An era quietly ended in late 2023, when Ted Pappas, MD, rounded on his patients for the last time at Cincinnati Children’s.
Ted, a community physician with the Northern Kentucky Pediatric Group, was the last community doctor to hold Cincinnati Children’s rounding privileges, meaning that he was the attending physician for patients he admitted.
Until the 1990s, it was common for community physicians to maintain their status as attending physicians and round on their patients in the hospital. Since then, hospitals and health systems have evolved toward what we now know as Hospital Medicine, meaning that once a patient is admitted, care is delivered entirely by in-house practitioners.
While most health systems manage their Hospital Medicine programs as “closed shops,” Cincinnati Children’s has an open model—allowing community physicians to participate in care and round on their patients during hospital stays as long as they meet our care and safety standards that have continually grown more rigorous.
While our open model continues, the challenges of rounding for community physicians—especially time commitments and patient complexity—make it highly unlikely that we will see another Ted Pappas.
“It was time to let it go,” said Ted, 61, who has admitted thousands of patients to Cincinnati Children’s in the last 30 years. “I think the families appreciated seeing a familiar face of their child’s pediatrician, but it’s appropriate for care to be managed by hospital staff. I’ll miss seeing the residents because it’s fun to collaborate and learn.”
Ted will continue to practice so he will still see his patients. He also plans to continue rounding on newborn patients at newborn nurseries.
Early Evolution: General Inpatient Service
The evolution toward Hospital Medicine began as early as the 1980s, accelerated in the 1990s, and became the new standard in the early 2000s due to several factors.
It was becoming increasingly difficult for community physicians to round at various hospitals and still care for patients in their own practices—especially when their practices were becoming more spread out geographically. As more clinical issues began being handled in outpatient settings, it made less sense for them to come to the hospital. And with more moderate-acuity care delivered at individual practices, the patients who did get admitted required more complex care from physicians who could be at the bedside.
Cincinnati Children’s already had a process for assigning physicians to patients who were admitted without an attending physician, and in the ’90s that process became formalized as the General Inpatient Service (GIS). Under the GIS model, community physicians could refer patients to be admitted under the care of one of the GIS doctors at Cincinnati Children’s, or they could admit the patient under their own care.
From the outset, it was important for Cincinnati Children’s to make community physicians comfortable with this transition.
“We did not want to appear that we were soliciting their patients,” said Michael Vossmeyer, MD, Division of Hospital Medicine. “We wanted to maintain collaborative relationships with them, so we focused on strong communications, something that we continue today through our liaison program.”
"In those days you would round but not necessarily on highly complex patients,” said Camille Graham, MD. She’s now a staff physician at our Kenwood Crossing Primary Care location, but Camille remembers being a community physician and rounding at Cincinnati Children’s using paper charts and telephones. “You could be in charge of some patients and change orders, but it was a collaborative experience,” she said. “The (paper) chart might not physically be at the patient’s bedside, so you would rely on the residents and nurses to provide information.”
Camille said there were advantages to community rounding physicians—especially camaraderie, collaboration, and learning—but the challenges were heavy, making the GIS model attractive.
By the early- to mid-2000s, the GIS model was so popular that some large practices announced that their physicians would no longer round. Such en masse transitions meant a significant influx of GIS admissions. By the early 2010s, most physicians admitted patients under GIS.
Also in the 2010s, Cincinnati Children’s was undergoing two more significant shifts. The first was an increased focus on our safety culture following a serious safety event. The need to deliver care with consistent quality and safety became paramount, and that meant being exacting about the standards community physicians would have to meet to continue providing care within our walls. The second shift was technology. With the broad adoption of Epic, community physicians could monitor the care of their patients online without the need to round.
Hospital Medicine: Doing it Our Way
In 2013, Cincinnati Children’s evolved further and established our Division of Hospital Medicine, a specialty that has recently been recognized by the American Board of Medical Specialties.
“Cincinnati Children’s was a real leader in Hospital Medicine, especially with bedside rounds—having the discussion about the treatment plan right in front of the patients and family. We championed that,” said Tom Dewitt, MD, and retired division director of General Pediatrics. Cincinnati Children’s also chose to continue its open policy, allowing community physicians to round if they met our standards. As complexity of patients continued to grow, the need to focus on either the clinic or inpatient setting continued. The result was fewer and fewer participating community physicians. Those who continued to participate tended to be from Northern Kentucky, including Ted. But their numbers kept falling, and by 2023, there were only three still rounding. Ted was the last to stop.
“I'm proud that we made this transition in a way that was respectful of community physicians and maintained quality and safety of care,” said Tom. “We have a very different mentality here in the way we collaborate with community physicians.”
Today, Cincinnati Children’s remains a leader in Hospital Medicine, with service lines at Burnet, Liberty, Surgical Services and Adult Services. We have a strong history in quality improvement, safety, translating evidence into practice, and leadership in education. Our Pediatric Hospital Medicine Fellowship, which was created about nine years ago, was one of the first in the nation to be accredited by the Accreditation Council for Graduate Medical Education (ACGME).
“Our Hospital Medicine fellows are highly recruited by other hospitals,” said Michael. “They often go on to be division directors elsewhere.”
"We are proud to be a model for Pediatric Hospital Medicine divisions nationwide and at the core of this model is that we take care of patients together with our colleagues in primary care,” said Karen Jerardi, MD, interim co-director and clinical director, Division of Hospital Medicine. “The strong connection with our community providers has allowed us to maintain a focus on the transition from hospital to home in our clinical care, education, quality improvement, and research."
End of an Era
“The residents today are much more independent than they were when I was a resident,” said Ted, who completed his residency at Cincinnati Children’s. “They train on much more complex patients and it’s very high tech. I hope that as they deliver care, they always consider what the community physician would do.”
Ted continues to be badged at Cincinnati Children’s and can still visit his patients without rounding.
“It’s just an honor and a privilege to have cared for so many children,” he said. “I’ll always remember the four words I learned from my uncle: ‘the patient comes first.’ Be the advocate for the patient and treat them as you treat your own.”