency department,” she says. “However, we do admit patients coming in from the community, and we have input with community physicians if it’s not a clear-cut decision.”
The length of stay (LOS) for the nearly 300 beds in the hospital varies based on the patient’s condition. The average LOS for patients in the short-stay unit is three days. Facility-wide, the average LOS ranges from three to five days.
Challenges, Frustrations, Rewards, and Successes
“Challenges—such as dealing with very ill children who are not going to survive and addressing social situations where children are abused—also are rewarding, [and] we know we have worked in the best interest of the children,” says Dr. Ottolini. She and her team have the satisfaction of knowing they did everything they could to protect their patients, provide them with excellent care, and maximize their quality of life.
Dr. Ottolini says that she faces many of the same frustrations as others who work in a large organization. “With medically fragile children, a lot of coordination and communication needs to take place,” she says. “Sometimes, when lines of communication break down, you think something is happening when it isn’t. For example, after you have prepared a patient for an MRI, you find out that he or she has been bumped because of a more urgent situation. This frustrates the family and affects all of us.”
Pride of a Seasoned Hospitalist
A hospitalist since 1992, Dr. Ottolini is proud to have the title. She enjoys the teamwork she experiences on a daily basis, and even the challenges she experiences bring her tremendous professional and personal satisfaction.
While she sees herself as a generalist, Dr. Ottolini says her work “has enabled me to become especially good at those diagnoses we see a lot of—such as infectious disease problems and dehydration and fluid imbalance.”
An area in which Dr. Ottolini has become something of an expert is one that she would rather not have to see. “Sometimes we are lucky and see no abuse and neglect cases. The majority of the time, there is at least one admitted in a two-week period,” she says. “Out of necessity, I have learned quite a bit about abuse and neglect and caring for children who are abused and neglected. And, in presenting testimony on various cases, I have learned a bit about the court system.”
Helping students deal with this difficult reality is an important part of her teaching and mentoring activities. “From a clinical viewpoint, I help my students understand how to evaluate patients and look for red flags suggesting abuse or neglect,” she says. “However, it also is important for them to consider abuse in terms of different problems.”
Dr. Ottolini teaches her students “not to be closed-minded and not to be prejudiced concerning patients’ socieoeconomic status. They need to understand that abuse and neglect don’t just happen to poor children.”
From a personal standpoint, “we really need to focus on caring for children and not focus on who’s to blame. We want to work in a therapeutic relationship with parents as well as the child,” explains Dr. Ottolini. “It is not for us to figure out who is responsible for the abuse or neglect but to care for the child and work with the parent who is there. It is our job to make it clear to the police when abuse has occurred. Then we make sure that the situation to which the child is being sent when he or she leaves the hospital is reasonable and safe.”
A Happy Hospitalist
Dr. Ottolini rushes down the hall to see a patient as two residents hurry to keep up with her. They pepper her with questions as they walk, and she answers between glances at the chart in front of her. The smile on her face makes it clear that she is enjoying every minute of her “busy, crazy day.” TH
Joanne Kaldy writes regularly for The Hospitalist.