Mark Leiser

Robert Wachter, MD, MHM, has spoken at SHM’s annual meeting every year since 2003.

The opportunity to address 2,500 physician leaders in clinical work, education, and quality improvement—and the chance to suggest where they should be placing their emphasis—is incredibly special, Dr. Wachter says.

“It’s an amazing chance to try to influence the fastest-growing specialty in history,” says the professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center.

“I like to think I have some small impact on the work they go out and do the next day, so it feels like a way of extending my own influence on this extraordinary field,” adds Dr. Wachter, a former SHM president and author of the blog Wachter’s World (www.wachtersworld.com). “That’s a great privilege.”

Dr. Wachter will speak at HM11 on Friday, May 13. The Hospitalist caught up with him to discuss some of his presentation.

Question: Why would you encourage hospitalists to attend HM11?

Answer: The content is great, and it is broad enough that it doesn’t matter whether you are coming to learn the latest ways to manage sepsis or the best ways to organize your program. We are able to attract the best leaders in the world to come speak, so the talent pool is unmatched. And the collegial exchange is fantastic. There’s as much important work that happens in the hallways as happens in the conference room.

Q: Bob Kocher, MD, a former special assistant to the president for healthcare and economic policy, will be a featured speaker this year. Why is it important for hospitalists to hear from him?

A: He was as important as any architect of the healthcare reform legislation. Because he left the White House, he can be open and honest about what’s working and not working. I think we need to understand what reform means, why it was organized the way it was, and where someone who was in the middle of that thinks it will go over time.

Q: What do you see as the legislation’s most significant impact on HM?

A: The dominant issue is, how do we create an environment, and a set of policy and payment initiatives, that incent and promote the delivery of the highest quality, safest, most satisfying care at the lowest cost? That’s not just within the silo we call a hospital but across the continuum of care. The bill takes that concept and puts it on steroids.

Robert Wachter, MD, MHM, has spoken at SHM’s annual meeting every year since 2003.

The opportunity to address 2,500 physician leaders in clinical work, education, and quality improvement—and the chance to suggest where they should be placing their emphasis—is incredibly special, Dr. Wachter says.

“It’s an amazing chance to try to influence the fastest-growing specialty in history,” says the professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center.

“I like to think I have some small impact on the work they go out and do the next day, so it feels like a way of extending my own influence on this extraordinary field,” adds Dr. Wachter, a former SHM president and author of the blog Wachter’s World (www.wachtersworld.com). “That’s a great privilege.”

Dr. Wachter will speak at HM11 on Friday, May 13. The Hospitalist caught up with him to discuss some of his presentation.

Question: Why would you encourage hospitalists to attend HM11?

Answer: The content is great, and it is broad enough that it doesn’t matter whether you are coming to learn the latest ways to manage sepsis or the best ways to organize your program. We are able to attract the best leaders in the world to come speak, so the talent pool is unmatched. And the collegial exchange is fantastic. There’s as much important work that happens in the hallways as happens in the conference room.

Q: Bob Kocher, MD, a former special assistant to the president for healthcare and economic policy, will be a featured speaker this year. Why is it important for hospitalists to hear from him?

A: He was as important as any architect of the healthcare reform legislation. Because he left the White House, he can be open and honest about what’s working and not working. I think we need to understand what reform means, why it was organized the way it was, and where someone who was in the middle of that thinks it will go over time.

Q: What do you see as the legislation’s most significant impact on HM?

A: The dominant issue is, how do we create an environment, and a set of policy and payment initiatives, that incent and promote the delivery of the highest quality, safest, most satisfying care at the lowest cost? That’s not just within the silo we call a hospital but across the continuum of care. The bill takes that concept and puts it on steroids.

Robert Wachter, MD, MHM, has spoken at SHM’s annual meeting every year since 2003.

The opportunity to address 2,500 physician leaders in clinical work, education, and quality improvement—and the chance to suggest where they should be placing their emphasis—is incredibly special, Dr. Wachter says.

“It’s an amazing chance to try to influence the fastest-growing specialty in history,” says the professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center.

“I like to think I have some small impact on the work they go out and do the next day, so it feels like a way of extending my own influence on this extraordinary field,” adds Dr. Wachter, a former SHM president and author of the blog Wachter’s World (www.wachtersworld.com). “That’s a great privilege.”

Dr. Wachter will speak at HM11 on Friday, May 13. The Hospitalist caught up with him to discuss some of his presentation.

Question: Why would you encourage hospitalists to attend HM11?

Answer: The content is great, and it is broad enough that it doesn’t matter whether you are coming to learn the latest ways to manage sepsis or the best ways to organize your program. We are able to attract the best leaders in the world to come speak, so the talent pool is unmatched. And the collegial exchange is fantastic. There’s as much important work that happens in the hallways as happens in the conference room.

Q: Bob Kocher, MD, a former special assistant to the president for healthcare and economic policy, will be a featured speaker this year. Why is it important for hospitalists to hear from him?

A: He was as important as any architect of the healthcare reform legislation. Because he left the White House, he can be open and honest about what’s working and not working. I think we need to understand what reform means, why it was organized the way it was, and where someone who was in the middle of that thinks it will go over time.

Q: What do you see as the legislation’s most significant impact on HM?

A: The dominant issue is, how do we create an environment, and a set of policy and payment initiatives, that incent and promote the delivery of the highest quality, safest, most satisfying care at the lowest cost? That’s not just within the silo we call a hospital but across the continuum of care. The bill takes that concept and puts it on steroids.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

Kelly Cunningham, MD, acknowledges she followed a “pretty traditional” path into medicine. She can’t point to one role model or a single experience that sparked her interest in the field. Rather, she felt medical school would be the ideal way to combine her love for biological sciences, her passion for helping others, and her desire to make a difference.

But Dr. Cunningham didn’t have to wait long for career inspiration. “When I was doing my initial clinical rotations, I had very good hospitalist mentors,” she says. “I started thinking, ‘I really like your job, and I can see myself wanting to be like you.’ ”

Those mentors developed Dr. Cunningham’s interest in quality improvement (QI) and patient safety, which tied in well with hospitalists’ evolving role and complemented her interest in caring for medically complex patients. “I’m a thinker, so I realized early on internal medicine was a good fit for me,” says Dr. Cunningham, an assistant professor of medicine at Vanderbilt University in Nashville, Tenn., and an attending physician at Vanderbilt University Hospital and the Veterans Affairs Medical Center in Nashville. “It became clear I wasn’t going to be a surgeon. I don’t like to fix things using my hands. I like to fix things using my mind.”

Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Question: How do you balance your academic appointment with your clinical responsibilities?

Answer: That’s the biggest challenge for me. I went into hospital medicine first and foremost because I enjoy taking care of patients. But I really like teaching. I’m very interested in working with residents and students. I’m at the point now where I’m starting to have to say no to things and prioritize a bit just to maintain my sanity.

Q: Does one aspect of your career complement the other?

A: Absolutely. You can’t do clinical activities or academic activities in a vacuum. In order to be a good clinician, you need to have the perspective of being able to ask research questions or understand how to teach and be able to tie QI activities into your daily work. On the other hand, I don’t think you can be involved with a residency program without having the knowledge of what it’s like to be on the front line of patient care.

Q: What do you find rewarding about working at the VA?

A: The physicians who are working in the VAs very much appreciate veterans’ service. They enjoy sitting down with them and hearing their stories and seeing them as people. In turn, the veterans are very grateful for the care they receive. Most veterans only receive care within the VA system, so it’s kind of like its own community, and I really like that.

Q: You are passionate about improving the quality of care transitions. What sparked that interest?

A: When I was a resident at Emory University, much of my clinical work was at Grady Hospital in Atlanta. The patient population tends to be underinsured and doesn’t have great access to healthcare. On the day of discharge, we’d give them the right instructions and the right prescriptions, and we’d schedule a follow-up appointment. Two weeks later, they were readmitted. We’d find out they didn’t understand the instructions, couldn’t afford the prescriptions, or didn’t go to the follow-up appointment. It made me realize how important the transition is between hospital and home, and what a vulnerable time it is for patients.

Q: How can hospitalists help improve those transitions?

A: It’s about doing the right thing and providing good customer service. Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Q: How do you respond to someone who says there’s not enough time?

A: It’s critical to being a good physician. Sometimes when I’m taking care of 15 or 20 patients, it’s easy to think about cutting corners. But this is one area where it’s not worth it to cut corners.

Q: What is your biggest professional reward?

A: Working with so many trainees and being able to help shape their career path or interest. At the end of a rotation, if they tell me they learned something from me—not necessarily facts but something that they feel will make them a better doctor—that truly is the most rewarding thing.

Q: What advice are you giving to the next generation of hospitalists?

A: It’s important for them to realize that residency is not always completely representative of the real world.

Q: How so?

A: Since the Accreditation Council for Graduate Medical Education is becoming more strict with work hours and workload, the doctors who are graduating from residency now may not have as much clinical experience when they’re coming out of residency and transitioning into their role as an attending physician or practicing hospitalist. … When I was a resident, I was taking care of 12 or 15 patients. As a hospitalist, I’m sometimes taking care of 20 or 25 patients. Being aware of the workload and how to balance work with the rest of your life is something I didn’t have a great perspective into when I started.

Q: How will the ACGME duty-hour changes affect HM?

A: Interns can only work 16-hour shifts. Who is going to take care of patients when interns have to take a nap or go off shift? Who will pick up all of the resident duties? A lot of it is going to fall on the hospitalists. We can increase our workload, but at what cost? We still need to maintain job satisfaction and have a career that is sustainable and desirable.

Q: Do you see any other solution?

A: Doctors spend a lot of time doing activities that don’t require a medical degree. I think a lot of case managers, midlevel providers, and ancillary support will help us improve our efficiency and workload to help our resident teams while still helping us maintain our sanity.

Q: What’s next for you professionally?

A: I’m finally at the point where I’m starting to define my niche academically. On the clinical side, I really enjoy the variety of the work I do. I’d like to get involved more with handovers within the hospital and also medication reconciliation. Those are two things I’m involved in on a small scale, but they are priorities for the medical center.

Beyond that, I want to try to balance everything and be more selective when choosing opportunities that come my way and be thoughtful about how they fit with my work before just saying yes. TH

Mark Leiser is a freelance writer based in New Jersey.

Kelly Cunningham, MD, acknowledges she followed a “pretty traditional” path into medicine. She can’t point to one role model or a single experience that sparked her interest in the field. Rather, she felt medical school would be the ideal way to combine her love for biological sciences, her passion for helping others, and her desire to make a difference.

But Dr. Cunningham didn’t have to wait long for career inspiration. “When I was doing my initial clinical rotations, I had very good hospitalist mentors,” she says. “I started thinking, ‘I really like your job, and I can see myself wanting to be like you.’ ”

Those mentors developed Dr. Cunningham’s interest in quality improvement (QI) and patient safety, which tied in well with hospitalists’ evolving role and complemented her interest in caring for medically complex patients. “I’m a thinker, so I realized early on internal medicine was a good fit for me,” says Dr. Cunningham, an assistant professor of medicine at Vanderbilt University in Nashville, Tenn., and an attending physician at Vanderbilt University Hospital and the Veterans Affairs Medical Center in Nashville. “It became clear I wasn’t going to be a surgeon. I don’t like to fix things using my hands. I like to fix things using my mind.”

Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Question: How do you balance your academic appointment with your clinical responsibilities?

Answer: That’s the biggest challenge for me. I went into hospital medicine first and foremost because I enjoy taking care of patients. But I really like teaching. I’m very interested in working with residents and students. I’m at the point now where I’m starting to have to say no to things and prioritize a bit just to maintain my sanity.

Q: Does one aspect of your career complement the other?

A: Absolutely. You can’t do clinical activities or academic activities in a vacuum. In order to be a good clinician, you need to have the perspective of being able to ask research questions or understand how to teach and be able to tie QI activities into your daily work. On the other hand, I don’t think you can be involved with a residency program without having the knowledge of what it’s like to be on the front line of patient care.

Q: What do you find rewarding about working at the VA?

A: The physicians who are working in the VAs very much appreciate veterans’ service. They enjoy sitting down with them and hearing their stories and seeing them as people. In turn, the veterans are very grateful for the care they receive. Most veterans only receive care within the VA system, so it’s kind of like its own community, and I really like that.

Q: You are passionate about improving the quality of care transitions. What sparked that interest?

A: When I was a resident at Emory University, much of my clinical work was at Grady Hospital in Atlanta. The patient population tends to be underinsured and doesn’t have great access to healthcare. On the day of discharge, we’d give them the right instructions and the right prescriptions, and we’d schedule a follow-up appointment. Two weeks later, they were readmitted. We’d find out they didn’t understand the instructions, couldn’t afford the prescriptions, or didn’t go to the follow-up appointment. It made me realize how important the transition is between hospital and home, and what a vulnerable time it is for patients.

Q: How can hospitalists help improve those transitions?

A: It’s about doing the right thing and providing good customer service. Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Q: How do you respond to someone who says there’s not enough time?

A: It’s critical to being a good physician. Sometimes when I’m taking care of 15 or 20 patients, it’s easy to think about cutting corners. But this is one area where it’s not worth it to cut corners.

Q: What is your biggest professional reward?

A: Working with so many trainees and being able to help shape their career path or interest. At the end of a rotation, if they tell me they learned something from me—not necessarily facts but something that they feel will make them a better doctor—that truly is the most rewarding thing.

Q: What advice are you giving to the next generation of hospitalists?

A: It’s important for them to realize that residency is not always completely representative of the real world.

Q: How so?

A: Since the Accreditation Council for Graduate Medical Education is becoming more strict with work hours and workload, the doctors who are graduating from residency now may not have as much clinical experience when they’re coming out of residency and transitioning into their role as an attending physician or practicing hospitalist. … When I was a resident, I was taking care of 12 or 15 patients. As a hospitalist, I’m sometimes taking care of 20 or 25 patients. Being aware of the workload and how to balance work with the rest of your life is something I didn’t have a great perspective into when I started.

Q: How will the ACGME duty-hour changes affect HM?

A: Interns can only work 16-hour shifts. Who is going to take care of patients when interns have to take a nap or go off shift? Who will pick up all of the resident duties? A lot of it is going to fall on the hospitalists. We can increase our workload, but at what cost? We still need to maintain job satisfaction and have a career that is sustainable and desirable.

Q: Do you see any other solution?

A: Doctors spend a lot of time doing activities that don’t require a medical degree. I think a lot of case managers, midlevel providers, and ancillary support will help us improve our efficiency and workload to help our resident teams while still helping us maintain our sanity.

Q: What’s next for you professionally?

A: I’m finally at the point where I’m starting to define my niche academically. On the clinical side, I really enjoy the variety of the work I do. I’d like to get involved more with handovers within the hospital and also medication reconciliation. Those are two things I’m involved in on a small scale, but they are priorities for the medical center.

Beyond that, I want to try to balance everything and be more selective when choosing opportunities that come my way and be thoughtful about how they fit with my work before just saying yes. TH

Mark Leiser is a freelance writer based in New Jersey.

Kelly Cunningham, MD, acknowledges she followed a “pretty traditional” path into medicine. She can’t point to one role model or a single experience that sparked her interest in the field. Rather, she felt medical school would be the ideal way to combine her love for biological sciences, her passion for helping others, and her desire to make a difference.

But Dr. Cunningham didn’t have to wait long for career inspiration. “When I was doing my initial clinical rotations, I had very good hospitalist mentors,” she says. “I started thinking, ‘I really like your job, and I can see myself wanting to be like you.’ ”

Those mentors developed Dr. Cunningham’s interest in quality improvement (QI) and patient safety, which tied in well with hospitalists’ evolving role and complemented her interest in caring for medically complex patients. “I’m a thinker, so I realized early on internal medicine was a good fit for me,” says Dr. Cunningham, an assistant professor of medicine at Vanderbilt University in Nashville, Tenn., and an attending physician at Vanderbilt University Hospital and the Veterans Affairs Medical Center in Nashville. “It became clear I wasn’t going to be a surgeon. I don’t like to fix things using my hands. I like to fix things using my mind.”

Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Question: How do you balance your academic appointment with your clinical responsibilities?

Answer: That’s the biggest challenge for me. I went into hospital medicine first and foremost because I enjoy taking care of patients. But I really like teaching. I’m very interested in working with residents and students. I’m at the point now where I’m starting to have to say no to things and prioritize a bit just to maintain my sanity.

Q: Does one aspect of your career complement the other?

A: Absolutely. You can’t do clinical activities or academic activities in a vacuum. In order to be a good clinician, you need to have the perspective of being able to ask research questions or understand how to teach and be able to tie QI activities into your daily work. On the other hand, I don’t think you can be involved with a residency program without having the knowledge of what it’s like to be on the front line of patient care.

Q: What do you find rewarding about working at the VA?

A: The physicians who are working in the VAs very much appreciate veterans’ service. They enjoy sitting down with them and hearing their stories and seeing them as people. In turn, the veterans are very grateful for the care they receive. Most veterans only receive care within the VA system, so it’s kind of like its own community, and I really like that.

Q: You are passionate about improving the quality of care transitions. What sparked that interest?

A: When I was a resident at Emory University, much of my clinical work was at Grady Hospital in Atlanta. The patient population tends to be underinsured and doesn’t have great access to healthcare. On the day of discharge, we’d give them the right instructions and the right prescriptions, and we’d schedule a follow-up appointment. Two weeks later, they were readmitted. We’d find out they didn’t understand the instructions, couldn’t afford the prescriptions, or didn’t go to the follow-up appointment. It made me realize how important the transition is between hospital and home, and what a vulnerable time it is for patients.

Q: How can hospitalists help improve those transitions?

A: It’s about doing the right thing and providing good customer service. Studies show it’s not uncommon for patients to not know the name of their treating physician in a hospital or to not know their diagnosis or to not know why they’re taking a certain medication. It comes down to taking the time to talk to patients and empower them to take an active part in their medical care.

Q: How do you respond to someone who says there’s not enough time?

A: It’s critical to being a good physician. Sometimes when I’m taking care of 15 or 20 patients, it’s easy to think about cutting corners. But this is one area where it’s not worth it to cut corners.

Q: What is your biggest professional reward?

A: Working with so many trainees and being able to help shape their career path or interest. At the end of a rotation, if they tell me they learned something from me—not necessarily facts but something that they feel will make them a better doctor—that truly is the most rewarding thing.

Q: What advice are you giving to the next generation of hospitalists?

A: It’s important for them to realize that residency is not always completely representative of the real world.

Q: How so?

A: Since the Accreditation Council for Graduate Medical Education is becoming more strict with work hours and workload, the doctors who are graduating from residency now may not have as much clinical experience when they’re coming out of residency and transitioning into their role as an attending physician or practicing hospitalist. … When I was a resident, I was taking care of 12 or 15 patients. As a hospitalist, I’m sometimes taking care of 20 or 25 patients. Being aware of the workload and how to balance work with the rest of your life is something I didn’t have a great perspective into when I started.

Q: How will the ACGME duty-hour changes affect HM?

A: Interns can only work 16-hour shifts. Who is going to take care of patients when interns have to take a nap or go off shift? Who will pick up all of the resident duties? A lot of it is going to fall on the hospitalists. We can increase our workload, but at what cost? We still need to maintain job satisfaction and have a career that is sustainable and desirable.

Q: Do you see any other solution?

A: Doctors spend a lot of time doing activities that don’t require a medical degree. I think a lot of case managers, midlevel providers, and ancillary support will help us improve our efficiency and workload to help our resident teams while still helping us maintain our sanity.

Q: What’s next for you professionally?

A: I’m finally at the point where I’m starting to define my niche academically. On the clinical side, I really enjoy the variety of the work I do. I’d like to get involved more with handovers within the hospital and also medication reconciliation. Those are two things I’m involved in on a small scale, but they are priorities for the medical center.

Beyond that, I want to try to balance everything and be more selective when choosing opportunities that come my way and be thoughtful about how they fit with my work before just saying yes. TH

Mark Leiser is a freelance writer based in New Jersey.

Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Kenneth G. Simone, DO, FHM, grew up as the son of a revered pediatrician. As a child, he often accompanied his father on hospital rounds and house calls, developing an appreciation for the “old-fashioned” medicine his father practiced.

Already inspired to follow in his father’s footsteps, Dr. Simone became even more convinced of his calling when the physician-patient roles were reversed: His dad developed a kidney disorder that cut his career—and ultimately his life—short. “His illness and my exposure to hospitals added to my desire to pursue medicine,” Dr. Simone says. “It instilled the drive to help others, to make a difference in someone’s or some family’s life.”

He has done that by developing multiple private medical practices, building the hospitalist program at St. Joseph Hospital in Bangor, Maine, and offering consulting services to more than 100 practices.

“It has always been my nature to challenge myself and put myself in situations that take me out of my comfort zone,” says Dr. Simone, president of Hospitalist and Practice Solutions, a practice-management consultancy in Veazie, Maine. “I enjoy building things from scratch, creating, rebuilding, thinking outside the box, and networking with other healthcare professionals.”

Question: What made you decide to start Hospitalist and Practice Solutions (HPS)?

Answer: HPS was established because of the demand for my services. Initially, word spread locally and then regionally about the work I did at St. Joseph Hospital. As a natural offshoot of my growing interest in helping other programs, HPS became a national consulting firm.

Q: Why did you think this venture could provide a valuable service?

A: I believed there were more effective healthcare delivery systems with which to provide both quality and cost-effective medical care. As time went on, I gained a very unique perspective working as both a hospitalist and referring PCP in private practice. This experience, coupled with my work as an administrative director for a hospitalist program, allowed me to develop applications to help hospitalist programs on a broader basis. I realized the advice I offered to other programs consistently rendered a positive effect.

Q: Which do you find more enjoyable: building a hospitalist program from the ground up or rebuilding a struggling program?

A: I truly enjoy the challenges of both equally. Projects that involve building a program de novo appeal to my creative side. These projects enable me to work with professionals to build a customized program that meets the needs of the community.

Q: What challenges are unique to each?

A: Rebuilding an established program involves critical analysis of the current program to identify what has gone wrong, what has been successful, and what will work in the future. It calls upon one’s skills to build consensus and instill trust in the process because the stakeholders may be apprehensive to have a consultant critically review their program and hospital. In many instances, conflict management is necessary.

In both the creation and rebuilding of an HM program, it is imperative to implement strategies that guide the program to future success. Both projects also require strategic planning and the development of tools and tactics that emphasize collaboration and collegiality.

Q: Do the failing programs you help to rebuild have characteristics in common?

A: Common themes include lack of planning and consensus-building before program start-up, inadequate tools and strategies to support effective practice management, and failure to align the hospitalist practice and sponsoring hospital’s goals and vision. Another common problem is the absence of a hospitalist recruitment and retention plan, which may lead to provider turnover and program instability.

Many programs experience problems due to ineffective leadership, poor implementation and follow-through, and lack of both a short- and long-term strategic plan. Some programs are victims of their own success. The program is not properly prepared to handle the demand for its services and grow accordingly.

Q: You help programs create effective recruitment and retention plans. You also wrote a book on the subject. Why are recruitment and retention challenging for so many programs?

A: The primary contributor is that [hospitalist] supply falls significantly short of physician demand. A secondary contributor is the generational expectations of the younger physician workforce. … In addition, leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts.

Q: What advice would you offer hospitalist program leaders about how they can improve those aspects of their programs?

A: No. 1, create an effective recruitment and retention plan and execute the plan with precision. No. 2, approach recruitment and retention with the same attention to detail as you approach patient care.

Q: You’re offering best-practice advice to help your clients develop and sustain effective programs. What advice do you find yourself giving to your clients that you wish someone gave to you early in your career?

A: From my perspective as a hospitalist administrative director, the advice I would offer is for individuals to believe in themselves and stay engaged. If you feel you have something to offer to the practice or healthcare system as a whole, share it with the appropriate parties. If you experience problems within the workplace, seek resolution in a timely manner. Stay positive and be part of the solution, not part of the problem.

Q: You have written two hospitalist books and coauthored two others. Do you have plans to write another?

A: I wouldn’t say I have immediate plans, but I am always thinking about topics and other projects that would provide value to readers. I’ve got some exciting ideas for future projects, but they are in a very early stage of development.

Q: How would you compare the feeling you get from finishing a book with the satisfaction you derive from other aspects of your career?

A: Writing a book is a highly personal accomplishment for me, while caring for patients is more of a team accomplishment that involves the patient, family, and other healthcare professionals. Typically, the completion of a book is a finite event, while caring for a patient is a long-term commitment.

Q: What is your biggest professional reward?

A: Helping people, whether they are patients in my role as physician, or other professionals—physicians, practice administrators, and hospital administrators—in my role as a practice management consultant. Whenever I reflect on my career, I tell myself how lucky I am. There are not many professions or individuals who have an opportunity to close the door behind them and have other human beings entrust them with their most intimate information. Also, there are very few individuals who are able to impact the delivery of medical care from a systems perspective. I get to do both, and for that I am most grateful.

Q: What is your biggest professional challenge?

A: Saying “no” when someone asks for help. There is nothing more rewarding for me than to help others. With that said, I try not to overextend myself, because that wouldn’t be fair to my family, colleagues, friends, or clients.

Q: What’s next for you professionally?

A: I will continue to concentrate my effort on building my hospitalist consultative practice and expanding the services I offer. In addition, I’m always tempted to explore the valley of the unknown. What excites me is venturing into new areas and to challenge myself to grow as both an individual and professional. TH

Mark Leiser is a freelance writer based in New Jersey.

Rachel George, MD, MBA, FHM, CPE, acknowledges she found her calling through a fluke. After completing an internal-medicine residency in Chicago in 2002, she knew she wanted to stay in the region. She hadn’t decided much else.

“I was not excited about private practice, and I had thought about a cardiology fellowship,” Dr. George recalls. “I was trying to figure out what I wanted to do when I grew up, so to speak.”

She found a job as the lone hospitalist with OSF Medical Group in Rockford, Ill. Despite knowing she’d see “a ridiculous number of patients”—up to 30 per day on weekends—she liked it enough to sign on. “I decided I’d give it a chance for six months or a year while I figured out what I was really going to do,” she says.

Before long, she realized she already was doing it.

“I absolutely loved it,” says Dr. George, one of six new Team Hospitalist members who joined our reader advisory group in April. She now oversees five hospitalist programs in three states as regional medical director and vice president of operations for Brentwood, Tenn.-based Cogent Healthcare. “It was perfect. It was the niche I was looking for.”

Question: What did you enjoy so much about being a hospitalist?

Answer: The acuity of care, the instant gratification of fixing someone and sending them on their way, the intensity in the hospital, not feeling like I was being pulled in 15 different directions like you are in primary-care practice—all the good things about being a hospitalist.

Q: Within a year of joining OSF, you became medical director of its hospitalist service and oversaw its expansion. Did you always envision yourself moving into a leadership role?

A: When I started, I probably would have said my ultimate goal was to get my MBA and think about hospital administration. That was the 10-year plan, or maybe even the 15- or 20-year plan. But when people at the hospital began talking about expanding the [HM] program, I got thrust into the [medical director] role. By that point, I was hooked.

Q: Within three years, you grew the service from one physician to nine. How did you approach expansion?

A: The goal was sustainable growth—growth without sacrificing quality of patient care. When PCPs approached me about taking over their patient population, I’d say we’d take them on as we hired more people. I didn’t want to take off more than we could chew, and I didn’t want to have ridiculous turnover. That wouldn’t do anybody any good.

Q: You joined Cogent in 2006. What prompted the move?

A: I knew Cogent through SHM, and it was too good of an opportunity to pass up. The chance to expand my management responsibilities also was very appealing.

Q: What do you see as the biggest advantage of Cogent’s model?

A: I was part of an in-house program, and I think they’re great in a lot of ways. What they can’t do is economies of scale. There are certain things you can’t do just because it doesn’t make sense financially.

Q: Can you give an example?

A: The classic example I’ll give is discharge summaries in less than 24 hours. [At OSF], I did everything short of getting on my hands and knees and begging them to transcribe discharge summaries in less than 24 hours. They wouldn’t, and I understand why. It was a financial decision.

Cogent, from its inception, said this is too important and we’re going to make sure PCPs get information at discharge. Those types of economies of scale are very difficult to do in a small program, if you’re trying to do it yourself.

Q: What do you consider your biggest professional reward?

A: Seeing a really high-functioning HM team that I’ve helped make that way.

Q: What are the essential elements of such a team?

A: It’s the culture, that patient-first attitude. If everyone understands getting high-quality care to the patient is the most important thing, and we’re all working together to make sure that happens, everything else—core measure performance, decreasing the length of stay—will follow.

Q: What is your biggest challenge?

A: Trying to revamp broken programs.

Q: How do you begin that process?

A: Once the wrong attitude, wrong vision, and wrong culture have set in, we have to decide “How do we improve this?” It’s very difficult. You can’t just close the service and stop seeing patients until you’ve done what you need to do. It’s like trying to fix an airplane in midair.

Q: Despite an already full plate, you continue to see patients. Why?

A: I do it for myself. I don’t want to quit patient care. I enjoy talking to my patients, figuring out what’s wrong, and trying to help them.

Q: You attended the SHM Leadership Academy and have since facilitated academy sessions. What do you see as its benefit?

A: Hospital medicine is a business, whether we like to accept it or not. It’s important for physicians to understand the business drivers, not only for our own practice but for the hospital as well. The academy gives a great overview of the fundamentals of those business drivers.

Q: Would you recommend it for a physician who doesn’t intend to move into a leadership position?

A: I would. It’s valuable for anyone committed to hospital medicine. It helps them understand how their leaders are thinking and why they’re thinking the way they are.

Q: You are former chair of SHM’s Women in Hospital Medicine Task Force, and you pride yourself on balancing life and work. Is HM conducive to that balance?

A: It absolutely can be. Women sometimes think they have to be all things to all people all the time. It’s really about figuring out what your priorities are. I have two young kids and spending time with them is a bigger priority to me than cooking and cleaning. I’d rather live with a messy house and dishes in the sink than not spend time with them.

As a hospitalist, you have that flexibility, too. Most HM programs would love to have a stable, part-time physician. You can do that if you want, or you can be a nocturnist so you can be home with your kids during the day. You are in control of your own life. Understanding that is important, and you can make your choices accordingly.

Q: How do you think HM fares regarding the inclusion of women?

A: There isn’t as much of a good-old-boys’ club as opposed to other fields, which is really refreshing. Women are very well represented on boards and committees. What strikes me is the percentage of women hospitalist leaders is significantly lower.

Q: Why do you think that is?

A: I haven’t wrapped my mind around whether that’s because they aren’t interested because of the choices they made in their lives—which is perfectly fine—or if it’s a lack of opportunity. I do think some women choose not to have a leadership role because their priorities are different, and that’s wonderful. But I wonder if there are cases when women are being passed over for those positions for men instead. The percentages are something we need to keep an eye on so we can better understand why that’s happening. TH

Mark Leiser is a freelance writer in New Jersey.

Rachel George, MD, MBA, FHM, CPE, acknowledges she found her calling through a fluke. After completing an internal-medicine residency in Chicago in 2002, she knew she wanted to stay in the region. She hadn’t decided much else.

“I was not excited about private practice, and I had thought about a cardiology fellowship,” Dr. George recalls. “I was trying to figure out what I wanted to do when I grew up, so to speak.”

She found a job as the lone hospitalist with OSF Medical Group in Rockford, Ill. Despite knowing she’d see “a ridiculous number of patients”—up to 30 per day on weekends—she liked it enough to sign on. “I decided I’d give it a chance for six months or a year while I figured out what I was really going to do,” she says.

Before long, she realized she already was doing it.

“I absolutely loved it,” says Dr. George, one of six new Team Hospitalist members who joined our reader advisory group in April. She now oversees five hospitalist programs in three states as regional medical director and vice president of operations for Brentwood, Tenn.-based Cogent Healthcare. “It was perfect. It was the niche I was looking for.”

Question: What did you enjoy so much about being a hospitalist?

Answer: The acuity of care, the instant gratification of fixing someone and sending them on their way, the intensity in the hospital, not feeling like I was being pulled in 15 different directions like you are in primary-care practice—all the good things about being a hospitalist.

Q: Within a year of joining OSF, you became medical director of its hospitalist service and oversaw its expansion. Did you always envision yourself moving into a leadership role?

A: When I started, I probably would have said my ultimate goal was to get my MBA and think about hospital administration. That was the 10-year plan, or maybe even the 15- or 20-year plan. But when people at the hospital began talking about expanding the [HM] program, I got thrust into the [medical director] role. By that point, I was hooked.

Q: Within three years, you grew the service from one physician to nine. How did you approach expansion?

A: The goal was sustainable growth—growth without sacrificing quality of patient care. When PCPs approached me about taking over their patient population, I’d say we’d take them on as we hired more people. I didn’t want to take off more than we could chew, and I didn’t want to have ridiculous turnover. That wouldn’t do anybody any good.

Q: You joined Cogent in 2006. What prompted the move?

A: I knew Cogent through SHM, and it was too good of an opportunity to pass up. The chance to expand my management responsibilities also was very appealing.

Q: What do you see as the biggest advantage of Cogent’s model?

A: I was part of an in-house program, and I think they’re great in a lot of ways. What they can’t do is economies of scale. There are certain things you can’t do just because it doesn’t make sense financially.

Q: Can you give an example?

A: The classic example I’ll give is discharge summaries in less than 24 hours. [At OSF], I did everything short of getting on my hands and knees and begging them to transcribe discharge summaries in less than 24 hours. They wouldn’t, and I understand why. It was a financial decision.

Cogent, from its inception, said this is too important and we’re going to make sure PCPs get information at discharge. Those types of economies of scale are very difficult to do in a small program, if you’re trying to do it yourself.

Q: What do you consider your biggest professional reward?

A: Seeing a really high-functioning HM team that I’ve helped make that way.

Q: What are the essential elements of such a team?

A: It’s the culture, that patient-first attitude. If everyone understands getting high-quality care to the patient is the most important thing, and we’re all working together to make sure that happens, everything else—core measure performance, decreasing the length of stay—will follow.

Q: What is your biggest challenge?

A: Trying to revamp broken programs.

Q: How do you begin that process?

A: Once the wrong attitude, wrong vision, and wrong culture have set in, we have to decide “How do we improve this?” It’s very difficult. You can’t just close the service and stop seeing patients until you’ve done what you need to do. It’s like trying to fix an airplane in midair.

Q: Despite an already full plate, you continue to see patients. Why?

A: I do it for myself. I don’t want to quit patient care. I enjoy talking to my patients, figuring out what’s wrong, and trying to help them.

Q: You attended the SHM Leadership Academy and have since facilitated academy sessions. What do you see as its benefit?

A: Hospital medicine is a business, whether we like to accept it or not. It’s important for physicians to understand the business drivers, not only for our own practice but for the hospital as well. The academy gives a great overview of the fundamentals of those business drivers.

Q: Would you recommend it for a physician who doesn’t intend to move into a leadership position?

A: I would. It’s valuable for anyone committed to hospital medicine. It helps them understand how their leaders are thinking and why they’re thinking the way they are.

Q: You are former chair of SHM’s Women in Hospital Medicine Task Force, and you pride yourself on balancing life and work. Is HM conducive to that balance?

A: It absolutely can be. Women sometimes think they have to be all things to all people all the time. It’s really about figuring out what your priorities are. I have two young kids and spending time with them is a bigger priority to me than cooking and cleaning. I’d rather live with a messy house and dishes in the sink than not spend time with them.

As a hospitalist, you have that flexibility, too. Most HM programs would love to have a stable, part-time physician. You can do that if you want, or you can be a nocturnist so you can be home with your kids during the day. You are in control of your own life. Understanding that is important, and you can make your choices accordingly.

Q: How do you think HM fares regarding the inclusion of women?

A: There isn’t as much of a good-old-boys’ club as opposed to other fields, which is really refreshing. Women are very well represented on boards and committees. What strikes me is the percentage of women hospitalist leaders is significantly lower.

Q: Why do you think that is?

A: I haven’t wrapped my mind around whether that’s because they aren’t interested because of the choices they made in their lives—which is perfectly fine—or if it’s a lack of opportunity. I do think some women choose not to have a leadership role because their priorities are different, and that’s wonderful. But I wonder if there are cases when women are being passed over for those positions for men instead. The percentages are something we need to keep an eye on so we can better understand why that’s happening. TH

Mark Leiser is a freelance writer in New Jersey.

Rachel George, MD, MBA, FHM, CPE, acknowledges she found her calling through a fluke. After completing an internal-medicine residency in Chicago in 2002, she knew she wanted to stay in the region. She hadn’t decided much else.

“I was not excited about private practice, and I had thought about a cardiology fellowship,” Dr. George recalls. “I was trying to figure out what I wanted to do when I grew up, so to speak.”

She found a job as the lone hospitalist with OSF Medical Group in Rockford, Ill. Despite knowing she’d see “a ridiculous number of patients”—up to 30 per day on weekends—she liked it enough to sign on. “I decided I’d give it a chance for six months or a year while I figured out what I was really going to do,” she says.

Before long, she realized she already was doing it.

“I absolutely loved it,” says Dr. George, one of six new Team Hospitalist members who joined our reader advisory group in April. She now oversees five hospitalist programs in three states as regional medical director and vice president of operations for Brentwood, Tenn.-based Cogent Healthcare. “It was perfect. It was the niche I was looking for.”

Question: What did you enjoy so much about being a hospitalist?

Answer: The acuity of care, the instant gratification of fixing someone and sending them on their way, the intensity in the hospital, not feeling like I was being pulled in 15 different directions like you are in primary-care practice—all the good things about being a hospitalist.

Q: Within a year of joining OSF, you became medical director of its hospitalist service and oversaw its expansion. Did you always envision yourself moving into a leadership role?

A: When I started, I probably would have said my ultimate goal was to get my MBA and think about hospital administration. That was the 10-year plan, or maybe even the 15- or 20-year plan. But when people at the hospital began talking about expanding the [HM] program, I got thrust into the [medical director] role. By that point, I was hooked.

Q: Within three years, you grew the service from one physician to nine. How did you approach expansion?

A: The goal was sustainable growth—growth without sacrificing quality of patient care. When PCPs approached me about taking over their patient population, I’d say we’d take them on as we hired more people. I didn’t want to take off more than we could chew, and I didn’t want to have ridiculous turnover. That wouldn’t do anybody any good.

Q: You joined Cogent in 2006. What prompted the move?

A: I knew Cogent through SHM, and it was too good of an opportunity to pass up. The chance to expand my management responsibilities also was very appealing.

Q: What do you see as the biggest advantage of Cogent’s model?

A: I was part of an in-house program, and I think they’re great in a lot of ways. What they can’t do is economies of scale. There are certain things you can’t do just because it doesn’t make sense financially.

Q: Can you give an example?

A: The classic example I’ll give is discharge summaries in less than 24 hours. [At OSF], I did everything short of getting on my hands and knees and begging them to transcribe discharge summaries in less than 24 hours. They wouldn’t, and I understand why. It was a financial decision.

Cogent, from its inception, said this is too important and we’re going to make sure PCPs get information at discharge. Those types of economies of scale are very difficult to do in a small program, if you’re trying to do it yourself.

Q: What do you consider your biggest professional reward?

A: Seeing a really high-functioning HM team that I’ve helped make that way.

Q: What are the essential elements of such a team?

A: It’s the culture, that patient-first attitude. If everyone understands getting high-quality care to the patient is the most important thing, and we’re all working together to make sure that happens, everything else—core measure performance, decreasing the length of stay—will follow.

Q: What is your biggest challenge?

A: Trying to revamp broken programs.

Q: How do you begin that process?

A: Once the wrong attitude, wrong vision, and wrong culture have set in, we have to decide “How do we improve this?” It’s very difficult. You can’t just close the service and stop seeing patients until you’ve done what you need to do. It’s like trying to fix an airplane in midair.

Q: Despite an already full plate, you continue to see patients. Why?

A: I do it for myself. I don’t want to quit patient care. I enjoy talking to my patients, figuring out what’s wrong, and trying to help them.

Q: You attended the SHM Leadership Academy and have since facilitated academy sessions. What do you see as its benefit?

A: Hospital medicine is a business, whether we like to accept it or not. It’s important for physicians to understand the business drivers, not only for our own practice but for the hospital as well. The academy gives a great overview of the fundamentals of those business drivers.

Q: Would you recommend it for a physician who doesn’t intend to move into a leadership position?

A: I would. It’s valuable for anyone committed to hospital medicine. It helps them understand how their leaders are thinking and why they’re thinking the way they are.

Q: You are former chair of SHM’s Women in Hospital Medicine Task Force, and you pride yourself on balancing life and work. Is HM conducive to that balance?

A: It absolutely can be. Women sometimes think they have to be all things to all people all the time. It’s really about figuring out what your priorities are. I have two young kids and spending time with them is a bigger priority to me than cooking and cleaning. I’d rather live with a messy house and dishes in the sink than not spend time with them.

As a hospitalist, you have that flexibility, too. Most HM programs would love to have a stable, part-time physician. You can do that if you want, or you can be a nocturnist so you can be home with your kids during the day. You are in control of your own life. Understanding that is important, and you can make your choices accordingly.

Q: How do you think HM fares regarding the inclusion of women?

A: There isn’t as much of a good-old-boys’ club as opposed to other fields, which is really refreshing. Women are very well represented on boards and committees. What strikes me is the percentage of women hospitalist leaders is significantly lower.

Q: Why do you think that is?

A: I haven’t wrapped my mind around whether that’s because they aren’t interested because of the choices they made in their lives—which is perfectly fine—or if it’s a lack of opportunity. I do think some women choose not to have a leadership role because their priorities are different, and that’s wonderful. But I wonder if there are cases when women are being passed over for those positions for men instead. The percentages are something we need to keep an eye on so we can better understand why that’s happening. TH

Mark Leiser is a freelance writer in New Jersey.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

Michael-Anthony “M-A” Williams, MD, FHM, thought he had his future mapped out. After completing his residency in 1999, he joined Inpatient Services, PC (ISPC), in Denver with the intent to practice for a year and use his experience as a bridge to a fellowship or other professional opportunity.

The plan changed, however, when the IRS informed his HM group it owed $450,000 in unpaid payroll taxes, and banks began threatening to freeze accounts. After the dismissal of the group’s business manager for malfeasance, Dr. Williams offered to help. He took over as the practice’s financial officer, reconstructing two years’ worth of records and negotiating a compromise with the IRS.

The successful crisis resolution left Dr. Williams reassured that ISPC had a viable business. It also laid the foundation for his journey into HM leadership. He took over as the practice’s president in 2003. Four years later—after helping grow the practice from 16 physicians and 46,000 annual patient encounters to 38 physicians and 84,000 annual encounters—he helped orchestrate a merger with Tacoma, Wash.-based Sound Inpatient Physicians. He now serves as Sound’s executive director of business development.

“When I became financial officer, I didn’t know what P&L stood for,” Dr. Williams admits, referring to the common business jargon for a profit and loss statement as an example. “It really was an education from the ground up. But the reason I got involved in reconstructing the books in the first place was because I was interested in how the business of hospital medicine worked. That experience has served me well.”

Question: When you took over as president of ISPC, did you have a sense the growth would be so rapid?

Answer: We didn’t necessarily plan to continue to grow, but every time we turned around at a hospital, more primary-care doctors were asking us to take over their patients. It’s not something we actively sought. The business came to us. Before long, we realized the growth probably wasn’t going to stop.

Q: What prompted the merger with Sound?

A: It came down to infrastructure and support. We knew more growth was coming, and we were in a position where we needed more professional leadership. I wasn’t going to be in a position to do the president’s job forever, and we didn’t have other physicians necessarily clamoring for the opportunity. At the same time, we were very cautious. We wanted to make sure we merged with the right group that was physician-led.

Q: Three years into the partnership, what have the benefits been?

A: It has brought a lot of stability. There’s not that month-to-month worry the partners may have had about cash flow and how the business is functioning and what our health insurance premiums are doing, which were constant discussions before. And we have much stronger relationships with our hospital partners. That has allowed our doctors to get off the encounter treadmill. The biggest impetus for joining Sound was to provide a better workday for the hospitalists, because we kept seeing the encounters climbing higher and higher against our wishes.

Q: Have there been any unforeseen challenges?

A: The biggest challenge for those of us who were partners was ceding some control. It’s been a tradeoff. It’s been worth it to lose some control but gain a better workday and a little more stability.

Q: What advice would you give to someone whose group is going through an organizational change?

A: Thoroughly explore all of your options. Don’t be afraid to take a step back, take a pause and say, “Is this the right decision?” or “Why are we doing this?” Beyond that, make sure whoever you’re thinking of joining forces with has a philosophy that fits with yours. It doesn’t matter how much money is offered if, philosophically, you can’t come to terms.

Q: After the merger, you spent 18 months as chief medical officer of Sound’s Rocky Mountain Region. How hard was it to balance that role while caring for patients?

A: Incredibly hard. I used to joke I was two-thirds clinician and two-thirds administrative. It was a tremendous time commitment, but I always had a strong belief I could never be an effective physician leader without continuing to see patients in the hospital. I wanted to lead by example, but I also wanted to understand what my fellow physicians were going through on a day-to-day basis.

Q: In September 2008, you reverted strictly to clinical practice. Why did you make that choice?

A: I wanted to be able to have one job, not two. I wasn’t prepared to let go of clinical practice, and there was the issue of my time commitments as a physician leader. I have two young boys, and I wanted more time with my family. As trite as that may sound, it’s completely true.

Q: What did you learn in your leadership role that helps you as a practicing hospitalist?

A: It is imperative for working physicians to understand how the business works, and how it doesn’t work. I try to share—especially with younger physicians—all of the things that go into running a hospitalist practice. It doesn’t just happen by magic. I think it helps to have that perspective.

Q: What other advice would you offer to new physicians?

A: Don’t be afraid to get involved, whether it’s in hospital committee work or in the business of medicine. We are always looking for new leaders, and if that’s something that interests you, there will definitely be a role for you. It’s intimidating to come out of residency and think “Gosh, I didn’t get that much business education.” You can definitely learn it. If you have the interest, it’s worth asking the questions and getting involved.

Q: You say you better understand the value a hospitalist brings to the table. How does that translate into quality of care?

A: By expanding physicians’ view away from just direct clinical care to the quality metrics that need to be followed. What is the documentation appropriate for a patient? What are the hospital’s goals, from time of discharge to patient satisfaction scores, and how can we help meet them? While we all still very much prize our independence, we are part of a larger field of healthcare in general. We can’t make all of our decisions in a vacuum.

Q: What’s the biggest challenge you face?

A: The continual pursuit of the right mix of the right staffing and workload for our program. Having done this for 10 years now, I don’t have any doubt that you can do it, but it’s a continual adjustment to find the right balance.

Q: You gave a talk at an SHM annual meeting about hospitalist burnout. What’s the secret to recognizing it and preventing it?

A: One of the first things—before the hire ever happens—is to make sure the group’s philosophy and the individual’s philosophy about time and money and workload are in agreement. You need to continue to evaluate those principles on an ongoing basis to make sure they continue to agree, because they can diverge over time. It’s a constant focus on the group’s end.

Q: What’s your biggest reward?

A: Taking care of patients. There’s no greater satisfaction than making a complex and frightening hospital stay a little more simple to understand, and a little less frightening, by having an open discussion with the patient and their family to help them get through it. That’s still what gives me the greatest joy.

Q: You were inducted into SHM’s inaugural class of physicians who received Fellow in Hospital Medicine (FHM) distinction. What does that recognition mean to you?

A: I was very honored to be in the inaugural class, and I’m excited to see them offer that distinction. I think that’s very important. It allows SHM to recognize a greater variety of leaders beyond those who make it their focus to write and speak.

Q: What’s next for you professionally?

A: I’m enjoying the respite, as much as it is one. I’m sure I’ll get involved again with a physician leadership role. When I started, there was some concern no one would be a hospitalist forever. The thinking was you’d do it for a year or two, burn out, and do something else. The biggest question I had in 1999 was, Can HM be a career? Ten years later, it’s nice to see that question answered. TH

Mark Leiser is a freelance writer based in New Jersey.

Michael-Anthony “M-A” Williams, MD, FHM, thought he had his future mapped out. After completing his residency in 1999, he joined Inpatient Services, PC (ISPC), in Denver with the intent to practice for a year and use his experience as a bridge to a fellowship or other professional opportunity.

The plan changed, however, when the IRS informed his HM group it owed $450,000 in unpaid payroll taxes, and banks began threatening to freeze accounts. After the dismissal of the group’s business manager for malfeasance, Dr. Williams offered to help. He took over as the practice’s financial officer, reconstructing two years’ worth of records and negotiating a compromise with the IRS.

The successful crisis resolution left Dr. Williams reassured that ISPC had a viable business. It also laid the foundation for his journey into HM leadership. He took over as the practice’s president in 2003. Four years later—after helping grow the practice from 16 physicians and 46,000 annual patient encounters to 38 physicians and 84,000 annual encounters—he helped orchestrate a merger with Tacoma, Wash.-based Sound Inpatient Physicians. He now serves as Sound’s executive director of business development.

“When I became financial officer, I didn’t know what P&L stood for,” Dr. Williams admits, referring to the common business jargon for a profit and loss statement as an example. “It really was an education from the ground up. But the reason I got involved in reconstructing the books in the first place was because I was interested in how the business of hospital medicine worked. That experience has served me well.”

Question: When you took over as president of ISPC, did you have a sense the growth would be so rapid?

Answer: We didn’t necessarily plan to continue to grow, but every time we turned around at a hospital, more primary-care doctors were asking us to take over their patients. It’s not something we actively sought. The business came to us. Before long, we realized the growth probably wasn’t going to stop.

Q: What prompted the merger with Sound?

A: It came down to infrastructure and support. We knew more growth was coming, and we were in a position where we needed more professional leadership. I wasn’t going to be in a position to do the president’s job forever, and we didn’t have other physicians necessarily clamoring for the opportunity. At the same time, we were very cautious. We wanted to make sure we merged with the right group that was physician-led.

Q: Three years into the partnership, what have the benefits been?

A: It has brought a lot of stability. There’s not that month-to-month worry the partners may have had about cash flow and how the business is functioning and what our health insurance premiums are doing, which were constant discussions before. And we have much stronger relationships with our hospital partners. That has allowed our doctors to get off the encounter treadmill. The biggest impetus for joining Sound was to provide a better workday for the hospitalists, because we kept seeing the encounters climbing higher and higher against our wishes.

Q: Have there been any unforeseen challenges?

A: The biggest challenge for those of us who were partners was ceding some control. It’s been a tradeoff. It’s been worth it to lose some control but gain a better workday and a little more stability.

Q: What advice would you give to someone whose group is going through an organizational change?

A: Thoroughly explore all of your options. Don’t be afraid to take a step back, take a pause and say, “Is this the right decision?” or “Why are we doing this?” Beyond that, make sure whoever you’re thinking of joining forces with has a philosophy that fits with yours. It doesn’t matter how much money is offered if, philosophically, you can’t come to terms.

Q: After the merger, you spent 18 months as chief medical officer of Sound’s Rocky Mountain Region. How hard was it to balance that role while caring for patients?

A: Incredibly hard. I used to joke I was two-thirds clinician and two-thirds administrative. It was a tremendous time commitment, but I always had a strong belief I could never be an effective physician leader without continuing to see patients in the hospital. I wanted to lead by example, but I also wanted to understand what my fellow physicians were going through on a day-to-day basis.

Q: In September 2008, you reverted strictly to clinical practice. Why did you make that choice?

A: I wanted to be able to have one job, not two. I wasn’t prepared to let go of clinical practice, and there was the issue of my time commitments as a physician leader. I have two young boys, and I wanted more time with my family. As trite as that may sound, it’s completely true.

Q: What did you learn in your leadership role that helps you as a practicing hospitalist?

A: It is imperative for working physicians to understand how the business works, and how it doesn’t work. I try to share—especially with younger physicians—all of the things that go into running a hospitalist practice. It doesn’t just happen by magic. I think it helps to have that perspective.

Q: What other advice would you offer to new physicians?

A: Don’t be afraid to get involved, whether it’s in hospital committee work or in the business of medicine. We are always looking for new leaders, and if that’s something that interests you, there will definitely be a role for you. It’s intimidating to come out of residency and think “Gosh, I didn’t get that much business education.” You can definitely learn it. If you have the interest, it’s worth asking the questions and getting involved.

Q: You say you better understand the value a hospitalist brings to the table. How does that translate into quality of care?

A: By expanding physicians’ view away from just direct clinical care to the quality metrics that need to be followed. What is the documentation appropriate for a patient? What are the hospital’s goals, from time of discharge to patient satisfaction scores, and how can we help meet them? While we all still very much prize our independence, we are part of a larger field of healthcare in general. We can’t make all of our decisions in a vacuum.

Q: What’s the biggest challenge you face?

A: The continual pursuit of the right mix of the right staffing and workload for our program. Having done this for 10 years now, I don’t have any doubt that you can do it, but it’s a continual adjustment to find the right balance.

Q: You gave a talk at an SHM annual meeting about hospitalist burnout. What’s the secret to recognizing it and preventing it?

A: One of the first things—before the hire ever happens—is to make sure the group’s philosophy and the individual’s philosophy about time and money and workload are in agreement. You need to continue to evaluate those principles on an ongoing basis to make sure they continue to agree, because they can diverge over time. It’s a constant focus on the group’s end.

Q: What’s your biggest reward?

A: Taking care of patients. There’s no greater satisfaction than making a complex and frightening hospital stay a little more simple to understand, and a little less frightening, by having an open discussion with the patient and their family to help them get through it. That’s still what gives me the greatest joy.

Q: You were inducted into SHM’s inaugural class of physicians who received Fellow in Hospital Medicine (FHM) distinction. What does that recognition mean to you?

A: I was very honored to be in the inaugural class, and I’m excited to see them offer that distinction. I think that’s very important. It allows SHM to recognize a greater variety of leaders beyond those who make it their focus to write and speak.

Q: What’s next for you professionally?

A: I’m enjoying the respite, as much as it is one. I’m sure I’ll get involved again with a physician leadership role. When I started, there was some concern no one would be a hospitalist forever. The thinking was you’d do it for a year or two, burn out, and do something else. The biggest question I had in 1999 was, Can HM be a career? Ten years later, it’s nice to see that question answered. TH

Mark Leiser is a freelance writer based in New Jersey.

Michael-Anthony “M-A” Williams, MD, FHM, thought he had his future mapped out. After completing his residency in 1999, he joined Inpatient Services, PC (ISPC), in Denver with the intent to practice for a year and use his experience as a bridge to a fellowship or other professional opportunity.

The plan changed, however, when the IRS informed his HM group it owed $450,000 in unpaid payroll taxes, and banks began threatening to freeze accounts. After the dismissal of the group’s business manager for malfeasance, Dr. Williams offered to help. He took over as the practice’s financial officer, reconstructing two years’ worth of records and negotiating a compromise with the IRS.

The successful crisis resolution left Dr. Williams reassured that ISPC had a viable business. It also laid the foundation for his journey into HM leadership. He took over as the practice’s president in 2003. Four years later—after helping grow the practice from 16 physicians and 46,000 annual patient encounters to 38 physicians and 84,000 annual encounters—he helped orchestrate a merger with Tacoma, Wash.-based Sound Inpatient Physicians. He now serves as Sound’s executive director of business development.

“When I became financial officer, I didn’t know what P&L stood for,” Dr. Williams admits, referring to the common business jargon for a profit and loss statement as an example. “It really was an education from the ground up. But the reason I got involved in reconstructing the books in the first place was because I was interested in how the business of hospital medicine worked. That experience has served me well.”

Question: When you took over as president of ISPC, did you have a sense the growth would be so rapid?

Answer: We didn’t necessarily plan to continue to grow, but every time we turned around at a hospital, more primary-care doctors were asking us to take over their patients. It’s not something we actively sought. The business came to us. Before long, we realized the growth probably wasn’t going to stop.

Q: What prompted the merger with Sound?

A: It came down to infrastructure and support. We knew more growth was coming, and we were in a position where we needed more professional leadership. I wasn’t going to be in a position to do the president’s job forever, and we didn’t have other physicians necessarily clamoring for the opportunity. At the same time, we were very cautious. We wanted to make sure we merged with the right group that was physician-led.

Q: Three years into the partnership, what have the benefits been?

A: It has brought a lot of stability. There’s not that month-to-month worry the partners may have had about cash flow and how the business is functioning and what our health insurance premiums are doing, which were constant discussions before. And we have much stronger relationships with our hospital partners. That has allowed our doctors to get off the encounter treadmill. The biggest impetus for joining Sound was to provide a better workday for the hospitalists, because we kept seeing the encounters climbing higher and higher against our wishes.

Q: Have there been any unforeseen challenges?

A: The biggest challenge for those of us who were partners was ceding some control. It’s been a tradeoff. It’s been worth it to lose some control but gain a better workday and a little more stability.

Q: What advice would you give to someone whose group is going through an organizational change?

A: Thoroughly explore all of your options. Don’t be afraid to take a step back, take a pause and say, “Is this the right decision?” or “Why are we doing this?” Beyond that, make sure whoever you’re thinking of joining forces with has a philosophy that fits with yours. It doesn’t matter how much money is offered if, philosophically, you can’t come to terms.

Q: After the merger, you spent 18 months as chief medical officer of Sound’s Rocky Mountain Region. How hard was it to balance that role while caring for patients?

A: Incredibly hard. I used to joke I was two-thirds clinician and two-thirds administrative. It was a tremendous time commitment, but I always had a strong belief I could never be an effective physician leader without continuing to see patients in the hospital. I wanted to lead by example, but I also wanted to understand what my fellow physicians were going through on a day-to-day basis.

Q: In September 2008, you reverted strictly to clinical practice. Why did you make that choice?

A: I wanted to be able to have one job, not two. I wasn’t prepared to let go of clinical practice, and there was the issue of my time commitments as a physician leader. I have two young boys, and I wanted more time with my family. As trite as that may sound, it’s completely true.

Q: What did you learn in your leadership role that helps you as a practicing hospitalist?

A: It is imperative for working physicians to understand how the business works, and how it doesn’t work. I try to share—especially with younger physicians—all of the things that go into running a hospitalist practice. It doesn’t just happen by magic. I think it helps to have that perspective.

Q: What other advice would you offer to new physicians?

A: Don’t be afraid to get involved, whether it’s in hospital committee work or in the business of medicine. We are always looking for new leaders, and if that’s something that interests you, there will definitely be a role for you. It’s intimidating to come out of residency and think “Gosh, I didn’t get that much business education.” You can definitely learn it. If you have the interest, it’s worth asking the questions and getting involved.

Q: You say you better understand the value a hospitalist brings to the table. How does that translate into quality of care?

A: By expanding physicians’ view away from just direct clinical care to the quality metrics that need to be followed. What is the documentation appropriate for a patient? What are the hospital’s goals, from time of discharge to patient satisfaction scores, and how can we help meet them? While we all still very much prize our independence, we are part of a larger field of healthcare in general. We can’t make all of our decisions in a vacuum.

Q: What’s the biggest challenge you face?

A: The continual pursuit of the right mix of the right staffing and workload for our program. Having done this for 10 years now, I don’t have any doubt that you can do it, but it’s a continual adjustment to find the right balance.

Q: You gave a talk at an SHM annual meeting about hospitalist burnout. What’s the secret to recognizing it and preventing it?

A: One of the first things—before the hire ever happens—is to make sure the group’s philosophy and the individual’s philosophy about time and money and workload are in agreement. You need to continue to evaluate those principles on an ongoing basis to make sure they continue to agree, because they can diverge over time. It’s a constant focus on the group’s end.

Q: What’s your biggest reward?

A: Taking care of patients. There’s no greater satisfaction than making a complex and frightening hospital stay a little more simple to understand, and a little less frightening, by having an open discussion with the patient and their family to help them get through it. That’s still what gives me the greatest joy.

Q: You were inducted into SHM’s inaugural class of physicians who received Fellow in Hospital Medicine (FHM) distinction. What does that recognition mean to you?

A: I was very honored to be in the inaugural class, and I’m excited to see them offer that distinction. I think that’s very important. It allows SHM to recognize a greater variety of leaders beyond those who make it their focus to write and speak.

Q: What’s next for you professionally?

A: I’m enjoying the respite, as much as it is one. I’m sure I’ll get involved again with a physician leadership role. When I started, there was some concern no one would be a hospitalist forever. The thinking was you’d do it for a year or two, burn out, and do something else. The biggest question I had in 1999 was, Can HM be a career? Ten years later, it’s nice to see that question answered. TH

Mark Leiser is a freelance writer based in New Jersey.

Dr. Aguirre

Felix Aguirre, MD, entered the field of hospital medicine before the term “hospitalist” had been coined. He didn’t realize how quickly the field would explode, but it didn’t take long to find out. Aguirre helped start an inpatient service in 1994, taking care of patients for about 20 primary-care physicians. Within three years, his service cared for the patients of 360 doctors.

Dr. Aguirre cofounded Hospitalists of San Antonio in 2000, and he served as president of the company until it merged with IPC: The Hospitalist Co. three years later.

A graduate of the U.S. Military Academy at West Point, Dr. Aguirre spent several years as an air-traffic controller before attending medical school. He currently is vice president of medical affairs for California-based IPC, which provides management services to hospitalist practices in more than 400 facilities.

“The biggest reward is being part of a growth industry, helping to mold it and move it forward,” says Dr. Aguirre, who is responsible for medical and leadership oversight, as well as developing IPC’s physicians and providers. “I’m very proud it’s starting to get distinction as a separate specialty, and I really like the idea of getting in on the ground floor. Everybody likes to be one of the pioneers of an industry.”

Question: How did West Point help prepare you for your current career?

Answer: As part of your education at West Point, you need to learn to be a follower before you can learn to be a leader. Coming out of the academy, I was pretty cocky and I thought I could do anything. I’ve learned some pretty humbling lessons, and experience teaches you how to temper that attitude.

Q: How about your time as an air-traffic controller?

A: You have to be able to deal with many things at once and be able to deal with pressure. That experience is great for a career in an emergency room and in hospital medicine, where you’re juggling a lot of information and facing situations that require pretty rapid action.

Q: When you entered HM, did you have a sense of how much—and how quickly—the field would grow?

A: No. It really was in its infancy at that time … but when Dr. (Robert) Wachter (coined the term “hospitalist”), it began to pick up momentum. Before long, we could see there wasn’t going to be any slowing down of this type of medicine. It’s great to be a part of an industry that is still a growing industry, especially in this economic climate. It’s needed now more than ever, so I feel I made the correct decision to enter this field.

Q: Why do you feel it’s needed more now than ever?

A: With healthcare, there needs to be more control, clinically as well as financially. I think hospitalists are well positioned right in the middle of the hospital. They are exposed to every aspect of the hospital’s operation and staff, whether it’s the cleaning service or dietary or physical therapy or talking to specialists or other physicians. Who better to help control what happens than the person who is exposed to it?

Q: What is the biggest challenge you face in your current role?

A: One of the big ones is reduction in variance. Everybody is looking for ways to reduce variance in clinical care, and that’s going to continue to be one of the biggest challenges as we grow. If you’re a small mom-and-pop business, it’s pretty easy to control things. That gets more difficult as you grow. The things that worked when you were smaller don’t work in a medium-sized company, let alone when you become a large company. You have to change the way you manage things, which leads to another challenge—adapting to the change.

Q: Is the fear of a hospitalist shortage on your radar screen?

A: It is. But I can tell you this: We won’t stress about it, because it is going to happen. There will be a shortage—there already is. What we have to try to do is position ourselves as the company, or employer, of choice. We get close to 3,000 applicants a year and hire 200 or so, so we’re fortunate in that we have a tremendous amount of exposure to many of the people who are desiring a hospitalist career.

Q: What do you see as the biggest benefit to the IPC model?

A: There are a couple of things I see, not just as advantages but also as strengths. Number one, IPC has extremely strong leadership. All of the people I work with on the senior leadership level are top-notch people. It’s great to be part of an organization that surrounds itself with talent. The next thing is, it’s a great place to work. IPC was selected as one of the 100 best places to work in healthcare (by Modern Healthcare). We made this list, and a lot of other high-profile names in healthcare did not, so we’re very proud of that.

Q: How does the IPC model translate to increased quality of care?

A: We have resources to educate our physicians. There are hospitals around the country with one-person, two-person, or four-person groups that don’t have the resources to do certain types of training. They acquire it by experience. We’re able to orient them to hospital medicine first … and then bring them along slowly and give them the additional training we think they need to succeed. We also have the resources to do ongoing education and monitor quality measures and efficiency measures as well.

Q: You have been a member of SHM’s Public Policy Committee for about four years. How important is that role?

A: I think it’s incredibly important. The Public Policy Committee gets to be in tune with what the national issues are, and we can help the society foster and create relationships. We had the chance to meet with members of Congress and other national organizations like CMS (Centers for Medicare and Medicaid Services) and AHRQ (Agency for Healthcare Research and Quality), even before healthcare reform became important.

Q: You and other members of the committee went to Washington, D.C., in March. What was the benefit of that trip?

A: We’ve been to Washington several times. We try to do it at least yearly. In previous years, we spent a lot of time just educating people about what hospitalists do. When we first went there, we were surprised by how many members of Congress had never heard of what a hospitalist was. This past year, they were much more aware of what a hospitalist is and how we can help with the goals of healthcare reform.

Q: What’s next for you?

A: I think for now I’m pretty happy with my position and my roles and responsibilities. I help with several different aspects of IPC. I help with some of the risk-management compliance issues. I make presentations to different hospitals and groups we’re thinking of doing business with. I have a varied career, and I enjoy it very much. TH

Mark Leiser is a freelance writer based in New Jersey.

Dr. Aguirre

Felix Aguirre, MD, entered the field of hospital medicine before the term “hospitalist” had been coined. He didn’t realize how quickly the field would explode, but it didn’t take long to find out. Aguirre helped start an inpatient service in 1994, taking care of patients for about 20 primary-care physicians. Within three years, his service cared for the patients of 360 doctors.

Dr. Aguirre cofounded Hospitalists of San Antonio in 2000, and he served as president of the company until it merged with IPC: The Hospitalist Co. three years later.

A graduate of the U.S. Military Academy at West Point, Dr. Aguirre spent several years as an air-traffic controller before attending medical school. He currently is vice president of medical affairs for California-based IPC, which provides management services to hospitalist practices in more than 400 facilities.

“The biggest reward is being part of a growth industry, helping to mold it and move it forward,” says Dr. Aguirre, who is responsible for medical and leadership oversight, as well as developing IPC’s physicians and providers. “I’m very proud it’s starting to get distinction as a separate specialty, and I really like the idea of getting in on the ground floor. Everybody likes to be one of the pioneers of an industry.”

Question: How did West Point help prepare you for your current career?

Answer: As part of your education at West Point, you need to learn to be a follower before you can learn to be a leader. Coming out of the academy, I was pretty cocky and I thought I could do anything. I’ve learned some pretty humbling lessons, and experience teaches you how to temper that attitude.

Q: How about your time as an air-traffic controller?

A: You have to be able to deal with many things at once and be able to deal with pressure. That experience is great for a career in an emergency room and in hospital medicine, where you’re juggling a lot of information and facing situations that require pretty rapid action.

Q: When you entered HM, did you have a sense of how much—and how quickly—the field would grow?

A: No. It really was in its infancy at that time … but when Dr. (Robert) Wachter (coined the term “hospitalist”), it began to pick up momentum. Before long, we could see there wasn’t going to be any slowing down of this type of medicine. It’s great to be a part of an industry that is still a growing industry, especially in this economic climate. It’s needed now more than ever, so I feel I made the correct decision to enter this field.

Q: Why do you feel it’s needed more now than ever?

A: With healthcare, there needs to be more control, clinically as well as financially. I think hospitalists are well positioned right in the middle of the hospital. They are exposed to every aspect of the hospital’s operation and staff, whether it’s the cleaning service or dietary or physical therapy or talking to specialists or other physicians. Who better to help control what happens than the person who is exposed to it?

Q: What is the biggest challenge you face in your current role?

A: One of the big ones is reduction in variance. Everybody is looking for ways to reduce variance in clinical care, and that’s going to continue to be one of the biggest challenges as we grow. If you’re a small mom-and-pop business, it’s pretty easy to control things. That gets more difficult as you grow. The things that worked when you were smaller don’t work in a medium-sized company, let alone when you become a large company. You have to change the way you manage things, which leads to another challenge—adapting to the change.

Q: Is the fear of a hospitalist shortage on your radar screen?

A: It is. But I can tell you this: We won’t stress about it, because it is going to happen. There will be a shortage—there already is. What we have to try to do is position ourselves as the company, or employer, of choice. We get close to 3,000 applicants a year and hire 200 or so, so we’re fortunate in that we have a tremendous amount of exposure to many of the people who are desiring a hospitalist career.

Q: What do you see as the biggest benefit to the IPC model?

A: There are a couple of things I see, not just as advantages but also as strengths. Number one, IPC has extremely strong leadership. All of the people I work with on the senior leadership level are top-notch people. It’s great to be part of an organization that surrounds itself with talent. The next thing is, it’s a great place to work. IPC was selected as one of the 100 best places to work in healthcare (by Modern Healthcare). We made this list, and a lot of other high-profile names in healthcare did not, so we’re very proud of that.

Q: How does the IPC model translate to increased quality of care?

A: We have resources to educate our physicians. There are hospitals around the country with one-person, two-person, or four-person groups that don’t have the resources to do certain types of training. They acquire it by experience. We’re able to orient them to hospital medicine first … and then bring them along slowly and give them the additional training we think they need to succeed. We also have the resources to do ongoing education and monitor quality measures and efficiency measures as well.

Q: You have been a member of SHM’s Public Policy Committee for about four years. How important is that role?

A: I think it’s incredibly important. The Public Policy Committee gets to be in tune with what the national issues are, and we can help the society foster and create relationships. We had the chance to meet with members of Congress and other national organizations like CMS (Centers for Medicare and Medicaid Services) and AHRQ (Agency for Healthcare Research and Quality), even before healthcare reform became important.

Q: You and other members of the committee went to Washington, D.C., in March. What was the benefit of that trip?

A: We’ve been to Washington several times. We try to do it at least yearly. In previous years, we spent a lot of time just educating people about what hospitalists do. When we first went there, we were surprised by how many members of Congress had never heard of what a hospitalist was. This past year, they were much more aware of what a hospitalist is and how we can help with the goals of healthcare reform.

Q: What’s next for you?

A: I think for now I’m pretty happy with my position and my roles and responsibilities. I help with several different aspects of IPC. I help with some of the risk-management compliance issues. I make presentations to different hospitals and groups we’re thinking of doing business with. I have a varied career, and I enjoy it very much. TH

Mark Leiser is a freelance writer based in New Jersey.

Dr. Aguirre

Felix Aguirre, MD, entered the field of hospital medicine before the term “hospitalist” had been coined. He didn’t realize how quickly the field would explode, but it didn’t take long to find out. Aguirre helped start an inpatient service in 1994, taking care of patients for about 20 primary-care physicians. Within three years, his service cared for the patients of 360 doctors.

Dr. Aguirre cofounded Hospitalists of San Antonio in 2000, and he served as president of the company until it merged with IPC: The Hospitalist Co. three years later.

A graduate of the U.S. Military Academy at West Point, Dr. Aguirre spent several years as an air-traffic controller before attending medical school. He currently is vice president of medical affairs for California-based IPC, which provides management services to hospitalist practices in more than 400 facilities.

“The biggest reward is being part of a growth industry, helping to mold it and move it forward,” says Dr. Aguirre, who is responsible for medical and leadership oversight, as well as developing IPC’s physicians and providers. “I’m very proud it’s starting to get distinction as a separate specialty, and I really like the idea of getting in on the ground floor. Everybody likes to be one of the pioneers of an industry.”

Question: How did West Point help prepare you for your current career?

Answer: As part of your education at West Point, you need to learn to be a follower before you can learn to be a leader. Coming out of the academy, I was pretty cocky and I thought I could do anything. I’ve learned some pretty humbling lessons, and experience teaches you how to temper that attitude.

Q: How about your time as an air-traffic controller?

A: You have to be able to deal with many things at once and be able to deal with pressure. That experience is great for a career in an emergency room and in hospital medicine, where you’re juggling a lot of information and facing situations that require pretty rapid action.

Q: When you entered HM, did you have a sense of how much—and how quickly—the field would grow?

A: No. It really was in its infancy at that time … but when Dr. (Robert) Wachter (coined the term “hospitalist”), it began to pick up momentum. Before long, we could see there wasn’t going to be any slowing down of this type of medicine. It’s great to be a part of an industry that is still a growing industry, especially in this economic climate. It’s needed now more than ever, so I feel I made the correct decision to enter this field.

Q: Why do you feel it’s needed more now than ever?

A: With healthcare, there needs to be more control, clinically as well as financially. I think hospitalists are well positioned right in the middle of the hospital. They are exposed to every aspect of the hospital’s operation and staff, whether it’s the cleaning service or dietary or physical therapy or talking to specialists or other physicians. Who better to help control what happens than the person who is exposed to it?

Q: What is the biggest challenge you face in your current role?

A: One of the big ones is reduction in variance. Everybody is looking for ways to reduce variance in clinical care, and that’s going to continue to be one of the biggest challenges as we grow. If you’re a small mom-and-pop business, it’s pretty easy to control things. That gets more difficult as you grow. The things that worked when you were smaller don’t work in a medium-sized company, let alone when you become a large company. You have to change the way you manage things, which leads to another challenge—adapting to the change.

Q: Is the fear of a hospitalist shortage on your radar screen?

A: It is. But I can tell you this: We won’t stress about it, because it is going to happen. There will be a shortage—there already is. What we have to try to do is position ourselves as the company, or employer, of choice. We get close to 3,000 applicants a year and hire 200 or so, so we’re fortunate in that we have a tremendous amount of exposure to many of the people who are desiring a hospitalist career.

Q: What do you see as the biggest benefit to the IPC model?

A: There are a couple of things I see, not just as advantages but also as strengths. Number one, IPC has extremely strong leadership. All of the people I work with on the senior leadership level are top-notch people. It’s great to be part of an organization that surrounds itself with talent. The next thing is, it’s a great place to work. IPC was selected as one of the 100 best places to work in healthcare (by Modern Healthcare). We made this list, and a lot of other high-profile names in healthcare did not, so we’re very proud of that.

Q: How does the IPC model translate to increased quality of care?

A: We have resources to educate our physicians. There are hospitals around the country with one-person, two-person, or four-person groups that don’t have the resources to do certain types of training. They acquire it by experience. We’re able to orient them to hospital medicine first … and then bring them along slowly and give them the additional training we think they need to succeed. We also have the resources to do ongoing education and monitor quality measures and efficiency measures as well.

Q: You have been a member of SHM’s Public Policy Committee for about four years. How important is that role?

A: I think it’s incredibly important. The Public Policy Committee gets to be in tune with what the national issues are, and we can help the society foster and create relationships. We had the chance to meet with members of Congress and other national organizations like CMS (Centers for Medicare and Medicaid Services) and AHRQ (Agency for Healthcare Research and Quality), even before healthcare reform became important.

Q: You and other members of the committee went to Washington, D.C., in March. What was the benefit of that trip?

A: We’ve been to Washington several times. We try to do it at least yearly. In previous years, we spent a lot of time just educating people about what hospitalists do. When we first went there, we were surprised by how many members of Congress had never heard of what a hospitalist was. This past year, they were much more aware of what a hospitalist is and how we can help with the goals of healthcare reform.

Q: What’s next for you?

A: I think for now I’m pretty happy with my position and my roles and responsibilities. I help with several different aspects of IPC. I help with some of the risk-management compliance issues. I make presentations to different hospitals and groups we’re thinking of doing business with. I have a varied career, and I enjoy it very much. TH

Mark Leiser is a freelance writer based in New Jersey.

The Hippocratic Oath has served as the foundation of ethical medical practice since the fourth century B.C. Today, one of the oath’s core principles—the promise to do no harm—is guiding more than just bedside care. It is the cornerstone of the green movement in healthcare, a rapidly growing effort to help the profession evolve from one that simply cares for the sick to one that serves as a broader force for healing in society.

Some experts note the medical industry has been slow to understand the effects of its practices on public health. Barely a decade ago, U.S. Environmental Protection Agency (EPA) reports revealed staggering statistics: Medical waste incinerators were the leading producer of airborne carcinogenic dioxins, asthma rates for healthcare workers were among the highest of any profession, and healthcare waste was responsible for 10% of mercury air emissions.1

The incredible irony produced “a teachable moment,” says Gary Cohen, co-executive director of Health Care Without Harm in Arlington, Va., an international coalition established in 1996 to help make the industry more ecologically sustainable. Since then, hospitals have eliminated mercury from many of their supplies, including blood-pressure cuffs and thermometers. Additionally, the efforts to transform buying practices and lessen reliance on fossil fuels have gained considerable traction. And the number of medical waste incinerators in the U.S. has dropped from 5,000 to less than 100.

“The healthcare sector began to understand the links between the environment and disease. They realized they were both addressing the collateral damage of a poisoned environment, and they were contributing to it,” Cohen says.

Now, even those who are critical of the profession’s past practices are lauding industry leaders’ efforts to build more efficient facilities, reduce waste, and modify day-to-day practices to lessen their environmental footprint.

“Hospitals have been so focused, rightly so, on patient safety,” Cohen says. “Now we’re at the point where we’re talking about patient safety, worker safety, and environmental safety. It’s changing the architecture of how things are done, and it is becoming much more accepted as a mainstream concern.”

Concern should stretch beyond the C-suite to those on the front lines, says Don Williams, MD, a pediatric hospitalist at Dell Children’s Medical Center in Austin, Texas, and a board member of Austin Physicians for Social Responsibility. “Although it is rare for us to see the direct effects of green choices on the health of individual patients, I think it is important to recognize that less air pollution and less global warming leads to less illness,” says Dr. Williams, who works in the only platinum-rated Leadership in Environmental Energy and Design certified hospital in the U.S. The certification, through the U.S. Green Building Council (www.usgbc.org), means the hospital meets the highest of standards in sustainable site development, water savings, energy efficiency, materials selection, and indoor environmental quality.

Hospitalists should be engaged in environmental stewardship because they often are seen as role models for hospital staff, residents, students, patients, and families, Dr. Williams says. “We are also frequently in positions of influence when it comes to instituting hospital policy,” he adds. “Hospital administration officials usually like to keep a friendly relationship with us, and are therefore typically open to our thoughts and concerns on everything from recycling programs to new hospital design.”

PHOTO COURTESY OF KAISER PERMANENTE

New Ways to Build

The most visible sign of American hospitals’ commitment to environmental responsibility is evident in construction. About 81% of hospital building projects last year included environmentally friendly materials, according to a survey by the American Society for Healthcare Engineering. That’s up from 55% in 2006.

Kaiser Permanente, an integrated managed-care organization that operates 37 medical centers in nine Western states, is among the industry leaders in green construction. Its Modesto (Calif.) Medical Center, which opened in October 2008, has received national recognition as one of the greenest healthcare facilities in North America. How green? Permeable pavement in the parking area allows rainwater to filter into the ground, and solar panels generate enough electricity to power up to 20 homes. Building materials were selected with an eye toward patient and employee health. Kaiser worked with a carpet manufacturer to create a product free of potentially harmful polyvinyl chloride. It installed cabinetry made from medium-density fiberboard that did not contain formaldehyde, and it chose paints low in volatile organic compounds.

“People would walk into the hospital and say, ‘This place doesn’t smell new,’ ” says project director Jeffrey Deane. “That’s because people are used to smelling new carpet and new paint, because those materials are outgassing huge quantities of nauseous gases.”

Deane acknowledges it is difficult to create a truly green hospital, given the presence of chemicals and pharmaceuticals, and the way the facility must be cleaned to fight infectious bacteria. But the effort to make the environment within the building less harmful didn’t break the bank. The paint and essentially toxin-free fabrics cost the same or less than traditional materials, and a two-duct air system—which draws air solely from the outside, eliminating recirculation—is easier to maintain and costs less to operate.

“One of the biggest hurdles is getting people past the idea that it’s going to cost too much money,” Deane says. “We have a tendency to value-engineer things because they are cheaper up front. Even in cases when they aren’t, there are ramifications down the road that are pretty significant. For every dollar you spend upgrading your system to be more efficient and environmentally friendly, you’ll get paid back several times over.”

Energy Efficiency

Although new construction provides a clean slate for hospitals to go green, administrations at existing facilities have identified several ways to lessen their environmental footprint. One of the quickest—and most cost-effective—is to improve energy efficiency.

Hospitals are the second-most energy-intensive type of structure in the U.S. behind food service, according to the U.S. Department of Energy.1 That consumption costs inpatient healthcare facilities about $5.3 billion annually—about 3% of the average hospital’s operating budget—and results in about 30 pounds of carbon dioxide emissions per square foot, more than double the emissions of standard commercial office buildings, the department estimates.

Energy savings provide an immediate boost to the bottom line, says Clark Reed, director of the Healthcare Facilities Division at the EPA’s Energy Star program. Based on average profit margins, every dollar a nonprofit hospital saves on its energy costs is equivalent to generating $20 in new revenue, Reed says.

“Because of the dollars involved, energy management is getting C-suite attention,” says Nick DeDominicis of Arlington, Va.-based Practice Greenhealth, a networking organization for healthcare institutions that have committed to eco-friendly practices. “We see an increasing number of hospitals thinking about developing strategic master energy plans, looking at facility management in much the same way they’d look at asset management at the boardroom level.”

That’s why Practice Greenhealth created its Healthcare Clean Energy Exchange, an electronic marketplace in which more than 250 suppliers compete to meet healthcare facilities’ energy needs. The program debuted in 2008 and is operated in a reverse-auction format, with suppliers bidding downward to compete for contracts. It is designed to help healthcare entities lock in stable pricing and increase their percentage of green or renewable energy purchases. The auctions carry no upfront fees, and if a healthcare entity doesn’t like the results, it is not forced to sign a contract.

Ingalls Health System in Harvey, Ill., explored the exchange program after energy prices skyrocketed last summer. Before participating in the exchange, Ingalls used 100% “brown”—or conventionally produced—electricity. During the auction, it sought bids for varying mixes of conventional and renewable power. “I actually was very skeptical we would be able to get green energy at a lower cost,” says chief financial officer Vince Pryor. “Frankly, I was hoping to break even.”

The results surpassed expectations. Ingalls signed a three-year contract for electricity, 5% of which now comes from renewable sources. It’s a small step, one the health system believes is in the right direction, as they expect to save $375,000 over the contract period and cut carbon dioxide emissions by 3,433 tons. “I think we would have been happy if we had kept costs neutral and gotten a bit of a green footprint,” Pryor says. “But the process worked out far better than that. It’s obviously a win-win for us.”

We have a lot of growing to do on the physician side. That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.

—Paul Rosenau, MD, pediatric hospitalist, Fletcher Allen Health Care, Burlington, Vt.

Waste Reduction

U.S. hospitals generate approximately 6,600 tons of waste per day, and they pay more than $106 million each year to dispose of it, Practice Greenhealth reports. About 80% of waste generated in hospitals is nonhazardous solid material (i.e., paper, cardboard, food, and plastics), according to the Green Guide for Health Care, which offers recommendations for sustainable construction, operations, and maintenance of healthcare facilities (www.gghc.org).

Some health systems are putting pressure on vendors to reduce the amount of packaging materials they use. Others are finding alternative homes for items that ordinarily would go straight into dumpsters.

During construction of Kaiser’s Modesto hospital, Deane and his colleagues found one firm that turns Styrofoam into crown molding. They identified another company that recycles bubble wrap and foam, and a third that pays for certain nonrecyclable products. Their efforts prevented about 40 tons of waste from entering the landfill.

“It’s tough for some organizations to get past the culture of doing things the way they’ve always been done,” Deane says. “There’s a lot of opportunity if people just push their comfort level.”

The same holds true for hospital departments. Diane Imrie, director of nutrition services at Fletcher Allen Health Care in Burlington, Vt., led efforts to replace foam and plastic dishware with products that fully degrade when composted. A shift to reusable catering trays saved $1,000 a year.

“The key is to think about what would make a positive impact within your department,” Imrie says. “If there’s something that irritates you or you don’t feel comfortable doing because you know it’s not great for the environment, start there. If you don’t like it, your staff probably doesn’t like it, either.”

HM’s Role

Some hospitals are creating sustainability councils or “green teams” that involve many specialties rather than hiring one sustainability coordinator. The groups usually meet monthly or quarterly. Conversations range from how to reduce waste and promote alternative transportation, to how to utilize alternative energy sources, conserve water, and purchase environmentally friendly products. Such panels provide an excellent opportunity for hospitalists to take an active role in the greening of their facilities, says Paul Rosenau, MD, a pediatric hospitalist at Vermont Children’s Hospital at Fletcher Allen Health Care in Burlington. Dr. Rosenau has served on Fletcher Allen’s sustainability council since its inception more than a year ago.

As the only physician on the roughly 15-person panel, Dr. Rosenau represents what he calls “the clinical interface” with what otherwise would be operational issues. Consequently, when Fletcher Allen recently launched a program to begin collecting recyclables in patient rooms, physicians did not view the initiative simply as a directive coming down from the top. Instead, they embraced the effort, helping to legitimize the program and make it more efficient.

“We will counsel families about how to use these bins,” Dr. Rosenau says. “We identify areas where it isn’t working. We know where waste streams are getting mixed. We know where they are a hindrance and not a help because we’re in there day in and day out.”

Hospitalists who work at facilities where sustainability councils don’t exist still can play their part in the green movement. They can start by following the same rules they teach their children, such as turning out the lights when they leave the room.

“Hospitals use an incredible amount of equipment,” says Louis Dinneen, director of facilities management for Fletcher Allen Health Care, which reduced energy consumption at its main campus by 8% last year. “The next big drive is to improve awareness of the staff. … Developing a sense of ownership is a big part of it, especially in a large organization. We’re asking ourselves, ‘What equipment do we have on all the time?’ If it isn’t necessary to leave it on, make sure it gets turned off.”

Hospitalists also can look at program operations and QI projects with an eye toward environmental responsibility. Dr. Rosenau outlines several strategies:

• Begin with something that enables early success. “It really enforces the idea that this is a multidisciplinary effort,” he says. “It makes people feel like they are part of a team working to make the place better. It’s not this external, foreign idea that, ‘We’re going to green things.’ ”
• Be prepared to establish new relationships. For example, get to know the person who does the purchasing in your group if you are concerned about the environmental lifecycle of certain products. “We aren’t experts in these areas, and it’s important that we not take on a completely new activity. We need to be cognizant of the realities of time, burnout, and quality of care,” Dr. Rosenau says. “But having a dialogue with administrators or other key people who can help assess the environmental impact of healthcare delivery is part of the QI role we play. Some of these things probably are not going to change if the initial interest does not come from a clinician who says, ‘I’m concerned about X.’ ”
• Don’t reinvent the wheel. Take advantage of the growing number of resources (e.g., Practice Greenhealth and Health Care Without Harm) that explore the relationship between healthcare and the environment (see “Help Your Hospital Get Green,” p. 25).

The Next Step

Thanks to a shift in attitudes and practices among those in healthcare, including HM, the industry has taken significant steps to reduce its environmental footprint. The future, experts say, is to make sure physicians have the tools they need to improve the relationship between care delivery and the environment.

“We have a lot of growing to do on the physician side,” Dr. Rosenau says. “That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We’re in this to be healers. We say ‘Do no harm.’ We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.”

Cohen, Health Care Without Harm’s co-executive director, agrees. “Doctors get four hours in four years of environmental education, and most of that is about things like smoking,” he says. “If someone comes to a physician and says, ‘My child has asthma,’ most doctors have no idea to ask, ‘Do you apply pesticides at your home? Do you use toxic cleaners? Are you living down the street from a diesel truck route or incinerator?’ ”

The bottom line: Sustainable medicine goes beyond changing light bulbs or implementing recycling programs.

“We’re at a tipping point, and we feel these issues will become mainstream,” Cohen says. The business case has been made for a number of these initiatives, and I think the rapidly rising costs of healthcare and the epidemic of chronic disease is pushing the sector to realize it needs to move upstream and focus on prevention a little bit more.” TH

Mark Leiser is a freelance writer based in New Jersey.

Reference

1. Principal Building Activities in the Commercial Buildings Energy Consumption Survey. Energy Information Administration Web site. Available at: www.eia.doe.gov/emeu/consumptionbriefs/cbecs/pbawebsite/contents.htm. Accessed Sept. 10, 2009.

New Building Designs Equal Energy Savings

PHOTO COURTESY OF KAISER PERMANENTE

ALICE ST. CLAIR / METRO HEALTH

An estimated $200 billion will be spent on new hospital construction in the U.S. in the next decade, according to the U.S. Department of Health and Human Services. Many of those new facilities will showcase innovative design elements (e.g., displaced ventilation systems, geothermal power, and green roofs) intended to conserve energy and save money.

Although starting with a clean slate might make such efforts easier and more affordable, there are steps existing hospitals can take to reduce their environmental footprint and improve their bottom line.

The best place to start is to calculate your facility’s energy performance rating, says Clark Reed, director of the Healthcare Facilities Division at the U.S. Environmental Protection Agency’s Energy Star program. The rating shows how efficient a hospital is compared with others around the nation. It’s calculated on a scale of 1 to 100, with 50 being the industry average. The calculator is available at www.energystar.gov/benchmark.

“You don’t really know what steps you need to take at your facility unless you know how your hospital compares to your peers across the country,” Reed said.

If you have access to a year’s worth of utility bills, plus some basic information about your facility—square footage, the number of licensed beds, and the number of floors in the tallest building on your campus—you can get a rating in as little as an hour.

The rating serves as a “line in the sand” that helps hospitals determine where they are, where they want to be, and what steps they must take to get there. Steps can range from capital upgrades to business arrangements with new vendors.

To simplify the process, the Energy Star program recommends a five-step solution that, if followed chronologically, often helps hospitals save up to 30% on their energy bills, Reed says.

“When you’re looking at energy bills running into the millions of dollars a year, saving 10%, 20%, or 30% of that—and saving it pretty quickly—becomes significant,” he says. “That’s money that hospitals, rather than paying out to utilities, can put back into doing the work of their mission statement.”—ML

The Hippocratic Oath has served as the foundation of ethical medical practice since the fourth century B.C. Today, one of the oath’s core principles—the promise to do no harm—is guiding more than just bedside care. It is the cornerstone of the green movement in healthcare, a rapidly growing effort to help the profession evolve from one that simply cares for the sick to one that serves as a broader force for healing in society.

Some experts note the medical industry has been slow to understand the effects of its practices on public health. Barely a decade ago, U.S. Environmental Protection Agency (EPA) reports revealed staggering statistics: Medical waste incinerators were the leading producer of airborne carcinogenic dioxins, asthma rates for healthcare workers were among the highest of any profession, and healthcare waste was responsible for 10% of mercury air emissions.1

The incredible irony produced “a teachable moment,” says Gary Cohen, co-executive director of Health Care Without Harm in Arlington, Va., an international coalition established in 1996 to help make the industry more ecologically sustainable. Since then, hospitals have eliminated mercury from many of their supplies, including blood-pressure cuffs and thermometers. Additionally, the efforts to transform buying practices and lessen reliance on fossil fuels have gained considerable traction. And the number of medical waste incinerators in the U.S. has dropped from 5,000 to less than 100.

“The healthcare sector began to understand the links between the environment and disease. They realized they were both addressing the collateral damage of a poisoned environment, and they were contributing to it,” Cohen says.

Now, even those who are critical of the profession’s past practices are lauding industry leaders’ efforts to build more efficient facilities, reduce waste, and modify day-to-day practices to lessen their environmental footprint.

“Hospitals have been so focused, rightly so, on patient safety,” Cohen says. “Now we’re at the point where we’re talking about patient safety, worker safety, and environmental safety. It’s changing the architecture of how things are done, and it is becoming much more accepted as a mainstream concern.”

Concern should stretch beyond the C-suite to those on the front lines, says Don Williams, MD, a pediatric hospitalist at Dell Children’s Medical Center in Austin, Texas, and a board member of Austin Physicians for Social Responsibility. “Although it is rare for us to see the direct effects of green choices on the health of individual patients, I think it is important to recognize that less air pollution and less global warming leads to less illness,” says Dr. Williams, who works in the only platinum-rated Leadership in Environmental Energy and Design certified hospital in the U.S. The certification, through the U.S. Green Building Council (www.usgbc.org), means the hospital meets the highest of standards in sustainable site development, water savings, energy efficiency, materials selection, and indoor environmental quality.

Hospitalists should be engaged in environmental stewardship because they often are seen as role models for hospital staff, residents, students, patients, and families, Dr. Williams says. “We are also frequently in positions of influence when it comes to instituting hospital policy,” he adds. “Hospital administration officials usually like to keep a friendly relationship with us, and are therefore typically open to our thoughts and concerns on everything from recycling programs to new hospital design.”

PHOTO COURTESY OF KAISER PERMANENTE

New Ways to Build

The most visible sign of American hospitals’ commitment to environmental responsibility is evident in construction. About 81% of hospital building projects last year included environmentally friendly materials, according to a survey by the American Society for Healthcare Engineering. That’s up from 55% in 2006.

Kaiser Permanente, an integrated managed-care organization that operates 37 medical centers in nine Western states, is among the industry leaders in green construction. Its Modesto (Calif.) Medical Center, which opened in October 2008, has received national recognition as one of the greenest healthcare facilities in North America. How green? Permeable pavement in the parking area allows rainwater to filter into the ground, and solar panels generate enough electricity to power up to 20 homes. Building materials were selected with an eye toward patient and employee health. Kaiser worked with a carpet manufacturer to create a product free of potentially harmful polyvinyl chloride. It installed cabinetry made from medium-density fiberboard that did not contain formaldehyde, and it chose paints low in volatile organic compounds.

“People would walk into the hospital and say, ‘This place doesn’t smell new,’ ” says project director Jeffrey Deane. “That’s because people are used to smelling new carpet and new paint, because those materials are outgassing huge quantities of nauseous gases.”

Deane acknowledges it is difficult to create a truly green hospital, given the presence of chemicals and pharmaceuticals, and the way the facility must be cleaned to fight infectious bacteria. But the effort to make the environment within the building less harmful didn’t break the bank. The paint and essentially toxin-free fabrics cost the same or less than traditional materials, and a two-duct air system—which draws air solely from the outside, eliminating recirculation—is easier to maintain and costs less to operate.

“One of the biggest hurdles is getting people past the idea that it’s going to cost too much money,” Deane says. “We have a tendency to value-engineer things because they are cheaper up front. Even in cases when they aren’t, there are ramifications down the road that are pretty significant. For every dollar you spend upgrading your system to be more efficient and environmentally friendly, you’ll get paid back several times over.”

Energy Efficiency

Although new construction provides a clean slate for hospitals to go green, administrations at existing facilities have identified several ways to lessen their environmental footprint. One of the quickest—and most cost-effective—is to improve energy efficiency.

Hospitals are the second-most energy-intensive type of structure in the U.S. behind food service, according to the U.S. Department of Energy.1 That consumption costs inpatient healthcare facilities about $5.3 billion annually—about 3% of the average hospital’s operating budget—and results in about 30 pounds of carbon dioxide emissions per square foot, more than double the emissions of standard commercial office buildings, the department estimates.

Energy savings provide an immediate boost to the bottom line, says Clark Reed, director of the Healthcare Facilities Division at the EPA’s Energy Star program. Based on average profit margins, every dollar a nonprofit hospital saves on its energy costs is equivalent to generating $20 in new revenue, Reed says.

“Because of the dollars involved, energy management is getting C-suite attention,” says Nick DeDominicis of Arlington, Va.-based Practice Greenhealth, a networking organization for healthcare institutions that have committed to eco-friendly practices. “We see an increasing number of hospitals thinking about developing strategic master energy plans, looking at facility management in much the same way they’d look at asset management at the boardroom level.”

That’s why Practice Greenhealth created its Healthcare Clean Energy Exchange, an electronic marketplace in which more than 250 suppliers compete to meet healthcare facilities’ energy needs. The program debuted in 2008 and is operated in a reverse-auction format, with suppliers bidding downward to compete for contracts. It is designed to help healthcare entities lock in stable pricing and increase their percentage of green or renewable energy purchases. The auctions carry no upfront fees, and if a healthcare entity doesn’t like the results, it is not forced to sign a contract.

Ingalls Health System in Harvey, Ill., explored the exchange program after energy prices skyrocketed last summer. Before participating in the exchange, Ingalls used 100% “brown”—or conventionally produced—electricity. During the auction, it sought bids for varying mixes of conventional and renewable power. “I actually was very skeptical we would be able to get green energy at a lower cost,” says chief financial officer Vince Pryor. “Frankly, I was hoping to break even.”

The results surpassed expectations. Ingalls signed a three-year contract for electricity, 5% of which now comes from renewable sources. It’s a small step, one the health system believes is in the right direction, as they expect to save $375,000 over the contract period and cut carbon dioxide emissions by 3,433 tons. “I think we would have been happy if we had kept costs neutral and gotten a bit of a green footprint,” Pryor says. “But the process worked out far better than that. It’s obviously a win-win for us.”

We have a lot of growing to do on the physician side. That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.

—Paul Rosenau, MD, pediatric hospitalist, Fletcher Allen Health Care, Burlington, Vt.

Waste Reduction

U.S. hospitals generate approximately 6,600 tons of waste per day, and they pay more than $106 million each year to dispose of it, Practice Greenhealth reports. About 80% of waste generated in hospitals is nonhazardous solid material (i.e., paper, cardboard, food, and plastics), according to the Green Guide for Health Care, which offers recommendations for sustainable construction, operations, and maintenance of healthcare facilities (www.gghc.org).

Some health systems are putting pressure on vendors to reduce the amount of packaging materials they use. Others are finding alternative homes for items that ordinarily would go straight into dumpsters.

During construction of Kaiser’s Modesto hospital, Deane and his colleagues found one firm that turns Styrofoam into crown molding. They identified another company that recycles bubble wrap and foam, and a third that pays for certain nonrecyclable products. Their efforts prevented about 40 tons of waste from entering the landfill.

“It’s tough for some organizations to get past the culture of doing things the way they’ve always been done,” Deane says. “There’s a lot of opportunity if people just push their comfort level.”

The same holds true for hospital departments. Diane Imrie, director of nutrition services at Fletcher Allen Health Care in Burlington, Vt., led efforts to replace foam and plastic dishware with products that fully degrade when composted. A shift to reusable catering trays saved $1,000 a year.

“The key is to think about what would make a positive impact within your department,” Imrie says. “If there’s something that irritates you or you don’t feel comfortable doing because you know it’s not great for the environment, start there. If you don’t like it, your staff probably doesn’t like it, either.”

HM’s Role

Some hospitals are creating sustainability councils or “green teams” that involve many specialties rather than hiring one sustainability coordinator. The groups usually meet monthly or quarterly. Conversations range from how to reduce waste and promote alternative transportation, to how to utilize alternative energy sources, conserve water, and purchase environmentally friendly products. Such panels provide an excellent opportunity for hospitalists to take an active role in the greening of their facilities, says Paul Rosenau, MD, a pediatric hospitalist at Vermont Children’s Hospital at Fletcher Allen Health Care in Burlington. Dr. Rosenau has served on Fletcher Allen’s sustainability council since its inception more than a year ago.

As the only physician on the roughly 15-person panel, Dr. Rosenau represents what he calls “the clinical interface” with what otherwise would be operational issues. Consequently, when Fletcher Allen recently launched a program to begin collecting recyclables in patient rooms, physicians did not view the initiative simply as a directive coming down from the top. Instead, they embraced the effort, helping to legitimize the program and make it more efficient.

“We will counsel families about how to use these bins,” Dr. Rosenau says. “We identify areas where it isn’t working. We know where waste streams are getting mixed. We know where they are a hindrance and not a help because we’re in there day in and day out.”

Hospitalists who work at facilities where sustainability councils don’t exist still can play their part in the green movement. They can start by following the same rules they teach their children, such as turning out the lights when they leave the room.

“Hospitals use an incredible amount of equipment,” says Louis Dinneen, director of facilities management for Fletcher Allen Health Care, which reduced energy consumption at its main campus by 8% last year. “The next big drive is to improve awareness of the staff. … Developing a sense of ownership is a big part of it, especially in a large organization. We’re asking ourselves, ‘What equipment do we have on all the time?’ If it isn’t necessary to leave it on, make sure it gets turned off.”

Hospitalists also can look at program operations and QI projects with an eye toward environmental responsibility. Dr. Rosenau outlines several strategies:

• Begin with something that enables early success. “It really enforces the idea that this is a multidisciplinary effort,” he says. “It makes people feel like they are part of a team working to make the place better. It’s not this external, foreign idea that, ‘We’re going to green things.’ ”
• Be prepared to establish new relationships. For example, get to know the person who does the purchasing in your group if you are concerned about the environmental lifecycle of certain products. “We aren’t experts in these areas, and it’s important that we not take on a completely new activity. We need to be cognizant of the realities of time, burnout, and quality of care,” Dr. Rosenau says. “But having a dialogue with administrators or other key people who can help assess the environmental impact of healthcare delivery is part of the QI role we play. Some of these things probably are not going to change if the initial interest does not come from a clinician who says, ‘I’m concerned about X.’ ”
• Don’t reinvent the wheel. Take advantage of the growing number of resources (e.g., Practice Greenhealth and Health Care Without Harm) that explore the relationship between healthcare and the environment (see “Help Your Hospital Get Green,” p. 25).

The Next Step

Thanks to a shift in attitudes and practices among those in healthcare, including HM, the industry has taken significant steps to reduce its environmental footprint. The future, experts say, is to make sure physicians have the tools they need to improve the relationship between care delivery and the environment.

“We have a lot of growing to do on the physician side,” Dr. Rosenau says. “That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We’re in this to be healers. We say ‘Do no harm.’ We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.”

Cohen, Health Care Without Harm’s co-executive director, agrees. “Doctors get four hours in four years of environmental education, and most of that is about things like smoking,” he says. “If someone comes to a physician and says, ‘My child has asthma,’ most doctors have no idea to ask, ‘Do you apply pesticides at your home? Do you use toxic cleaners? Are you living down the street from a diesel truck route or incinerator?’ ”

The bottom line: Sustainable medicine goes beyond changing light bulbs or implementing recycling programs.

“We’re at a tipping point, and we feel these issues will become mainstream,” Cohen says. The business case has been made for a number of these initiatives, and I think the rapidly rising costs of healthcare and the epidemic of chronic disease is pushing the sector to realize it needs to move upstream and focus on prevention a little bit more.” TH

Mark Leiser is a freelance writer based in New Jersey.

Reference

1. Principal Building Activities in the Commercial Buildings Energy Consumption Survey. Energy Information Administration Web site. Available at: www.eia.doe.gov/emeu/consumptionbriefs/cbecs/pbawebsite/contents.htm. Accessed Sept. 10, 2009.

New Building Designs Equal Energy Savings

PHOTO COURTESY OF KAISER PERMANENTE

ALICE ST. CLAIR / METRO HEALTH

An estimated $200 billion will be spent on new hospital construction in the U.S. in the next decade, according to the U.S. Department of Health and Human Services. Many of those new facilities will showcase innovative design elements (e.g., displaced ventilation systems, geothermal power, and green roofs) intended to conserve energy and save money.

Although starting with a clean slate might make such efforts easier and more affordable, there are steps existing hospitals can take to reduce their environmental footprint and improve their bottom line.

The best place to start is to calculate your facility’s energy performance rating, says Clark Reed, director of the Healthcare Facilities Division at the U.S. Environmental Protection Agency’s Energy Star program. The rating shows how efficient a hospital is compared with others around the nation. It’s calculated on a scale of 1 to 100, with 50 being the industry average. The calculator is available at www.energystar.gov/benchmark.

“You don’t really know what steps you need to take at your facility unless you know how your hospital compares to your peers across the country,” Reed said.

If you have access to a year’s worth of utility bills, plus some basic information about your facility—square footage, the number of licensed beds, and the number of floors in the tallest building on your campus—you can get a rating in as little as an hour.

The rating serves as a “line in the sand” that helps hospitals determine where they are, where they want to be, and what steps they must take to get there. Steps can range from capital upgrades to business arrangements with new vendors.

To simplify the process, the Energy Star program recommends a five-step solution that, if followed chronologically, often helps hospitals save up to 30% on their energy bills, Reed says.

“When you’re looking at energy bills running into the millions of dollars a year, saving 10%, 20%, or 30% of that—and saving it pretty quickly—becomes significant,” he says. “That’s money that hospitals, rather than paying out to utilities, can put back into doing the work of their mission statement.”—ML

The Hippocratic Oath has served as the foundation of ethical medical practice since the fourth century B.C. Today, one of the oath’s core principles—the promise to do no harm—is guiding more than just bedside care. It is the cornerstone of the green movement in healthcare, a rapidly growing effort to help the profession evolve from one that simply cares for the sick to one that serves as a broader force for healing in society.

Some experts note the medical industry has been slow to understand the effects of its practices on public health. Barely a decade ago, U.S. Environmental Protection Agency (EPA) reports revealed staggering statistics: Medical waste incinerators were the leading producer of airborne carcinogenic dioxins, asthma rates for healthcare workers were among the highest of any profession, and healthcare waste was responsible for 10% of mercury air emissions.1

The incredible irony produced “a teachable moment,” says Gary Cohen, co-executive director of Health Care Without Harm in Arlington, Va., an international coalition established in 1996 to help make the industry more ecologically sustainable. Since then, hospitals have eliminated mercury from many of their supplies, including blood-pressure cuffs and thermometers. Additionally, the efforts to transform buying practices and lessen reliance on fossil fuels have gained considerable traction. And the number of medical waste incinerators in the U.S. has dropped from 5,000 to less than 100.

“The healthcare sector began to understand the links between the environment and disease. They realized they were both addressing the collateral damage of a poisoned environment, and they were contributing to it,” Cohen says.

Now, even those who are critical of the profession’s past practices are lauding industry leaders’ efforts to build more efficient facilities, reduce waste, and modify day-to-day practices to lessen their environmental footprint.

“Hospitals have been so focused, rightly so, on patient safety,” Cohen says. “Now we’re at the point where we’re talking about patient safety, worker safety, and environmental safety. It’s changing the architecture of how things are done, and it is becoming much more accepted as a mainstream concern.”

Concern should stretch beyond the C-suite to those on the front lines, says Don Williams, MD, a pediatric hospitalist at Dell Children’s Medical Center in Austin, Texas, and a board member of Austin Physicians for Social Responsibility. “Although it is rare for us to see the direct effects of green choices on the health of individual patients, I think it is important to recognize that less air pollution and less global warming leads to less illness,” says Dr. Williams, who works in the only platinum-rated Leadership in Environmental Energy and Design certified hospital in the U.S. The certification, through the U.S. Green Building Council (www.usgbc.org), means the hospital meets the highest of standards in sustainable site development, water savings, energy efficiency, materials selection, and indoor environmental quality.

Hospitalists should be engaged in environmental stewardship because they often are seen as role models for hospital staff, residents, students, patients, and families, Dr. Williams says. “We are also frequently in positions of influence when it comes to instituting hospital policy,” he adds. “Hospital administration officials usually like to keep a friendly relationship with us, and are therefore typically open to our thoughts and concerns on everything from recycling programs to new hospital design.”

PHOTO COURTESY OF KAISER PERMANENTE

New Ways to Build

The most visible sign of American hospitals’ commitment to environmental responsibility is evident in construction. About 81% of hospital building projects last year included environmentally friendly materials, according to a survey by the American Society for Healthcare Engineering. That’s up from 55% in 2006.

Kaiser Permanente, an integrated managed-care organization that operates 37 medical centers in nine Western states, is among the industry leaders in green construction. Its Modesto (Calif.) Medical Center, which opened in October 2008, has received national recognition as one of the greenest healthcare facilities in North America. How green? Permeable pavement in the parking area allows rainwater to filter into the ground, and solar panels generate enough electricity to power up to 20 homes. Building materials were selected with an eye toward patient and employee health. Kaiser worked with a carpet manufacturer to create a product free of potentially harmful polyvinyl chloride. It installed cabinetry made from medium-density fiberboard that did not contain formaldehyde, and it chose paints low in volatile organic compounds.

“People would walk into the hospital and say, ‘This place doesn’t smell new,’ ” says project director Jeffrey Deane. “That’s because people are used to smelling new carpet and new paint, because those materials are outgassing huge quantities of nauseous gases.”

Deane acknowledges it is difficult to create a truly green hospital, given the presence of chemicals and pharmaceuticals, and the way the facility must be cleaned to fight infectious bacteria. But the effort to make the environment within the building less harmful didn’t break the bank. The paint and essentially toxin-free fabrics cost the same or less than traditional materials, and a two-duct air system—which draws air solely from the outside, eliminating recirculation—is easier to maintain and costs less to operate.

“One of the biggest hurdles is getting people past the idea that it’s going to cost too much money,” Deane says. “We have a tendency to value-engineer things because they are cheaper up front. Even in cases when they aren’t, there are ramifications down the road that are pretty significant. For every dollar you spend upgrading your system to be more efficient and environmentally friendly, you’ll get paid back several times over.”

Energy Efficiency

Although new construction provides a clean slate for hospitals to go green, administrations at existing facilities have identified several ways to lessen their environmental footprint. One of the quickest—and most cost-effective—is to improve energy efficiency.

Hospitals are the second-most energy-intensive type of structure in the U.S. behind food service, according to the U.S. Department of Energy.1 That consumption costs inpatient healthcare facilities about $5.3 billion annually—about 3% of the average hospital’s operating budget—and results in about 30 pounds of carbon dioxide emissions per square foot, more than double the emissions of standard commercial office buildings, the department estimates.

Energy savings provide an immediate boost to the bottom line, says Clark Reed, director of the Healthcare Facilities Division at the EPA’s Energy Star program. Based on average profit margins, every dollar a nonprofit hospital saves on its energy costs is equivalent to generating $20 in new revenue, Reed says.

“Because of the dollars involved, energy management is getting C-suite attention,” says Nick DeDominicis of Arlington, Va.-based Practice Greenhealth, a networking organization for healthcare institutions that have committed to eco-friendly practices. “We see an increasing number of hospitals thinking about developing strategic master energy plans, looking at facility management in much the same way they’d look at asset management at the boardroom level.”

That’s why Practice Greenhealth created its Healthcare Clean Energy Exchange, an electronic marketplace in which more than 250 suppliers compete to meet healthcare facilities’ energy needs. The program debuted in 2008 and is operated in a reverse-auction format, with suppliers bidding downward to compete for contracts. It is designed to help healthcare entities lock in stable pricing and increase their percentage of green or renewable energy purchases. The auctions carry no upfront fees, and if a healthcare entity doesn’t like the results, it is not forced to sign a contract.

Ingalls Health System in Harvey, Ill., explored the exchange program after energy prices skyrocketed last summer. Before participating in the exchange, Ingalls used 100% “brown”—or conventionally produced—electricity. During the auction, it sought bids for varying mixes of conventional and renewable power. “I actually was very skeptical we would be able to get green energy at a lower cost,” says chief financial officer Vince Pryor. “Frankly, I was hoping to break even.”

The results surpassed expectations. Ingalls signed a three-year contract for electricity, 5% of which now comes from renewable sources. It’s a small step, one the health system believes is in the right direction, as they expect to save $375,000 over the contract period and cut carbon dioxide emissions by 3,433 tons. “I think we would have been happy if we had kept costs neutral and gotten a bit of a green footprint,” Pryor says. “But the process worked out far better than that. It’s obviously a win-win for us.”

We have a lot of growing to do on the physician side. That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.

—Paul Rosenau, MD, pediatric hospitalist, Fletcher Allen Health Care, Burlington, Vt.

Waste Reduction

U.S. hospitals generate approximately 6,600 tons of waste per day, and they pay more than $106 million each year to dispose of it, Practice Greenhealth reports. About 80% of waste generated in hospitals is nonhazardous solid material (i.e., paper, cardboard, food, and plastics), according to the Green Guide for Health Care, which offers recommendations for sustainable construction, operations, and maintenance of healthcare facilities (www.gghc.org).

Some health systems are putting pressure on vendors to reduce the amount of packaging materials they use. Others are finding alternative homes for items that ordinarily would go straight into dumpsters.

During construction of Kaiser’s Modesto hospital, Deane and his colleagues found one firm that turns Styrofoam into crown molding. They identified another company that recycles bubble wrap and foam, and a third that pays for certain nonrecyclable products. Their efforts prevented about 40 tons of waste from entering the landfill.

“It’s tough for some organizations to get past the culture of doing things the way they’ve always been done,” Deane says. “There’s a lot of opportunity if people just push their comfort level.”

The same holds true for hospital departments. Diane Imrie, director of nutrition services at Fletcher Allen Health Care in Burlington, Vt., led efforts to replace foam and plastic dishware with products that fully degrade when composted. A shift to reusable catering trays saved $1,000 a year.

“The key is to think about what would make a positive impact within your department,” Imrie says. “If there’s something that irritates you or you don’t feel comfortable doing because you know it’s not great for the environment, start there. If you don’t like it, your staff probably doesn’t like it, either.”

HM’s Role

Some hospitals are creating sustainability councils or “green teams” that involve many specialties rather than hiring one sustainability coordinator. The groups usually meet monthly or quarterly. Conversations range from how to reduce waste and promote alternative transportation, to how to utilize alternative energy sources, conserve water, and purchase environmentally friendly products. Such panels provide an excellent opportunity for hospitalists to take an active role in the greening of their facilities, says Paul Rosenau, MD, a pediatric hospitalist at Vermont Children’s Hospital at Fletcher Allen Health Care in Burlington. Dr. Rosenau has served on Fletcher Allen’s sustainability council since its inception more than a year ago.

As the only physician on the roughly 15-person panel, Dr. Rosenau represents what he calls “the clinical interface” with what otherwise would be operational issues. Consequently, when Fletcher Allen recently launched a program to begin collecting recyclables in patient rooms, physicians did not view the initiative simply as a directive coming down from the top. Instead, they embraced the effort, helping to legitimize the program and make it more efficient.

“We will counsel families about how to use these bins,” Dr. Rosenau says. “We identify areas where it isn’t working. We know where waste streams are getting mixed. We know where they are a hindrance and not a help because we’re in there day in and day out.”

Hospitalists who work at facilities where sustainability councils don’t exist still can play their part in the green movement. They can start by following the same rules they teach their children, such as turning out the lights when they leave the room.

“Hospitals use an incredible amount of equipment,” says Louis Dinneen, director of facilities management for Fletcher Allen Health Care, which reduced energy consumption at its main campus by 8% last year. “The next big drive is to improve awareness of the staff. … Developing a sense of ownership is a big part of it, especially in a large organization. We’re asking ourselves, ‘What equipment do we have on all the time?’ If it isn’t necessary to leave it on, make sure it gets turned off.”

Hospitalists also can look at program operations and QI projects with an eye toward environmental responsibility. Dr. Rosenau outlines several strategies:

• Begin with something that enables early success. “It really enforces the idea that this is a multidisciplinary effort,” he says. “It makes people feel like they are part of a team working to make the place better. It’s not this external, foreign idea that, ‘We’re going to green things.’ ”
• Be prepared to establish new relationships. For example, get to know the person who does the purchasing in your group if you are concerned about the environmental lifecycle of certain products. “We aren’t experts in these areas, and it’s important that we not take on a completely new activity. We need to be cognizant of the realities of time, burnout, and quality of care,” Dr. Rosenau says. “But having a dialogue with administrators or other key people who can help assess the environmental impact of healthcare delivery is part of the QI role we play. Some of these things probably are not going to change if the initial interest does not come from a clinician who says, ‘I’m concerned about X.’ ”
• Don’t reinvent the wheel. Take advantage of the growing number of resources (e.g., Practice Greenhealth and Health Care Without Harm) that explore the relationship between healthcare and the environment (see “Help Your Hospital Get Green,” p. 25).

The Next Step

Thanks to a shift in attitudes and practices among those in healthcare, including HM, the industry has taken significant steps to reduce its environmental footprint. The future, experts say, is to make sure physicians have the tools they need to improve the relationship between care delivery and the environment.

“We have a lot of growing to do on the physician side,” Dr. Rosenau says. “That’s not to say we need to have a PhD in ecotoxicology, but we do need to learn some. … We’re in this to be healers. We say ‘Do no harm.’ We try to avoid adverse drug effects. We also have to avoid adverse environmental impacts.”

Cohen, Health Care Without Harm’s co-executive director, agrees. “Doctors get four hours in four years of environmental education, and most of that is about things like smoking,” he says. “If someone comes to a physician and says, ‘My child has asthma,’ most doctors have no idea to ask, ‘Do you apply pesticides at your home? Do you use toxic cleaners? Are you living down the street from a diesel truck route or incinerator?’ ”

The bottom line: Sustainable medicine goes beyond changing light bulbs or implementing recycling programs.

“We’re at a tipping point, and we feel these issues will become mainstream,” Cohen says. The business case has been made for a number of these initiatives, and I think the rapidly rising costs of healthcare and the epidemic of chronic disease is pushing the sector to realize it needs to move upstream and focus on prevention a little bit more.” TH

Mark Leiser is a freelance writer based in New Jersey.

Reference

1. Principal Building Activities in the Commercial Buildings Energy Consumption Survey. Energy Information Administration Web site. Available at: www.eia.doe.gov/emeu/consumptionbriefs/cbecs/pbawebsite/contents.htm. Accessed Sept. 10, 2009.

New Building Designs Equal Energy Savings

PHOTO COURTESY OF KAISER PERMANENTE

ALICE ST. CLAIR / METRO HEALTH

An estimated $200 billion will be spent on new hospital construction in the U.S. in the next decade, according to the U.S. Department of Health and Human Services. Many of those new facilities will showcase innovative design elements (e.g., displaced ventilation systems, geothermal power, and green roofs) intended to conserve energy and save money.

Although starting with a clean slate might make such efforts easier and more affordable, there are steps existing hospitals can take to reduce their environmental footprint and improve their bottom line.

The best place to start is to calculate your facility’s energy performance rating, says Clark Reed, director of the Healthcare Facilities Division at the U.S. Environmental Protection Agency’s Energy Star program. The rating shows how efficient a hospital is compared with others around the nation. It’s calculated on a scale of 1 to 100, with 50 being the industry average. The calculator is available at www.energystar.gov/benchmark.

“You don’t really know what steps you need to take at your facility unless you know how your hospital compares to your peers across the country,” Reed said.

If you have access to a year’s worth of utility bills, plus some basic information about your facility—square footage, the number of licensed beds, and the number of floors in the tallest building on your campus—you can get a rating in as little as an hour.

The rating serves as a “line in the sand” that helps hospitals determine where they are, where they want to be, and what steps they must take to get there. Steps can range from capital upgrades to business arrangements with new vendors.

To simplify the process, the Energy Star program recommends a five-step solution that, if followed chronologically, often helps hospitals save up to 30% on their energy bills, Reed says.

“When you’re looking at energy bills running into the millions of dollars a year, saving 10%, 20%, or 30% of that—and saving it pretty quickly—becomes significant,” he says. “That’s money that hospitals, rather than paying out to utilities, can put back into doing the work of their mission statement.”—ML

When Kenneth Patrick, MD, joined Chestnut Hill Hospital in Philadelphia in 1982, he was known simply as a physician who practiced HM. It wasn’t until 14 years later that the term “hospitalist” appeared for the first time in a New England Journal of Medicine article.

As Dr. Patrick’s job title changed, so did his outlook on the future of the profession. “My practice was exceedingly unique and, for many years, people didn’t understand that a physician could practice exclusively in a hospital,” says Dr. Patrick, now the ICU director at Chestnut Hill. “But when I first heard the word ‘hospitalist,’ I was surprised. I remember thinking, ‘Hey, I’m one of them.’ ”

He also knew that if other physicians were recognizing the specialty, more and more physicians were going to jump on the HM bandwagon. “I knew it wasn’t just a short-lived thing,” he says.

With three decades of HM experience in the bank, Dr. Patrick offers his take on the evolution of HM, changes to the delivery of care, and the importance of communicating with patients.

Question: What drew you into the medical field?

Answer: I earned an undergraduate degree in mechanical engineering [from Drexel University]. The country was going through a recession and there weren’t many job offers, so when I was a junior, I decided to switch careers. I went into medicine.

Q: Have you found any similarities between engineering and HM?

A: Very much so, particularly in the intensive-care unit (ICU). That’s what drew me to critical care and HM. You have to be very detail-oriented. You have to go through your thinking process in a very organized fashion, and you have to be prepared to solve problems that aren’t apparent when you first start caring for a patient. That’s the basis of engineering.

Q: Did you face challenges in 1982 that new hospitalists won’t face today because the field is more established?

A: No, I would say it’s the other way around, particularly in terms of regulation and monitoring. The Joint Commission existed then, but the standards of hospital care, pressures from insurers, and things like length of stay were not so much of an issue. The challenge to get people evaluated and discharged exceedingly quickly did not exist back then.

Q: How has your role as a hospitalist changed in 26 years?

A: The most significant change is speed. I remember during residency caring for a patient with an infection of the heart valves. That patient stayed in the hospital for 28 days getting antibiotics, and I went to see the person every day to listen to the heart. … Today, that patient would be in the hospital two or, at most, three days. They’d be discharged either to home on IV antibiotics or to a skilled nursing facility. They’d no longer stay in the hospital for a prolonged period of time.

Q: How has that changed the delivery of care?

A: Our job as hospitalists is to see someone who is sick enough to be in the hospital, evaluate and diagnose them exceedingly quickly, get them started on treatment exceedingly quickly, and, as soon as they start improving, the regulators or insurers say they no longer need to be in the hospital. We don’t get to follow them through their entire illness.

I think that is something that is lacking for young hospitalists and residents during training. They don’t see the illness from start to finish. They see it from the start until the moment the patient begins to improve and is discharged.

Q: What is the consequence of that shift?

A: Less-experienced physicians, in terms of management of a patient from the beginning to end, unless there is good communication between hospital physicians and outpatient physicians. And I just think younger physicians are less well prepared for the complications that may ensue from a given illness because they only see the illness for such a short period of time.

Q: What’s the biggest reward of being a hospitalist?

A: Making patients better, if that can be done, and helping them through illnesses that can’t be made better. The outcome may be death, permanent disability, or something tragic, but patients and their families still feel thankful if they feel you’ve been a caring physician. Without the patient and the family being satisfied, I wouldn’t have many rewards.

Q: After 26 years as a hospitalist, what’s the best advice you could offer to someone new in the field?

A: Don’t cut corners. Be as complete and as thorough as you need to be. Communicate with patients and their families, which is crucial. Be open to suggestions, because you don’t know everything. I still feel that way after 26 years. Be optimistic and enjoy what you do. And it’s very important for busy, high-pressure physician specialists to keep their mind on their family and their outside-the-hospital relationships. Don’t forget your kids are going to grow up.

Q: You often emphasize the importance of physicians communicating with patients and their families. What’s the biggest barrier to communication?

A: First, reimbursement isn’t there for explanations and counseling. You get reimbursed for the evaluation, the diagnosis, and the management of the illness. No. 2, it takes time—sometimes an inordinate amount of time. If a patient is critically ill, I can spend 30 to 90 minutes with a family, not treating the patient, but explaining what’s the matter with the patient and what the treatment options are. During that time, you’re giving up other patient-care responsibilities.

And I don’t think physicians have been well trained to communicate with someone and explain the details of an illness and the treatment options nonmedically. I’ve seen doctors try to explain to families that a patient is dead and the family didn’t know what the doctor meant. I teach residents to speak English to patients and their families, not speak medical.

Q: Should there be a greater emphasis on communication during education and residency?

A: Absolutely. I tell residents they need this training as much as they need to know what antibiotic to use for pneumonia. … My experience over the years is patients think they’re getting better care from average doctors who communicate well than doctors who are brilliant and can’t communicate.

Q: What has kept you at Chestnut Hill Hospital for 26 years?

A: Some of it is inertia. When my children were young, it was the community in which I lived. And I like working in a small, community hospital because of the personal relationships I’ve developed with the other professionals, everyone from medical records to the secretarial staff.

Q: What’s next for you?

A: As I’ve gotten older, being woken up in the middle of the night gets harder and harder, so I’ve thought of doing something where the hours are more fixed and I have a little more time. I have thought about starting satellite practices in other community hospitals that are looking to start hospitalist programs, being more of an administrator and delivering less patient care. But I still like what I’m doing, and that’s why I keep doing it. TH

Mark Leiser is a freelance writer based in New Jersey.

When Kenneth Patrick, MD, joined Chestnut Hill Hospital in Philadelphia in 1982, he was known simply as a physician who practiced HM. It wasn’t until 14 years later that the term “hospitalist” appeared for the first time in a New England Journal of Medicine article.

As Dr. Patrick’s job title changed, so did his outlook on the future of the profession. “My practice was exceedingly unique and, for many years, people didn’t understand that a physician could practice exclusively in a hospital,” says Dr. Patrick, now the ICU director at Chestnut Hill. “But when I first heard the word ‘hospitalist,’ I was surprised. I remember thinking, ‘Hey, I’m one of them.’ ”

He also knew that if other physicians were recognizing the specialty, more and more physicians were going to jump on the HM bandwagon. “I knew it wasn’t just a short-lived thing,” he says.

With three decades of HM experience in the bank, Dr. Patrick offers his take on the evolution of HM, changes to the delivery of care, and the importance of communicating with patients.

Question: What drew you into the medical field?

Answer: I earned an undergraduate degree in mechanical engineering [from Drexel University]. The country was going through a recession and there weren’t many job offers, so when I was a junior, I decided to switch careers. I went into medicine.

Q: Have you found any similarities between engineering and HM?

A: Very much so, particularly in the intensive-care unit (ICU). That’s what drew me to critical care and HM. You have to be very detail-oriented. You have to go through your thinking process in a very organized fashion, and you have to be prepared to solve problems that aren’t apparent when you first start caring for a patient. That’s the basis of engineering.

Q: Did you face challenges in 1982 that new hospitalists won’t face today because the field is more established?

A: No, I would say it’s the other way around, particularly in terms of regulation and monitoring. The Joint Commission existed then, but the standards of hospital care, pressures from insurers, and things like length of stay were not so much of an issue. The challenge to get people evaluated and discharged exceedingly quickly did not exist back then.

Q: How has your role as a hospitalist changed in 26 years?

A: The most significant change is speed. I remember during residency caring for a patient with an infection of the heart valves. That patient stayed in the hospital for 28 days getting antibiotics, and I went to see the person every day to listen to the heart. … Today, that patient would be in the hospital two or, at most, three days. They’d be discharged either to home on IV antibiotics or to a skilled nursing facility. They’d no longer stay in the hospital for a prolonged period of time.

Q: How has that changed the delivery of care?

A: Our job as hospitalists is to see someone who is sick enough to be in the hospital, evaluate and diagnose them exceedingly quickly, get them started on treatment exceedingly quickly, and, as soon as they start improving, the regulators or insurers say they no longer need to be in the hospital. We don’t get to follow them through their entire illness.

I think that is something that is lacking for young hospitalists and residents during training. They don’t see the illness from start to finish. They see it from the start until the moment the patient begins to improve and is discharged.

Q: What is the consequence of that shift?

A: Less-experienced physicians, in terms of management of a patient from the beginning to end, unless there is good communication between hospital physicians and outpatient physicians. And I just think younger physicians are less well prepared for the complications that may ensue from a given illness because they only see the illness for such a short period of time.

Q: What’s the biggest reward of being a hospitalist?

A: Making patients better, if that can be done, and helping them through illnesses that can’t be made better. The outcome may be death, permanent disability, or something tragic, but patients and their families still feel thankful if they feel you’ve been a caring physician. Without the patient and the family being satisfied, I wouldn’t have many rewards.

Q: After 26 years as a hospitalist, what’s the best advice you could offer to someone new in the field?

A: Don’t cut corners. Be as complete and as thorough as you need to be. Communicate with patients and their families, which is crucial. Be open to suggestions, because you don’t know everything. I still feel that way after 26 years. Be optimistic and enjoy what you do. And it’s very important for busy, high-pressure physician specialists to keep their mind on their family and their outside-the-hospital relationships. Don’t forget your kids are going to grow up.

Q: You often emphasize the importance of physicians communicating with patients and their families. What’s the biggest barrier to communication?

A: First, reimbursement isn’t there for explanations and counseling. You get reimbursed for the evaluation, the diagnosis, and the management of the illness. No. 2, it takes time—sometimes an inordinate amount of time. If a patient is critically ill, I can spend 30 to 90 minutes with a family, not treating the patient, but explaining what’s the matter with the patient and what the treatment options are. During that time, you’re giving up other patient-care responsibilities.

And I don’t think physicians have been well trained to communicate with someone and explain the details of an illness and the treatment options nonmedically. I’ve seen doctors try to explain to families that a patient is dead and the family didn’t know what the doctor meant. I teach residents to speak English to patients and their families, not speak medical.

Q: Should there be a greater emphasis on communication during education and residency?

A: Absolutely. I tell residents they need this training as much as they need to know what antibiotic to use for pneumonia. … My experience over the years is patients think they’re getting better care from average doctors who communicate well than doctors who are brilliant and can’t communicate.

Q: What has kept you at Chestnut Hill Hospital for 26 years?

A: Some of it is inertia. When my children were young, it was the community in which I lived. And I like working in a small, community hospital because of the personal relationships I’ve developed with the other professionals, everyone from medical records to the secretarial staff.

Q: What’s next for you?

A: As I’ve gotten older, being woken up in the middle of the night gets harder and harder, so I’ve thought of doing something where the hours are more fixed and I have a little more time. I have thought about starting satellite practices in other community hospitals that are looking to start hospitalist programs, being more of an administrator and delivering less patient care. But I still like what I’m doing, and that’s why I keep doing it. TH

Mark Leiser is a freelance writer based in New Jersey.

When Kenneth Patrick, MD, joined Chestnut Hill Hospital in Philadelphia in 1982, he was known simply as a physician who practiced HM. It wasn’t until 14 years later that the term “hospitalist” appeared for the first time in a New England Journal of Medicine article.

As Dr. Patrick’s job title changed, so did his outlook on the future of the profession. “My practice was exceedingly unique and, for many years, people didn’t understand that a physician could practice exclusively in a hospital,” says Dr. Patrick, now the ICU director at Chestnut Hill. “But when I first heard the word ‘hospitalist,’ I was surprised. I remember thinking, ‘Hey, I’m one of them.’ ”

He also knew that if other physicians were recognizing the specialty, more and more physicians were going to jump on the HM bandwagon. “I knew it wasn’t just a short-lived thing,” he says.

With three decades of HM experience in the bank, Dr. Patrick offers his take on the evolution of HM, changes to the delivery of care, and the importance of communicating with patients.

Question: What drew you into the medical field?

Answer: I earned an undergraduate degree in mechanical engineering [from Drexel University]. The country was going through a recession and there weren’t many job offers, so when I was a junior, I decided to switch careers. I went into medicine.

Q: Have you found any similarities between engineering and HM?

A: Very much so, particularly in the intensive-care unit (ICU). That’s what drew me to critical care and HM. You have to be very detail-oriented. You have to go through your thinking process in a very organized fashion, and you have to be prepared to solve problems that aren’t apparent when you first start caring for a patient. That’s the basis of engineering.

Q: Did you face challenges in 1982 that new hospitalists won’t face today because the field is more established?

A: No, I would say it’s the other way around, particularly in terms of regulation and monitoring. The Joint Commission existed then, but the standards of hospital care, pressures from insurers, and things like length of stay were not so much of an issue. The challenge to get people evaluated and discharged exceedingly quickly did not exist back then.

Q: How has your role as a hospitalist changed in 26 years?

A: The most significant change is speed. I remember during residency caring for a patient with an infection of the heart valves. That patient stayed in the hospital for 28 days getting antibiotics, and I went to see the person every day to listen to the heart. … Today, that patient would be in the hospital two or, at most, three days. They’d be discharged either to home on IV antibiotics or to a skilled nursing facility. They’d no longer stay in the hospital for a prolonged period of time.

Q: How has that changed the delivery of care?

A: Our job as hospitalists is to see someone who is sick enough to be in the hospital, evaluate and diagnose them exceedingly quickly, get them started on treatment exceedingly quickly, and, as soon as they start improving, the regulators or insurers say they no longer need to be in the hospital. We don’t get to follow them through their entire illness.

I think that is something that is lacking for young hospitalists and residents during training. They don’t see the illness from start to finish. They see it from the start until the moment the patient begins to improve and is discharged.

Q: What is the consequence of that shift?

A: Less-experienced physicians, in terms of management of a patient from the beginning to end, unless there is good communication between hospital physicians and outpatient physicians. And I just think younger physicians are less well prepared for the complications that may ensue from a given illness because they only see the illness for such a short period of time.

Q: What’s the biggest reward of being a hospitalist?

A: Making patients better, if that can be done, and helping them through illnesses that can’t be made better. The outcome may be death, permanent disability, or something tragic, but patients and their families still feel thankful if they feel you’ve been a caring physician. Without the patient and the family being satisfied, I wouldn’t have many rewards.

Q: After 26 years as a hospitalist, what’s the best advice you could offer to someone new in the field?

A: Don’t cut corners. Be as complete and as thorough as you need to be. Communicate with patients and their families, which is crucial. Be open to suggestions, because you don’t know everything. I still feel that way after 26 years. Be optimistic and enjoy what you do. And it’s very important for busy, high-pressure physician specialists to keep their mind on their family and their outside-the-hospital relationships. Don’t forget your kids are going to grow up.

Q: You often emphasize the importance of physicians communicating with patients and their families. What’s the biggest barrier to communication?

A: First, reimbursement isn’t there for explanations and counseling. You get reimbursed for the evaluation, the diagnosis, and the management of the illness. No. 2, it takes time—sometimes an inordinate amount of time. If a patient is critically ill, I can spend 30 to 90 minutes with a family, not treating the patient, but explaining what’s the matter with the patient and what the treatment options are. During that time, you’re giving up other patient-care responsibilities.

And I don’t think physicians have been well trained to communicate with someone and explain the details of an illness and the treatment options nonmedically. I’ve seen doctors try to explain to families that a patient is dead and the family didn’t know what the doctor meant. I teach residents to speak English to patients and their families, not speak medical.

Q: Should there be a greater emphasis on communication during education and residency?

A: Absolutely. I tell residents they need this training as much as they need to know what antibiotic to use for pneumonia. … My experience over the years is patients think they’re getting better care from average doctors who communicate well than doctors who are brilliant and can’t communicate.

Q: What has kept you at Chestnut Hill Hospital for 26 years?

A: Some of it is inertia. When my children were young, it was the community in which I lived. And I like working in a small, community hospital because of the personal relationships I’ve developed with the other professionals, everyone from medical records to the secretarial staff.

Q: What’s next for you?

A: As I’ve gotten older, being woken up in the middle of the night gets harder and harder, so I’ve thought of doing something where the hours are more fixed and I have a little more time. I have thought about starting satellite practices in other community hospitals that are looking to start hospitalist programs, being more of an administrator and delivering less patient care. But I still like what I’m doing, and that’s why I keep doing it. TH

Mark Leiser is a freelance writer based in New Jersey.