John Nelson, MD, MHM

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Sorting out whether a hospitalist’s bonus and other compensation elements are in line with survey data often leads to confusion. The 2013 MGMA Physician Compensation and Production Survey report, based on 2012 data, shows median compensation of $240,352 for internal-medicine hospitalists (I’ll round it to $240,000 for the rest of this piece). So is your compensation in line with survey medians if your base pay is $230,000 and you have a performance bonus of up to $20,000?

The problem is that you can’t know in advance how much of the $20,000 performance bonus you will earn. And isn’t a bonus supposed to be on top of typical compensation? To be in line with the survey, shouldn’t your base pay equal the $240,000 median, with any available bonus dollars on top of that? (Base pay means all forms of compensation other than a performance bonus; it could be productivity-based compensation, pay connected to numbers of shifts or hours worked, or a fixed annual salary, etc.)

The short answer is no, and to demonstrate why, I’ll first review some facts about the survey itself, then apply that knowledge to the hospitalist marketplace.

I want to emphasize that in this article, I’m not taking a position on the right amount of workload, compensation, or bonus for any hospitalist practice. And I’m using survey medians just to simplify the discussion, not because they’re optimal for any particular practice.

Survey Data

The most important thing to know about the survey data is that the $240,000 figure takes into account all forms of pay, including extra shift pay and any bonuses that might have been paid to each provider in the data set. Such benefits as health insurance and retirement-plan contribution are not included in this figure.

There are several ways a hospitalist might have earned compensation that matches the survey median. He or she might have a fixed annual salary equal to the median with no bonus available or had a meaningful bonus (e.g. $10,000 to $20,000) available and failed to earn any of it. Or the base might have come to $230,000, and he or she earned half of the available $20,000 performance bonus. Many other permutations of bonus and other salary elements could occur to arrive at the same $240,000 figure.

The important thing to remember is that whatever bonus dollars were paid, they are included in the salary figure from the survey—not added on top of that figure. So if all bonus dollars earned were subtracted from the survey, the total “nonbonus” compensation would be lower than $240,000.

How much lower?

Typical Hospitalist Bonus Amounts

The MGMA survey doesn’t report the portion of compensation tied to a bonus, but SHM’s does. SHM’s 2012 State of Hospital Medicine Report, based on 2011 data (www.hospitalmedicine.org/survey), is based on the most recent data available, and it showed (on page 60) that an average of 7% of pay was tied to performance for nonacademic hospitalist groups serving adults only. This included any payments for good individual or group performance on quality, efficiency, service, satisfaction, and/or other nonproduction measures. In conversation, this often is referred to as a “bonus” rather than “performance compensation.”

One way to estimate the nonbonus compensation would be to reduce the total pay by 7%, which comes to $223,200. Keep in mind that there are all kinds of mathematical and methodological problems in manipulating the reported survey numbers from two separate surveys to derive additional benchmarks. But this seems like a reasonable guess.

An increasing portion of hospitalist groups have some pay tied to performance, and the portion of total pay tied to performance seems to be going up at least a little. It was 5% of pay in 2010 and 4% in 2011, compared with 7% in the 2012 survey.

Keep in mind two things. First, this 7% reflects the performance or bonus dollars actually paid out, not the total amount available. In other words, even if the median total bonus dollars available were 20% of compensation, hospitalists earned less than that. Some hospitalists earned all dollars available, and some earned only a portion of what was available. And second, some hospitalists fail to earn any bonus or don’t have one available at all. So the survey would show for them zero compensation tied to bonus.

Making Sense of the Numbers

If you follow the reasoning above, then you probably agree that if your goal is to match mean compensation from the MGMA survey (I’m not suggesting that is the best goal, merely using it for simplicity), then you would set nonbonus compensation 7% below median—as long as you’re likely to get the same portion of a bonus as the median practice.

In some practices, performance thresholds are set at a level that is very easy to achieve, meaning the hospitalists are almost guaranteed to get all of the bonus compensation available. To be consistent with survey medians, it would be appropriate for them to set nonbonus compensation by subtracting all bonus dollars from the survey median. For example, if a $20,000 bonus is available and all of it is likely to be earned by the hospitalists, then total nonbonus compensation would be $220,000.

However, what if the bonus requires significant improvements in performance by the doctors (which seems most appropriate to me; why have a bonus otherwise?) and it is likely they will earn only 25% of all bonus dollars available? If the total available bonus is $20,000, then something like 25%, or $5,000, should be subtracted from the median to yield a total nonbonus compensation of $235,000.

Simple Thinking

I think it makes most sense to set total nonbonus compensation below the targeted total compensation. Failure to achieve any performance thresholds means no bonus and compensation will be below target that year. Meeting some thresholds (some improvement in performance) should result in matching the target compensation, and truly terrific performance that meets or exceeds all thresholds should result in the doctor being paid above the target.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

I continue to believe that hospitalists should routinely provide patients a copy of their discharge summary. I made the case for this in a 2006 column (“Keeping Patients in the Loop,” October 2006, p. 74), but I don’t see the idea catching on. I bet this simple act would have all kinds of benefits, including at least modest reductions in overall health-care expenditures and readmissions.

The whole dynamic of this issue seems to be changing as a result of “patient portals” allowing direct access to review test results and, in some cases, physician documentation. Typically, these are integrated with or at least connected to an electronic health record (EHR) and allow a patient, and those provided access (e.g. the password) by the patient, to review records. My own PCP provides access to a portal that I’ve found very useful, but I think, like most others, it doesn’t provide access to physician notes.

So there still is a case to be made for hospitalists (and all specialties) to provide copies of the discharge summary directly to patients and perhaps other forms of documentation as well.

Timeliness

I think all discharge summaries should be completed before the patient leaves the hospital and amended as needed to capture any last-minute changes and details. The act of generating the summary often leads the discharging doctor to notice, and have a chance to address, important details that may have dropped off the daily problem list. Things like the need to recheck a lab test to ensure normalization prior to discharge, or make arrangements for outpatient colonoscopy to pursue the heme-positive stool found on admission, have sometimes slipped off the radar during the hospital stay and can be caught when preparing discharge summary.

Preparing a discharge summary the night before anticipated discharge can have many advantages, including improving early discharge times the next morning. And it means the doctor can prepare the summary late in the day after routine rounding is finished and interruptions are less likely. Although I think quality of care is enhanced by generating the summary the night before (and amending it as needed), I worked with a hospital that was cited by the Centers for Medicare & Medicaid Services (CMS) for doing this and was told they can’t be done prior to the calendar day of discharge.

Creation of the discharge summary isn’t the only relevant step. It should be transcribed on a stat basis (e.g. within two to four hours) and pushed to the PCP and other treating physicians. It isn’t enough that the document is available to the PCP via an EHR; these doctors need some sort of notice, such as an email.

To take advantage of the new “transitional-care management” codes (99495 and 99496), PCPs must make telephone contact with patients within two days of discharge and must have a face-to-face visit within one or two weeks of discharge (depending on whether the patient is high- or moderate-risk). Making the summary available to the PCP quickly can be crucial in ensuring these phone calls and visits are meaningful. (For an excellent review of the TCM codes, see Dr. Lauren Doctoroff’s article “New Codes Bridge Hospitals’ Post-Discharge Billing Gap” in the February 2013 issue of The Hospitalist.)

So I think both patients and other treating physicians should get the discharge summary on the day of discharge or no more than a day or two after. I bet this improves quality of care and readmissions, but one study found no association, and another found a trend toward reduced readmissions that did not reach statistical significance.^1,2

Content

Just what information should go in a discharge summary? There are lots of opinions here, but it is worth starting with the components required by The Joint Commission. (You were aware of these, right?) The commission requires:

• Reason for hospitalization;
• Significant findings;
• Procedures and treatment provided;
• Patient’s discharge condition;
• Patient and family instructions; and
• Attending physician’s signature

To this list, I would add enumeration of tests pending at discharge.

The May/June 2005 issue of The Hospitalist has a terrific article by three thoughtful hospitalists titled “Advancing Toward the Ideal Hospital Discharge for the Elderly Patient.” It summarizes a 2005 workshop at the SHM annual meeting that produced a checklist of elements to consider including in every summary.

Brevity is a worthwhile goal but not at the expense of conveying the thought processes behind decisions. Things like how a decision was made to pursue watchful waiting versus aggressive workup now should be spelled out. Was it simply patient preference? It is common to start a trial of a medical therapy during a hospital stay, and it should be made clear that its effect should be assessed and a deliberate decision regarding continuing or stopping the therapy will be needed after discharge.

Lots of things need context and explanation for subsequent caregivers.

Format

The hospital in which I practice recently switched to a new EHR, and our hospitalist group has talked some about all of us using the same basic template for our notes. This should be valuable to all other caregivers who read a reasonable number of our notes and might improve our communication with one another around handoffs, etc. Although we haven’t reached a final decision about this, I’m an advocate for a shared template rather than each doctor using his or her own. This would be a worthwhile thing for all groups to consider.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

References

1. Hanson LO. Hospital discharge documentation and risk of rehospitalization. BMJ Qual Saf. 2011;20(9):773-778.
2. Van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186-192.

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

Back in the 1980s, I would go by medical records every day or two and find, on the front of the charts of my recently discharged patients, a form listing the diagnoses the hospital was billing to Medicare. Before the hospital could submit a patient’s bill, the attending physician was required to review the form and, by signing it, indicate agreement.

The requirement for this signature by the physician went away a long time ago and in my memory is one of the very few examples of reducing a doctor’s paperwork.

For my first few months in practice, I regularly would seek out the people who completed the form and explain they had misunderstood the patient’s clinical situation. “The main issue was a urinary tract infection,” I would say, “but you listed diabetes as the principal diagnosis.”

I don’t ever remember them changing anything based on my feedback. Instead, they explained to me that, for billing purposes, it was legitimate to list diabetes as the principal diagnosis because it had the additional benefit of resulting in a higher payment to the hospital than having “urinary tract infection” listed first.

Such was my introduction to the world of documentation and coding for hospital billing purposes and how it can sometimes differ significantly from the way a doctor sees the clinical picture. Things have evolved a lot since then, but the way doctors document medical conditions still has a huge influence on hospital reimbursement.

Hospital CDI Programs

About 80% of hospitals have formal clinical documentation improvement (CDI) programs to help ensure all clinical conditions are captured and described in the medical record in ways that are valuable for billing and other recordkeeping purposes. These programs might lead to you receive queries about your documentation. For example, you might be asked to clarify whether your patient’s pneumonia might be on the basis of aspiration.

Within SHM’s Code-H program, Dr. Richard Pinson, a former ED physician who now works with Houston-based HCQ Consulting, has a good presentation explaining these documentation issues. In it, he makes the point that, in addition to influencing how hospitals are paid, the way various conditions are documented also influences quality ratings.

click for large version

Novel Approach

The most common approach to engaging hospitalists in CDI initiatives is to have them attend a presentation on the topic, then put in place documentation specialists who generate queries asking the doctor to clarify diagnoses when it might influence payment, severity of illness determination, etc. Dr. Kenji Asakura, a Seattle hospitalist, and Erik Ordal, MBA, have a company called ClinIntell that analyzes each hospitalist (or other specialty) group’s historical patient mix and trains them on the documentation issues that they see most often. The idea of this focused approach is to make “documentation queries” unnecessary, or at least much less necessary. The benefits of this approach are many, including reducing or eliminating the risk of “leading queries”—that is, queries that seem to encourage the doctor to document a diagnosis because it is an advantage to the hospital rather than a well-considered medical opinion. Leading queries can be regarded as fraudulent and can get a lot of people in trouble.

I asked Kenji and Erik if they could provide me with a list of common documentation issues that most hospitalists need to know more about. Table 1 is what they came up with. I hope it helps you and your practice.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

To my way of thinking, a person’s diagnosis or pathophysiology is not as strong a predictor of needing inpatient hospital care as it might have been 10 or 20 years ago. Rather than the clinical diagnosis (e.g. pneumonia), it seems to me that frailty or social complexity often are the principal determinants of which patients are admitted to a hospital for medical conditions.

Some of these patients are admitted frequently but appear to realize little or no benefit from hospitalization. These patients typically have little or no social support, and they often have either significant mental health disorders or substance abuse, or both. Much has been written about these patients, and I recommend an article by Dr. Atul Gawande in the Jan. 24, 2011, issue of The New Yorker titled “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?”

The Agency for Healthcare Research and Quality’s “Statistical Brief 354” on how health-care expenditures are allocated across the population reported that 1% of the population accounted for more than 22% of health-care spending in 2008. One in 5 of those were in that category again in 2009. Some of these patients would benefit from care plans.

The Role of Care Plans

It seems that there may be few effective inpatient interventions that will benefit these patients. After all, they have chronic issues that require ongoing relationships with outpatient providers, something that many of these patients lack. But for some (most?) of these patients, it seems clear that frequent hospitalizations don’t help and sometimes just perpetuate or worsen the patient’s dependence on the hospital at a high financial cost to society—and significant frustration and burnout on the part of hospital caregivers, including hospitalists.

For most hospitals, this problem is significant enough to require some sort of coordinated approach to the care of the dozens of types of patients in this category. Implementing whatever plan of care seems appropriate to the caregivers during each admission is frustrating, ensures lots of variation in care, and makes it easier for manipulative patients to abuse the hospital resources and personnel.

A better approach is to follow the same plan of care from one hospital visit to the next. You already knew that. But developing a care plan to follow during each ED visit and admission is time-consuming and often fraught with uncertainty about where boundaries should be set. So if you’re like me, you might just try to guide the patient to discharge this time and hope that whoever sees the patient on the next admission will take the initiative to develop the care plan. The result is that few such plans are developed.

Your Hospital Needs a Care Plan

Relying on individual doctors or nurses to take the initiative to develop care plans will almost always mean few plans are developed, they will vary in their effectiveness, and other providers may not be aware a plan exists. This was the case at the hospital where I practice until I heard Dr. Rick Hilger, MD, SFHM, a hospitalist at Regions Hospital in Minneapolis, present on this topic at HM12 in San Diego.

Dr. Hilger led a multidisciplinary team to develop care plans (they call them “restriction care plans”) and found that they dramatically reduced the rate of hospital admissions and ED visits for these patients. Hearing about this experience served as a kick in the pants for me, so I did much the same thing at “my” hospital. We have now developed plans for more than 20 patients and found that they visit our ED and are admitted less often. And, anecdotally at least, hospitalists and other hospital staff find that the care plans reduce, at least a little, the stress of caring for these patients.

Unanswered Questions

Although it seems clear that care plans reduce visits to the hospital that develops them, I suspect that some of these patients aren’t consuming any fewer health-care resources. They may just seek care from a different hospital.

My home state of Washington is working to develop individual patient care plans available to all hospitals in the state. A system called the Emergency Department Information Exchange (EDIE) has been adopted by nearly all the hospitals in the state. It allows them to share information on ED visits and such things as care plans with one another. For example, through EDIE, each hospital could see the opiate dosing schedule and admission criteria agreed to by patient and primary-care physician.

So it seems that care plans and the technology to share them can make it more difficult for patients to harm themselves by visiting many hospitals to get excessive opiate prescriptions, for example. This should benefit the patient and lower ED and hospital expenditures for these patients. But we don’t know what portion of costs simply is shifted to other settings, so there is no easy way to know the net effect on health-care costs.

An important unanswered question is whether these care plans improve patient well-being. It seems clear they do in some cases, but it is hard to know whether some patients may be worse off because of the plan.

Conclusion

I think nearly every hospital would benefit from a care plan committee composed of at least one hospitalist, ED physician, a nursing representative, and potentially other disciplines (see “Care Plan Attributes,” above). Our committee includes our inpatient psychiatrist, a really valuable contributor.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

“Forty percent of physicians reported that their typical inpatient census exceeded safe levels at least monthly.”¹

This quote is taken from an article by Henry Michtalik and colleagues that appeared at the end of January this year in JAMA Internal Medicine. In 2010 the authors conducted an on-line survey asking hospitalists their perceptions of their workload. Respondents indicated that with concerning frequency a high workload prevented them from adequately discussing with patients treatment options or answering questions, delay admitting or discharging patients until the next day or shift, or in some other way risk patient safety or the overall quality of their work.

This alarming finding matches my anecdotal experience working with many different hospitalist groups around the country. I think few hospitalists were surprised by the survey’s findings. Excess hospitalist workloads are indeed a problem in some settings, and those who bear them are typically not shy about speaking out.

The demand for hospitalists has exceeded the supply of doctors available to do the work throughout the history of the field. Under the weight of stunningly rapid growth in referral volume, from about 1995 to 2002, it was reasonably common for the original doctors in a hospitalist practice to become overwhelmed and leave for other work after a year or two, sometimes resulting in the collapse of the practice. Most practices are no longer in such a rapid-growth phase, but for many of them, staffing has not yet caught up with workload. The result can be chronic excess work, and even if daily patient volume is not seen as being unsafe, the number of days or shifts worked might be excessive and lead to fatigue and poor performance.

Other Workload Data

The respondents to the Michtalik survey reported that regardless of any assistance, “they could safely see 15 patients per shift, if their effort was 100% clinical.” What we don’t know is how long their shifts were, whether they included things like ICU coverage, and how many shifts they work consecutively or in a year.

SHM’s 2012 State of Hospital Medicine report, which is based on 2011 data, provides additional context. It shows that hospitalists serving adult patients report a median 2,092 billed encounters annually (mean 2,245, standard deviation 1,161). They spread this work over a median 185 shifts (“work periods”) annually (mean 192). While there are lots of methodological problems in manipulating those numbers further, 2,092 encounters divided by 185 shifts yields 11.3 encounters per shift. These numbers exclude academicians who typically spend significant time in activities other than direct patient care, and I’m intentionally ignoring such issues as the night-shift doctor, who typically has low productivity, bringing down the average per full-time doctor in a practice.

The numbers from both surveys are sort of fuzzy because they aren’t audited or verified, but the 2012 State of Hospital Medicine data suggest that typical workloads aren’t too high in most practices, yet 40% of respondents in the Michtalik survey said they were high enough—unreasonably high—to risk quality and safety at least once a month.

One way to reconcile these findings is to take into account the standard deviation in daily volume in a single practice of about 30% to 40% on above or below the mean. If a hospitalist averages 14 encounters each day shift, then he should expect that the daily number might vary between about eight and 20. The Michtalik survey responses were likely reflecting the shifts on the high end.

Perspective

I wonder what a survey of physician workload opinions in other specialties would show, or what a survey of workers across all segments of the U.S. workforce in and out of healthcare would show. Of course, many or most jobs outside of healthcare don’t risk another’s health or well-being as significantly as ours do, but it would still be instructive to know how people in general think about the work they do.

I suspect a significant number of people across many different jobs feel like too much work is expected of them, and they can point to the ways their performance suffers as a result. It is difficult to know what portion of those who report too much work is just complaining versus a thoughtful self-reflection of the determinants of their performance. Lots of hospitalists do face worrisome high workloads, but some would probably still complain even with a much lower workload.

What Can Be Done?

For those practices facing remarkably high patient volumes, the solution is to make sure you’re recruiting additional doctors, and/or NPs/PAs, as fast as you can. But a portion of these practices must first convince their employers that more staff is needed. Some practices face a real uphill battle in getting the required additional funding, and the place to start is with a careful analysis of your current workload—based on hard numbers from your practice, not just anecdotes and estimates.

Don’t forget that some hospitalists put themselves in the position of having to manage high daily patient volumes by choosing a schedule of relatively few worked days annually. For example, a group working a seven-on/seven-off schedule that also has 14 shifts of time off means that each doctor will work only 168.5 shifts annually. Compressing a year’s worth of work into only 168 shifts means that each shift will be busy, and many will involve patient volumes that exceed what is seen as safe.

It could make more sense to titrate that same work volume over more annual shifts so that the average shift is less busy. I would love to see the Michtalik data segregated by those who work many shifts annually versus those who work few shifts. It is possible that those working more shifts have reported excessive workloads less often.

SHM has a role in influencing hospitalist workloads and promotes dissemination of data and opinions about it. At HM13 next month in Washington, D.C., I am leading a session titled “Hospitalist Workload: Is 15 the Right Number?” Although it won’t provide the “right” workload for all hospitalists, it will offer worthwhile data and food for thought.

It is much more difficult to do studies of how workload influences performance than something like effects of sleep deprivation on performance, so we may never get clear answers. You could take some consolation in the fact that successive surveys have shown little change or even modest decreases in annual patient encounters. But then again, maybe that hasn’t helped with excess work since providing hospital care gets harder and more complex every year.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM's "Best Practices in Managing a Hospital Medicine Program" course. Write to him at [email protected].

Reference

1. Michtalik HJ, Yeh HC, Pronovost PJ, Brotman DJ. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;28:1-2.

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Delayed diagnosis of, or treatment for, a spinal epidural abscess (SEA): that will be the case over which you are sued.

Over the last 15 years, I’ve served as an expert witness for six or seven malpractice cases. Most were related to spinal cord injuries, and in all but one of those, the etiology was epidural abscess. I’ve been asked to review about 40 or 50 additional cases, and while I’ve turned them down (I just don’t have time to do reviews), I nearly always ask about the clinical picture in every case. A significant number have been SEA-related. This experience has convinced me that SEA poses a particular liability risk for hospitalists.

Of course, it is patients who bear the real risk and unfortunate consequences of SEA. Being a defendant physician in a lawsuit is stressful, but it’s nothing compared to the distress of permanent loss of neurologic function. To prevent permanent sequelae, we need to maintain a very high index of suspicion to try to make a prompt diagnosis, and ensure immediate intervention once the diagnosis is made.

Data from Malpractice Insurers

I had the pleasure of getting to know a number of leaders at The Doctor’s Company, a large malpractice insurer that provides malpractice policies for all specialties, including a lot of hospitalists. From 2007 to 2011, they closed 28 SEA-related claims, for which they spent an average of $212,000 defending each one. Eleven of the 28 resulted in indemnity payments averaging $754,000 each (median was $455,000). These dollar amounts are roughly double what might be seen for all other claims and reflect only the payments made on behalf of the company’s insured doctors. The total award to each patient was likely much higher, because in most cases, several defendants (other doctors and a hospital) probably paid money to the patient.

The Physician Insurers Association of America (PIAA) “is the insurance industry trade association representing domestic and international medical professional liability insurance companies.” Their member malpractice insurance companies have the opportunity to report claims data that PIAA aggregates and makes available. Data from 2002 to 2011 showed 312 closed claims related to any diagnosis (not just SEA) for hospitalists, with an average indemnity payment of $272,553 (the highest hospitalist-related payment was $1.4 million). The most common allegations related to paid claims were 1) “errors in diagnosis,” 2) “failure/delay in referral or consultation,” and 3) “failure to supervise/monitor case.” Although only three of the 312 claims were related to “diseases of the spinal cord,” that was exceeded in frequency only by “diabetes.”

I think these numbers from the malpractice insurance industry support my concern that SEA is a high-risk area, but it doesn’t really support my anecdotal experience that SEA is clearly hospitalists’ highest-risk area. Maybe SEA is only one of several high-risk areas. Nevertheless, I’m going to stick to my sensationalist guns to get your attention.

Why Is Epidural Abscess a High Risk?

There likely are several reasons SEA is a treacherous liability problem. It can lead to devastating permanent disabling neurologic deficits in people who were previously healthy, and if the medical care was substandard, then significant financial compensation seems appropriate.

Delays in diagnosis of SEA are common. It can be a very sneaky illness that in the early stages is very easy to confuse with less-serious causes of back pain or fever. Even though I think about this particular diagnosis all the time, just last year I had a patient who reported an increase in his usual back pain. I felt reassured that he had no neurologic deficit or fever, and took the time to explain why there was no reason to repeat the spine MRI that had been done about two weeks prior to admission. But he was insistent that he have another MRI, and after a day or two I finally agreed to order it, assuring him it would not explain the cause of his pain. But it did. He had a significant SEA and went to emergency surgery. I was stunned, and profoundly relieved that he had no neurologic sequelae.

One of the remarkable things I’ve seen in the cases I’ve reviewed is that even when there is clear cause for concern, there is too often no action taken. In a number of cases, the nurses’ note indicates increasing back pain, loss of ability to stand, urinary retention, and other alarming signs. Yet the doctors either never learn of these issues, or they choose to attribute them to other causes.

Even when the diagnosis of SEA is clearly established, it is all too common for doctors caring for the patient not to act on this information. In several cases I reviewed, a radiologist had documented reporting the diagnosis to the hospitalist (and in one case the neurosurgeon as well), yet nothing was done for 12 hours or more. It is hard to imagine that establishing this diagnosis doesn’t reliably lead to an emergent response, but it doesn’t. (In some cases, nonsurgical management may be an option, but in these malpractices cases, there was just a failure to act on the diagnosis with any sort of plan.)

Practice Management Perspective

I usually discuss hospitalist practice operations in this space—things like work schedules and compensation. But attending to risk management is one component of effective practice operations, so I thought I’d raise the topic here. Obviously, there is a lot more to hospitalist risk management than one diagnosis, but a column on the whole universe of risk management would probably serve no purpose other than as a sleep aid. I hope that by focusing solely on SEA, there is some chance that you’ll remember it, and you’ll make sure that you disprove my first two sentences.

Lowering your risk of a malpractice lawsuit is valuable and worth spending time on. But far more important is that by keeping the diagnosis in mind, and ensuring that you act emergently when there is cause for concern, you might save someone from the devastating consequences of this disease.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].