A History of Hospital Medicine in Pittsburgh with Dr. Basil Zitelli

Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis

Paul C. Gaffney Division of Pediatric Hospital Medicine | CHP.edu

Our History | Paul C. Gaffney Division of Pediatric Hospital Medicine | Department of Pediatrics | University of Pittsburgh School of Medicine

Podcast: Meet the Plenary Speaker Dr. Basil Zitelli – PHM from Pittsburgh | Apple Podcasts

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Allison Williams: Hi, I'm Alli Williams, a Pediatric Hospitalist here at Children's Hospital of Pittsburgh.

Dr. Sameer Agnihotri: I'm Sameer Agnihotri, an Assistant Professor in the Department of Neurological Surgery.

Dr. Williams: And we are so thrilled today to have Dr. Basil Zitelli joining us for our recording today of That's Pediatrics. He has been a medical professional for over 50 years, he was here for 40 years at Children's and he's a pioneer. So today when we discuss hospital medicine and the history of hospital medicine, I think it's the perfect pairing.

Dr. Agnihotri: It's an honor to have you here.

Dr. Basil Zitelli: Thank you very much. Great to be here.

Dr. Williams: So the first thing I was going to ask you was, as you've been here for 40 years, do you have an amusing anecdote or a personal story from some of your clinical time here that's really fond for you or something that was just very amusing?

Dr. Zitelli: I have a lot of amusing stories, probably most of them I can't say. Let me see. There are a lot of amusing stories and I think one of the... I received trophy.

Dr. Williams: Okay.

Dr. Zitelli: Because one of the things that I enjoy doing with children, particularly if they've been in the hospital for a while to try to distract them is to thumb wrestle them. And so I challenge them to thumb wrestling and try as I may and practice upon practice, I never win. And of course, the kids absolutely love it to pin me down because I come in bombastically saying, "I'm the champ. I'm going to win easily, no problem," and so forth. And so within a matter of a few thumb movements, they pin my thumb. And of course, I want to rematch

Dr. Williams: Naturally.

Dr. Zitelli: And the rematch is a little tougher for them, but they win again and then I demand a rematch tomorrow when I make rounds. And so this goes on and finally I had one child who was in the intensive care unit for a prolonged period of time and thumb wrestled in frequently and rarely did I win. He was ultimately discharged from the hospital, he had a prolonged intubation and I saw him back in the office in follow up. And I wanted to see how his voice was because of the intubation and so I asked him in the office, I said, "I want you to scream." Well, he wouldn't do it. He just wouldn't do it. So I let it go for a little while, I said, "Okay, it's time for our match." I said, "I'll make you a bet. If you win, then you don't have to scream. But if I win, you have to scream." Well, that's easy because he's always won before. Well, low and behold, I won.

Dr. Williams: Oh, my.

Dr. Zitelli: So he was true to form, I mean, he was honorable, he kept his end of the bargain and that little episode gave me some information about his dexterity, his strength and his voice. So it's a lot of fun, it's fun for me to engage with kids, most of the time it's just playful, but I can use it for diagnostic purposes and evaluation as well. So yeah, so that's-

Dr. Williams: And is that what you got your trophy for? The one time you won?

Dr. Zitelli: Yeah, he gave me a little, it almost looks like an Oscar.

Dr. Williams: Okay. Oh my gosh. Well, I think that's one of the best parts about pediatrics is the playfulness of the exam and the patients that we get to help and to heal. And most of the time we get to watch them heal and improve, which is great.

Dr. Zitelli: Right.

Dr. Williams: I don't think we're known for thumb wrestling here, at least I haven't heard of the Children's Hospital of Pittsburgh being the thumb wrestling champions.

Dr. Zitelli: No.

Dr. Agnihotri: It's time to bring it back.

Dr. Williams: No, I don't think we are, but we are known for lots of other things. So as a history buff yourself, we would love if you could tell us a little bit about some of the medical history that our hospital is known for? It's a tough question. It's a big topic.

Dr. Zitelli: Without going back to the very beginnings of the hospital, I think one of course is our transplant program. Dr. Starzl came from Colorado in 1980, began doing adult and pediatric liver transplants here. At that time, there was only one other institution in the United States that was doing pediatric liver transplants. And so with that, and particularly as our success improved and we were doing fairly well, we became a world center for not only adult, but also pediatric transplants. That of course went on to other kinds of transplants, just not liver as well.

I think we are world renowned in our research. We are among a leader in NIH funding, for example, and for anybody here who would attend a research conference, sometimes Grand Rounds or whatever, and listen to what research projects are going on here. It is amazing, it's almost in the realm of science fiction of what people are doing and what their aim is and how they're doing as far as combating some of these very difficult healthcare problems in pediatrics. And so research is really a major drive. Cardiac surgery here is phenomenal and is well known and has one of the best overall survival rates for pediatric heart surgery in the country. We're well known for that as well. And then to become a little more personal, I'd like to brag a little bit about our pediatric hospitalist program.

I joined Dr. Paul Gaffney, who was the founder of our group. He was a pediatric hematologist oncologist by trade, but as many very well-known and respected pediatricians, who are pediatricians, because they see more than just their subspecialty. And Paul Gaffney was that kind of a person. And he was well respected within the entire community of Western Pennsylvania. And people would refer patients to him, not only in pediatric hematology and oncology, but general pediatrics as well. And he would see those patients in his office, and he also would admit them if necessary and care for them with appropriate consultation, if necessary. And so, in a sense, he was a pediatric hospitalist. And that model actually had existed in many other major institutions around the country, but usually only a solo practitioner, one person.

In the late '70s, 1977, '78, '79, several of us began working with Dr. Gaffney and as generalists, our job was to see patients referred by pediatricians within the community and see them in our office for outpatient evaluation, as well as admitting them to the hospital for care. It was very successful and pediatricians in the community were very happy to have a group of generalists who would take care of the patients and then send them back to their pediatrician rather than taking over all the care. So we didn't want to do that, we didn't want to interfere with that primary care pediatrician's relationship with the family. We wanted to help the patient and the pediatrician. And it was immensely successful to the point ultimately, where many of the pediatricians in the community gave up their inpatient rounding and asked our group to be the inpatient doctor for their patients.

Dr. Williams: So at that point in time, if you were an outpatient pediatrician, many of them also had hospital responsibilities that they would come in and see the patients that were from their practice is how I'm hearing it.

Dr. Zitelli: That's correct. But as time went on, there were increasing demands on the private pediatrician time demands. And for them to come in to the hospital to see one patient, they found was not time efficient.

Dr. Williams: Sure.

Dr. Zitelli: And so that was a motivation for them to ask our group to be the hospitalist for those patients. And so that's why our group grew immensely. In our outpatient part of the practice, initially we did some primary care, we did primary care for some of the residents, families and some of the faculty children, but we also did primary care for the medically complex child. We're part of the medical home. We also served as an extension of the medical home for the primary care pediatrician providing in hospital care. So we were a team. And so this was a model that we actually published in, I believe, 1986 and in our research looking for this, we believe we were the first group in the United States to do this as a group rather than as a solo practitioner. And so we had many different institutions coming to us asking, how do you do this? How can we establish a similar kind of program at our own hospital? And so we were a model for others to emulate. So we're very proud of that.

Dr. Williams: Feeling a little naive, as a pediatric hospitalist, I feel like I should have known all of this about us. I'm so glad you're here so that I can further appreciate my job here at this institution. Sorry, Sameer, did you have a question?

Dr. Agnihotri: No, go ahead.

Dr. Williams: Okay. Because I was just curious as someone who does this now as a large group, I'm having a really hard time envisioning how this worked for one person. Did that one person, was it more like a consult at that point in time where they came in or they were still the primary doc that was just on call all the time for these patients?

Dr. Zitelli: Dr. Gaffney was on call all the time.

Dr. Williams: Wow.

Dr. Zitelli: Yeah. So in the late '70s he wanted to slow down and that's when he began taking on partners.

Dr. Williams: Okay.

Dr. Zitelli: And that's when Holly Davis, who was in the emergency room, joined the group for a period of time. Tom Gessner, whose son was a president of this hospital. Carl Gartner, who was a chief resident in 1977, joined the group. And then in 1978, I joined the group and then it went on from there. Dr. Andrew Urbach joined the group as well, I think in 1980. No, I'm sorry, 1983 or '84. Yes. And then obviously the group has grown. As more and more patients and our responsibilities grew, we began taking on other kinds of responsibilities that we used to round at the MU Family Center and we were doing that and we did consultations. We work closely with surgeons providing consultative services for any subspecialty really. And so out of necessity we grew, which I believe is great.

Dr. Agnihotri: Yeah. That's absolutely amazing. You have such an interesting view of this place a history buff, a pioneer. It's always nice to ask someone, I consider you a historian as well of the hospital, where do you see the future? Because I think you have an interesting perspective and an interesting lens and you've seen so many programs grow. What do you see for us in the next 5, 10, 20 years?

Dr. Zitelli: For the Children's Hospital or?

Dr. Agnihotri: For Children's Hospital and medicine in general?

Dr. Zitelli: Well, I think the Children's Hospital has a unique position, I believe, in particularly Western Pennsylvania, but because our reputation and because our strengths have expanded to so many different subspecialties that we are ranked, as you know, in the top 10 programs in the country. And so it's an enviable position, but it's also one that is fraught with much responsibility to be able to care for patients in the best manner possible. So I think that we do have the resources to continue to do that. Superb faculty, superb research capabilities and physicians to provide the care, including general pediatrics, I think with our hospitalist group and to continue the tradition of excellent care, research and academic work. That should continue, we should solidify our role and expand it and offer it more widely, I believe.

For medicine in general, I think that it's challenging for medicine at this time from particularly, I believe, a financial point of view. There are always challenges of payment that's fair for the hospital, as well as fair for the patient and family. And this is a systemic issue that needs to be looked at from many different facets. Insurance companies seem to have, I believe, a narrow focus and I think that in order to care for children and family members, we need to have a system where, to get insulin, they don't have to sell their house in order to get medications appropriately and access to care.

I can tell you that as a physician caring for medically complex children, I frequently was on the phone to insurance companies trying to get authorization for issues, medications, as well as procedures or diagnostic testing. It took a substantial amount of time and oftentimes the request was refused. Extraordinarily frustrating for me and more so obviously for the family. Now I know that our own administration, particularly with Dr. Urbach, deals with insurance companies to try to solve the conflicts. And that's an extraordinary resource that this hospital has. So I think that there are challenges in medicine that I think we need to try to overcome.

Dr. Agnihotri: Right. And you touched upon this very lightly, but it'd be nice to... Is there any advice you could give to the future generation? There're amazing residents here, medical students that we interact with daily, right, Al?

Dr. Williams: Yeah.

Dr. Agnihotri: And they can gain so much from your insight, but they're always looking for people like you in the past and how much you've contributed and you seem like a larger than life figure. Any advice you can give these guys, to the next generation in terms of their passion, what to look out, career advice, something small?

Dr. Zitelli: Wow, that's a broad question.

Dr. Agnihotri: Yeah.

Dr. Zitelli: Before I go to there, I think you mentioned the residents and students. This is one of the major reasons why I came back to Pittsburgh and came back here, I was a student here.

Dr. Agnihotri: Right.

Dr. Zitelli: And because I loved working with residents and I think our residents are the top of the tier. They're phenomenally dedicated, just like Alli here. And it is a true joy to be able to work with the students and the residents. My advice to them, number one, just in general, do what you love, as far as your future career, follow your bliss. I've spoken with many residents here, they struggle with decisions about, "Should I go into a subspecialty? Should I go into primary care? Should I be a hospitalist, whatever?"

And my advice is regardless, "What do you enjoy? What do you like most? That's where you should go. That's where you will be the happiest." But I also think that as caretakers, we have a responsibility to be activists as leaders, for us and the American Academy of Pediatrics. And perhaps even in a broader sense, in the community, schools, local community groups, to not only teach and to provide the care necessary, but also to help guide policy. And I think that, that has been lacking, that certainly was lacking in the very early years of my career in which physicians were relegated, not relegated so much, but we thought our job was really to take care of patients, the medical aspect of it, rather than looking at the broader picture. And I think that we need to have our young people look at the broad picture and become activists and leaders in policy making at every level of government.

Dr. Williams: We are so fortunate here to have such a strong history and development of programs and sharing that program with the nation as well through publication and through academic work and learning how to make models sustainable for other hospitals too. One of the things you had talked about too is supporting our community and financial burdens on family. UPMC Children's Hospital of Pittsburgh is working on expansion to more of our satellite communities now too, which I just think is so important because one of the biggest stresses that I see for families when they come here is they come from our other areas, UPMC Hamot, Harrisburg, all other areas throughout Western Pennsylvania, even other of our states that are close to us, but not Pennsylvania, and it's a financial burden. And I just hope that our foundation of hospital medicine here can continue to expand so we can provide care for them in hospitals and I know that we're actively working on that here, which is just so great.

Dr. Zitelli: I agree. Again, particularly in caring for children who have medically complex issues and particularly live in rural area, because they don't have the expertise for these complex issues, oftentimes locally, they have to rely on a medical center where those services are concentrated. And as a result, these families oftentimes have to drive 3, 4, 5 hours or even more in order to get the care that they need. And so you're right, we have specialty clinics scattered around, different specialty clinics, but to use the term, I think Children's Hospital needs to metastasize-

Dr. Williams: That's an interesting choice of word, but I know what you're saying.

Dr. Agnihotri: Right. I love it.

Dr. Zitelli: ... to provide more hospitalist services at some of these other hospitals. So I applaud the initiatives in order to do that so that our families have access and access has been a major problem for many children.

Dr. Williams: Absolutely.

Dr. Zitelli: And so if we can improve access, we can improve care.

Dr. Williams: Thank you, again, so much for being here with us, we've truly appreciated learning more about the history of our hospital and especially for me, I guess I'm a little selfish in this, but the birth of hospital medicine here, which is really interesting to learn. For those out listening to us, whether you're patients, you're trainees, you work in the hospital, you're part of UPMC Children's, if you're interested in history and you have the opportunity to visit the hospital, it's quite literally painted along the hallways, which is great. So you can start from square one, which we didn't go all the way back to, I think it would've been much longer than a 20 minute episode.

Dr. Zitelli: Right.

Dr. Williams: But it is on the third floor by the outpatient centers, there's more history related to Starzl and liver transplant, related to Salk and Sabin and the polio vaccine, all of which were birthed here at UPMC Children's Hospital of Pittsburgh. So thank you again for listening to That's Pediatrics.

Dr. Agnihotri: Thank you.

Dr. Williams: Cool.

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