There's No Place Like Home for Hospital Care

This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. I'm Eric Topol, and this is the Medicine and the Machine podcast. I'm with my co-host, Dr Abraham Verghese. We have a great opportunity today to have a conversation with Dr. Helen Ouyang, who is an associate professor at Columbia University. She's an emergency medicine physician and one of the outstanding physician authors of our time. Welcome, Helen.

Helen Ouyang, MD, MPH: Thank you so much. I feel like I'm in the presence of greatness, so thank you for having me.

Topol: You're much too humble. You're an incredible force. We will eventually get to your most recent New York Times Magazine cover article, Your Next Hospital Bed Might Be at Home, one of several about the hospital-at-home trend.

But before we get into that, I know you have had an incredible educational background at Brown and Johns Hopkins, a master's of public health from Harvard, and Brigham and Women's Hospital emergency room training. You have distinguished yourself not only by being a great emergency physician, but also by being an author. How did that get started?

Ouyang: I was in seventh grade, taking a summer writing class. I loved reading and writing. We read this beautiful story by Dr Richard Selzer, who was a surgeon at Yale. It was called "Imelda." He wrote about how he went to Honduras and worked there and performed cranioplasty on kids' faces.

I was quite struck by the story. I thought, I really want to work overseas. Fast-forward many years and I did that for a long time, but I always returned to writing, and his writing specifically, until I found out more recently that a lot of his work was fictionalized. But his words stuck with me. I think that was when that seed was planted.

Abraham Verghese, MD: Helen, welcome. It's a pleasure to put a voice to the writing I have enjoyed. It's interesting that you mention Dick Selzer because in many ways, he was one of the people who helped me think about the possibility of writing. My brother gave me his book when I was a medical student, and I was blown away because he was a surgeon and somehow the stereotype that I had as a medical student was that surgeons did anything but write such touching prose. I had the opportunity to meet him many, many years later in life.

Tell us about your first step. You had an interest in writing, but what was the actual moment of breakthrough?

Ouyang: I worked in global health for a long time. I started to write more op-eds, which got me into trouble with some of the nonprofits I was working with, for being a bit outspoken about circumstances and some of these humanitarian crises. So, I started to peel away from global health work and do a bit more writing.

Initially, it was a lot more essays and op-eds. But then I wanted to dig deeper and spend more time with the subjects, and that's how I worked my way more into long-form feature writing.

Topol: You've become a regular at the New York Times Magazine with cover features, but also many other places of high regard: The New Yorker, New York Magazine, Harper's, The Atlantic. You're all over, and you're prolific. When you pick a topic, how do you decide how you're going to delve into it, do your reporting, and where it's going to go? When you have a topic of interest, how do you figure out what to do with it?

Ouyang: I have to confess, I don't always know. I talk to people and see what they say. Oftentimes, I don't know how the story is going to go.

But I often pick issues that make me think there's more to the story. I wrote a piece about compassionate use of investigational drugs for Harper's . I think that's how we both first interacted on Twitter, Eric, because I believe you tweeted out that piece, and we started to communicate after that.

The media storyline was that there was a child who had cancer and he needed an experimental drug, but there was an evil CEO who didn't want to give it to him. That was the story in the media. I was interested in the backstory, because I don't think most people are pure good or pure evil. I wanted to see what was actually going on there. It's often issues like that that I dig into. But it's often unpredictable what happens once you start reporting.

Verghese: The amount of research you have to do is striking. I'm struck by how deep you dig into things. Your most recent article about hospital-at-home was not only edifying, but it must have been like writing a research paper. You have to go to all the sources and find the references and read them. Would that be a fair description of the process?

Ouyang: That's fair, and also finding people who can carry the narrative in a compelling way, right? So, I need to talk to people who can tell their stories and can give light and color to the issue.

Topol: In 2020, you wrote about the pandemic from your own experience as well as that of colleagues looking after patients in the midst of probably the worst health crisis in New York City. You wrote about the children in Pakistan who have HIV. You wrote about the metaverse and virtual reality for treatment of pain in 2022. And then the most recent one, as Abraham just mentioned, about hospital-at-home. That's just at the New York Times Magazine in the recent couple of years, and not all the other things you've been writing.

I do want to drill down a bit on the hospital-at-home idea. This is a big movement that has started. It was kind of lying dormant, as you discussed in your feature. For years, there were these programs at Columbia and Mount Sinai and other hospitals that included relatively small numbers of patients treated at home with clinicians and nurses — not sensors, not modern artificial intelligence (AI) technology and algorithms. But there certainly seemed to be some promise. Then it seemed like the pandemic took it to a new level because, all of a sudden, there was this waiver for 250 hospitals in the United States that would be paid the same for hospital-at-home care as they would for hospital inpatient care. So, where are we headed with this?

Ouyang: As you said, once the waiver hit, suddenly everyone was interested. Because the hospital could be reimbursed as though you were in the brick-and-mortar building, but you were at home. Once you take away some of the overhead, including food, room and board, then the costs are cheaper. It makes economic sense.

We were already heading that way: People wanted their care at home. But the pandemic accelerated it, not only because of the waiver but also because people were used to seeing their doctors in their living rooms using telehealth. That became much more popular during the pandemic, and it kind of stuck. Even though it's declined some since the pandemic has waned, a lot of people are used to it and comfortable with it now. Technology has moved in that direction — now you can do remote monitoring with patients at home that you weren't able to do a few decades ago. All of those forces will push hospital-at-home.

Verghese: I was struck by the fact that even though the Centers for Medicare & Medicaid Services (CMS) did some progressive things like quickly funding telemedicine and so on, in a way, they remain an obstacle to fully implementing some of these programs. Is their obstinacy just red tape? Or does one really need to have the enormous scale of a Kaiser Permanente for this to be worthwhile to CMS? I didn't quite understand why they weren't on board with something that should save them money.

Ouyang: Sometimes people are used to doing things a certain way. And there are a lot of variables once you're in somebody's home. Your home is different from another person's home, but hospital rooms are pretty similar, with similar equipment. In a home, many things are different, including distance from the hospital and how you will get back to the hospital if you need to.

What if there are dogs at home? What if you have a roommate who doesn't want someone else there? All of these variables come into play and it becomes a much less controlled, and therefore scarier, environment.

Topol: As George Orwell put it many years ago, the hospital is the antechamber to the tomb. The problem is that we have lots of errors in hospitals, nosocomial infections, people can't sleep, you can't eat the food.

There's another front, in addition to reimbursement. It's looking into the future, and connecting the patient via the appropriate sensors. You can get continuous vital signs, for example. You have cameras, if you need them. You have mats for walking and for people with gait disturbances or frailty or who are prone to falls, and all sorts of ambient sensing and algorithms. Do you see a time when this will become very popular, Helen? Or, because of the absence of the human touch, it that inconceivable?

Ouyang: We're going to see some forward, then a little backward, movement. Unfortunately, in medicine, it's unpredictable. Perhaps something will go wrong for a patient and people will become more cautious. But I still believe the movement is going in a forward direction.

Abraham mentioned CMS. They're almost acting like the startup funding for this in a way. They're paying for this. They know it costs less, but they're doing it because that's how they're going to get institutions to invest in it. Otherwise, who's going to take that up? Nobody wants to be the first to pay a lot for something and end up losing money.

Verghese: You did a great job of telling us about the history of being hospitalized and how we've slowly gone from everyone being at home to this model where we believe we need nurses around the clock. It has to be this model or nothing; there's no in between. You could be homeless and getting no care, or you have to be in the most expensive care in the world.

What was also surprising to me was the resistance that came, I thought, from an unexpected quarter: the nurses. The nursing profession, as a whole, is against this movement. Why would that be? What's the rationale there?

Ouyang: I wouldn't say nurses as a whole. But the largest nursing union, which I wrote about, is against it. Again, there's a fear of what could go wrong at home. Nurses are at the bedside. They're monitoring the patient. They're observing the patient. To remove all of that and bring patients home — CMS was pretty loose with this waiver. It only requires two nursing visits a day, and those visits can be virtual, plus two in-person visits that, in some states, could come from a medic or a physician extender. But the nursing visits can be virtual. That's a huge change from what we do in the hospital.

A few years down the road, maybe we'll realize that we actually need to rein it in a bit and that we need more nursing visits. I'm not sure. But the setup right now is quite different from what we experience with a brick-and-mortar hospital.

Topol: Certainly, the American Hospital Association isn't going to be getting behind this movement, because the hospital is their financial model. Speaking of models, with GPT4 — which is now multimodal, bringing in image, video, text and speech — we have the first opportunity using this large language model, generative AI, whatever term you prefer, to actually do the validation, do the randomized trials. In your piece, you touched on the randomized trials (60 of them in 2012) that already showed an advantage to the hospital-at-home vs the hospital. And that was without some of the opportunities we have now. Clearly, it's going to need a lot of work to provide that proof and to take on the entities that have a conflict.

The United States isn't well positioned for this. Hospitals account for one third of our healthcare spending: $4.2 trillion plus. They're not going to be inclined to let go, what with all these facilities around the country. But in other countries that are more interested in providing the best care without a perverse incentive, do you see that as an issue for how this goes forward?

Ouyang: The hospitals, in a way, don't have a choice. As I alluded to in the article, everything is pushing in the direction of home care, for good or for bad. The pandemic accelerated a lot of that.

There are companies out there — one is called Dispatch — with which you're basically bypassing the front doors of the hospital. If a patient has cold symptoms, they will send somebody to their house, usually a physician assistant. Then they will get the x-ray company to come to your house. They take an x-ray, and if it looks like you have pneumonia, they will just hospitalize you at home. That's what hospitals are contending with. Whether they like it or not, whether they have beds that are empty or they've built new buildings, they're going to have to think in that direction.

Verghese: As Eric was saying, the incentives are all around reimbursement. From reading your article, it seemed that the only hospital systems that were interested were those that were also insuring their own group of patients. Otherwise, hospitalizing someone at home loses them money. Would that be a fair statement, that if a hospital isn't part of a healthcare system, that they're insuring their own patients, they wouldn't be incentivized to be doing much in this space?

Ouyang: That's definitely true for now. Moving forward, I think if private insurers start to cover it and they get good enough rates, then maybe it'll be a good proposition for other hospital systems. But you're right. It's the hospital systems that have their own insurance programs that are saving money right now.

Topol: One thing I wanted to get into, beyond this hot topic, is the intersection of your career in academic medicine and as a physician author, and the fact that great institutions like Columbia University may not recognize that your writing is a major contribution, not just for the medical community but for the public. It's not like it's a paper in Science or The New England Journal of Medicine. It's an article that has a much bigger audience, that's making vast contributions to knowledge and progress and limitations.

For example, in that recent piece, you talked about a company, Biofourmis, one of the tech companies leading this hospital-at-home movement. And it has problems. You brought this out. So, you have a much broader reach and impact than the things in our microcosm that appear in some leading medical journal. But the university may not actually understand how big and important it is. Could you comment on that?

Ouyang: First of all, Eric, you've been a huge cheerleader in that department. Thank you for that. I think you're right. The academic institutions value traditional research and education. But more and more medical students are interested in writing. Narrative medicine has pushed to the forefront. So, there is a space for it, but often, it does feel like I'm working in a silo.

Verghese: I would just say that things have come a long way. When I started out, this was not something you told many people about. You just did it on the side and pleasantly surprised people when something was published. But I don't think they saw it as much added value. Then, gradually, there was a public relations value to it. First at the University of Texas San Antonio, and then especially at Stanford, I felt that those institutions had embraced the idea that my output was going to be slightly different from the scientists'. But it was equivalent in its own way; you have to use a different metric to calculate it.

I believe things are opening up. There's a sense that this is of value, that we need people to communicate the science in some fashion to the public. It's a form of creativity, academic freedom, all of that. In many ways, people like Richard Selzer have helped open the door for careers like yours, Helen, which is gratifying.

But I want to switch gears and ask you about an element that struck me in your writing. You're exposed to incredible dangers in some of these situations you're going to. I was reading the piece about HIV from needle misuse in Pakistan, and picturing you there. It must have been quite challenging.

Then, you're in the middle of that when COVID breaks out, because your piece on COVID begins with you being in Karachi. And then you wind up in Italy. Talk about that sense of vulnerability you must feel when you go out there like this to strange places.

Ouyang: I worked overseas for over a decade on and off, so I didn't necessarily feel unsafe. I had worked in Pakistan before, under totally different circumstances after the earthquake more than a decade ago. It felt like I was returning to a place I had been to before.

Topol: One of the themes that comes across in your work, and that intersects with Abraham as well, is the humanistic aspect. In the hospital, it was about human touch, and this is also something that resonates in the piece that Abraham mentioned. You bring it back for your readers.

Is this something that you find thematic? You may go into something that's highly technical, like the metaverse and virtual reality, but you bring it back to the humanistic aspects.

Ouyang: For me, it always comes back to people, the situations they're in, the decisions they make, how they behave, and bringing that to life. It would be hard for me to write a story without that human touch, without human characters driving the narrative and showing what happens to them. That's always first and foremost when I'm looking at stories and considering them and talking to people, to see how they will bring an issue to life.

Verghese: What is the general direction of your career? Where do you want it to go? Are you looking to continue with this wonderful, investigative journalism with a very medical bent? What else do you see coming down the pike?

Ouyang: I honestly don't know. I love writing magazine features. They're the perfect length for me in terms of the time I spend with them and the time it takes to read them. I like reporting. I love writing.

I have a huge admiration for people, such as you, who can write fiction and nonfiction. Writing fiction is something I've always toyed with in the back of my mind. But I am not even close to doing that yet. Right now, I want to continue writing magazine features for as long as I can.

Topol: Over the weekend, I read a book by a physician author whom I didn't know, Jennifer Lycette, called The Algorithm Will See You Now. This book is about the horror show, medical sci-fi, of the future of artificial intelligence in 2035 and everything that could possibly go wrong. It's a nightmare. But I was interested to read that the reason she got into writing is that she was suffering terrible burnout, and she turned to writing as a remedy. What does writing do for you in terms of your sense of fulfillment, your mood, your complementarity with your medical responsibilities in the emergency department? What does that do for you?

Ouyang: I have to admit that writing causes me a tremendous amount of stress. So, I don't know that it's quite as therapeutic for me as it is for a lot of people. But in reporting, for me, it's the time I don't get to spend with patients in the emergency room, I get to spend that when I'm reporting. I can spend hours talking to patients and learning about their personal lives and everything that's going on with them and not feeling rushed at all.

Reporting gives me that, and when I'm writing, reflecting on that. So, the time I don't get to have with patients in the emergency room, because it's so busy and chaotic, I love that I can have that time when I'm reporting and writing.

Verghese: Well, we want you to keep doing this. You're hitting your stride. Each piece I read in preparation for this interview was quite different from the previous one. It seemed like you were discovering different ways of cracking the code of each story. Good luck to you.

Ouyang: Thank you so much.

Topol: You are such a talent and, in many ways, unique with your approach to this. It's inevitable that you'll be writing books in the future. The magazine features are a pretty good warm-up for that.

Or like Abraham, you could work for 6 years on a 720-page tome. It has been a joy to have you, an interview that's long overdue. We are in awe of what you've been contributing. We think universities should recognize this much more than they do.

We will be cheering for you and reading all your pieces in the future. They're impactful. We hope this conversation will light things up for those who haven't seen the extraordinary work you do.

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Cite this: There's No Place Like Home for Hospital Care - Medscape - May 01, 2023.