Patrick Cawley, MD, FHM

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

“Hospital Doctors Brace for Layoff.”

As I was scanning an online news source recently, the headline above caught my eye. The story detailed a U.S. hospital experiencing a loss in the past year, and one of the cost-cutting measures being considered by the hospital administration was a layoff of some of the health system’s hospitalists.

Now, while the story caught my eye, I was not surprised. All hospitalists and hospital medicine group leaders should take this as a warning and be prepared for potential cost tightening at your local hospital in the next year. Many hospitalist groups are vulnerable to cutbacks, because support often is needed to maintain the viability of the HM program and, in tough economic times, all HM support receives closer scrutiny.

It’s no secret; the U.S. economy is in a decline. A recession has yet to be declared, as a recession normally is defined as two consecutive fiscal quarters of negative gross domestic product growth. However, this economy has been flat the past two quarters, in terms of GDP, and expectations for the fourth quarter aren’t good. Additionally, the country is experiencing increased costs across the continuum related to oil prices, food prices, the housing downturn, and the mortgage mess. So, while there may not be an official recession, many businesses are experiencing a financial tightening, with decreased revenues from slower growth and higher costs from a variety of areas.

Even Healthcare Has Soft Spots

On Wall Street, conventional wisdom dictates the healthcare industry is more stable and resistant to recession than other industries. The general belief is people get sick no matter the state of the economy. But the healthcare industry is diverse and revenue has many avenues. Certainly in biotechnology and pharmaceuticals, there is a greater degree of recession resistance, but within the healthcare industry, hospitals and providers are much more sensitive to an economic downturn, even though a large percentage of revenues are from government sources.

In an economic downturn, hospital demand decreases secondary to a less admissions and elective procedures, particularly in patients with non-government payers. Additionally, the number of uninsured rises, which results in a change in payer mix at hospitals. Finally, due to the rise in out-of-pocket expenses associated with health insurance, it is highly likely patients will forgo healthcare at a quicker rate than in past recessions. When things get tough, patients must pick and choose what to pay for, and with the higher out-of-pocket expenses, healthcare is not as easy to access for many people.

In the meantime, the cost of running a hospital continues to escalate. Labor shortages continue, so hospitals must continue to pay competitive salaries to attract and maintain employees. Hospitals have made significant investments in patient safety, information technology, new construction, and physician practices in the past several years. All of these factors continue to contribute to the high fixed costs of hospital financials.

And so, as hospitals begin to look at costs that are not as fixed, and thus easier to cut, payments to physician groups are one of the early items undergoing close examination. Hospitalists aren’t alone in this budgetary fix, as hospital CEOs are scrutinizing all physician support. Emergency medicine, surgeon on-call pay, medical directorships, and group practice support are just a few examples.

Proactive Steps

So what is a hospitalist group to do? Be prepared! Here are some steps you can take to stay ahead of the game.

• Understand the financial situation at your hospital. Is the hospital making money? Is it spending money on capital equipment? What is the hospital’s margin? What is the pattern over the last several years?
• Understand your HMG’s impact on the hospital. Regardless of your employment status, you need to know the impact. Do not rely on a hospital administrator to do the impact analysis for you. Don’t wait to seek out the data until you are forced to defend your group’s value. If you get into a situation where you must quickly defend your group’s value, time usually is not on your side, and it may be difficult to obtain the appropriate data in a timely manner. It is best to have the analysis already complete.
• Write down the impact analysis, obtain data to back up the assertions, and regularly review it with senior hospital leaders, medical staff leaders and your group. While a full SWOT analysis is ideal, as this provides a complete picture of your HMG’s strengths, weaknesses, opportunities, and threats, a regularly updated impact analysis is a living document that should be shared.

Executing an Impact Analysis

Begin by putting all your hospitalists in a room for a few hours and have everyone brainstorm the HMG’s impact on the hospital. The entire group should be involved, because it is important each individual hospitalist understands the impact you have on the facility.

• What is your impact on PCP referrals? What is your impact on elective surgical cases coming to the hospital? What about subspecialty care? Do you admit all the subspecialists’ patients? What is your impact on quality and patient safety? What is your impact on hospital committees?
• Once you have listed your potential impact areas, have a discussion about the kinds of data needed to back up each impact assertion. Find the data (hospital sources, practice resources, SHM data, etc.) and put it in the impact analysis.
• If your impact analysis exceeds two pages, you need to do an executive summary. The goal is for leaders to read this on a regular basis and understand the larger, global points.
• Update this impact analysis regularly. At a minimum, this should be yearly, but at times it may require updating every three to four months.

No Need to Reinvent the Wheel

None of this information is new at SHM. One of our core commitments is to make sure you have the information to understand your HMG’s value to the hospital and what you can do to provide greater value. The practice management committee has published a series of value-added articles, as well as a regular update on management best practices. SHM leaders have been talking about value and impact for years, and the need to keep your hospital group knowledgeable at all times.

But we also realize in a high-growth practice, some operational details are left to later. So, if you have not done an impact analysis, or if you have one and haven’t updated it in a while, use the urgency of the general economic downturn to get started. You, your group, your hospital, and your patients will be much better off if you are prepared. TH

Dr. Cawley is president of SHM.

“Hospital Doctors Brace for Layoff.”

As I was scanning an online news source recently, the headline above caught my eye. The story detailed a U.S. hospital experiencing a loss in the past year, and one of the cost-cutting measures being considered by the hospital administration was a layoff of some of the health system’s hospitalists.

Now, while the story caught my eye, I was not surprised. All hospitalists and hospital medicine group leaders should take this as a warning and be prepared for potential cost tightening at your local hospital in the next year. Many hospitalist groups are vulnerable to cutbacks, because support often is needed to maintain the viability of the HM program and, in tough economic times, all HM support receives closer scrutiny.

It’s no secret; the U.S. economy is in a decline. A recession has yet to be declared, as a recession normally is defined as two consecutive fiscal quarters of negative gross domestic product growth. However, this economy has been flat the past two quarters, in terms of GDP, and expectations for the fourth quarter aren’t good. Additionally, the country is experiencing increased costs across the continuum related to oil prices, food prices, the housing downturn, and the mortgage mess. So, while there may not be an official recession, many businesses are experiencing a financial tightening, with decreased revenues from slower growth and higher costs from a variety of areas.

Even Healthcare Has Soft Spots

On Wall Street, conventional wisdom dictates the healthcare industry is more stable and resistant to recession than other industries. The general belief is people get sick no matter the state of the economy. But the healthcare industry is diverse and revenue has many avenues. Certainly in biotechnology and pharmaceuticals, there is a greater degree of recession resistance, but within the healthcare industry, hospitals and providers are much more sensitive to an economic downturn, even though a large percentage of revenues are from government sources.

In an economic downturn, hospital demand decreases secondary to a less admissions and elective procedures, particularly in patients with non-government payers. Additionally, the number of uninsured rises, which results in a change in payer mix at hospitals. Finally, due to the rise in out-of-pocket expenses associated with health insurance, it is highly likely patients will forgo healthcare at a quicker rate than in past recessions. When things get tough, patients must pick and choose what to pay for, and with the higher out-of-pocket expenses, healthcare is not as easy to access for many people.

In the meantime, the cost of running a hospital continues to escalate. Labor shortages continue, so hospitals must continue to pay competitive salaries to attract and maintain employees. Hospitals have made significant investments in patient safety, information technology, new construction, and physician practices in the past several years. All of these factors continue to contribute to the high fixed costs of hospital financials.

And so, as hospitals begin to look at costs that are not as fixed, and thus easier to cut, payments to physician groups are one of the early items undergoing close examination. Hospitalists aren’t alone in this budgetary fix, as hospital CEOs are scrutinizing all physician support. Emergency medicine, surgeon on-call pay, medical directorships, and group practice support are just a few examples.

Proactive Steps

So what is a hospitalist group to do? Be prepared! Here are some steps you can take to stay ahead of the game.

• Understand the financial situation at your hospital. Is the hospital making money? Is it spending money on capital equipment? What is the hospital’s margin? What is the pattern over the last several years?
• Understand your HMG’s impact on the hospital. Regardless of your employment status, you need to know the impact. Do not rely on a hospital administrator to do the impact analysis for you. Don’t wait to seek out the data until you are forced to defend your group’s value. If you get into a situation where you must quickly defend your group’s value, time usually is not on your side, and it may be difficult to obtain the appropriate data in a timely manner. It is best to have the analysis already complete.
• Write down the impact analysis, obtain data to back up the assertions, and regularly review it with senior hospital leaders, medical staff leaders and your group. While a full SWOT analysis is ideal, as this provides a complete picture of your HMG’s strengths, weaknesses, opportunities, and threats, a regularly updated impact analysis is a living document that should be shared.

Executing an Impact Analysis

Begin by putting all your hospitalists in a room for a few hours and have everyone brainstorm the HMG’s impact on the hospital. The entire group should be involved, because it is important each individual hospitalist understands the impact you have on the facility.

• What is your impact on PCP referrals? What is your impact on elective surgical cases coming to the hospital? What about subspecialty care? Do you admit all the subspecialists’ patients? What is your impact on quality and patient safety? What is your impact on hospital committees?
• Once you have listed your potential impact areas, have a discussion about the kinds of data needed to back up each impact assertion. Find the data (hospital sources, practice resources, SHM data, etc.) and put it in the impact analysis.
• If your impact analysis exceeds two pages, you need to do an executive summary. The goal is for leaders to read this on a regular basis and understand the larger, global points.
• Update this impact analysis regularly. At a minimum, this should be yearly, but at times it may require updating every three to four months.

No Need to Reinvent the Wheel

None of this information is new at SHM. One of our core commitments is to make sure you have the information to understand your HMG’s value to the hospital and what you can do to provide greater value. The practice management committee has published a series of value-added articles, as well as a regular update on management best practices. SHM leaders have been talking about value and impact for years, and the need to keep your hospital group knowledgeable at all times.

But we also realize in a high-growth practice, some operational details are left to later. So, if you have not done an impact analysis, or if you have one and haven’t updated it in a while, use the urgency of the general economic downturn to get started. You, your group, your hospital, and your patients will be much better off if you are prepared. TH

Dr. Cawley is president of SHM.

“Hospital Doctors Brace for Layoff.”

As I was scanning an online news source recently, the headline above caught my eye. The story detailed a U.S. hospital experiencing a loss in the past year, and one of the cost-cutting measures being considered by the hospital administration was a layoff of some of the health system’s hospitalists.

Now, while the story caught my eye, I was not surprised. All hospitalists and hospital medicine group leaders should take this as a warning and be prepared for potential cost tightening at your local hospital in the next year. Many hospitalist groups are vulnerable to cutbacks, because support often is needed to maintain the viability of the HM program and, in tough economic times, all HM support receives closer scrutiny.

It’s no secret; the U.S. economy is in a decline. A recession has yet to be declared, as a recession normally is defined as two consecutive fiscal quarters of negative gross domestic product growth. However, this economy has been flat the past two quarters, in terms of GDP, and expectations for the fourth quarter aren’t good. Additionally, the country is experiencing increased costs across the continuum related to oil prices, food prices, the housing downturn, and the mortgage mess. So, while there may not be an official recession, many businesses are experiencing a financial tightening, with decreased revenues from slower growth and higher costs from a variety of areas.

Even Healthcare Has Soft Spots

On Wall Street, conventional wisdom dictates the healthcare industry is more stable and resistant to recession than other industries. The general belief is people get sick no matter the state of the economy. But the healthcare industry is diverse and revenue has many avenues. Certainly in biotechnology and pharmaceuticals, there is a greater degree of recession resistance, but within the healthcare industry, hospitals and providers are much more sensitive to an economic downturn, even though a large percentage of revenues are from government sources.

In an economic downturn, hospital demand decreases secondary to a less admissions and elective procedures, particularly in patients with non-government payers. Additionally, the number of uninsured rises, which results in a change in payer mix at hospitals. Finally, due to the rise in out-of-pocket expenses associated with health insurance, it is highly likely patients will forgo healthcare at a quicker rate than in past recessions. When things get tough, patients must pick and choose what to pay for, and with the higher out-of-pocket expenses, healthcare is not as easy to access for many people.

In the meantime, the cost of running a hospital continues to escalate. Labor shortages continue, so hospitals must continue to pay competitive salaries to attract and maintain employees. Hospitals have made significant investments in patient safety, information technology, new construction, and physician practices in the past several years. All of these factors continue to contribute to the high fixed costs of hospital financials.

And so, as hospitals begin to look at costs that are not as fixed, and thus easier to cut, payments to physician groups are one of the early items undergoing close examination. Hospitalists aren’t alone in this budgetary fix, as hospital CEOs are scrutinizing all physician support. Emergency medicine, surgeon on-call pay, medical directorships, and group practice support are just a few examples.

Proactive Steps

So what is a hospitalist group to do? Be prepared! Here are some steps you can take to stay ahead of the game.

• Understand the financial situation at your hospital. Is the hospital making money? Is it spending money on capital equipment? What is the hospital’s margin? What is the pattern over the last several years?
• Understand your HMG’s impact on the hospital. Regardless of your employment status, you need to know the impact. Do not rely on a hospital administrator to do the impact analysis for you. Don’t wait to seek out the data until you are forced to defend your group’s value. If you get into a situation where you must quickly defend your group’s value, time usually is not on your side, and it may be difficult to obtain the appropriate data in a timely manner. It is best to have the analysis already complete.
• Write down the impact analysis, obtain data to back up the assertions, and regularly review it with senior hospital leaders, medical staff leaders and your group. While a full SWOT analysis is ideal, as this provides a complete picture of your HMG’s strengths, weaknesses, opportunities, and threats, a regularly updated impact analysis is a living document that should be shared.

Executing an Impact Analysis

Begin by putting all your hospitalists in a room for a few hours and have everyone brainstorm the HMG’s impact on the hospital. The entire group should be involved, because it is important each individual hospitalist understands the impact you have on the facility.

• What is your impact on PCP referrals? What is your impact on elective surgical cases coming to the hospital? What about subspecialty care? Do you admit all the subspecialists’ patients? What is your impact on quality and patient safety? What is your impact on hospital committees?
• Once you have listed your potential impact areas, have a discussion about the kinds of data needed to back up each impact assertion. Find the data (hospital sources, practice resources, SHM data, etc.) and put it in the impact analysis.
• If your impact analysis exceeds two pages, you need to do an executive summary. The goal is for leaders to read this on a regular basis and understand the larger, global points.
• Update this impact analysis regularly. At a minimum, this should be yearly, but at times it may require updating every three to four months.

No Need to Reinvent the Wheel

None of this information is new at SHM. One of our core commitments is to make sure you have the information to understand your HMG’s value to the hospital and what you can do to provide greater value. The practice management committee has published a series of value-added articles, as well as a regular update on management best practices. SHM leaders have been talking about value and impact for years, and the need to keep your hospital group knowledgeable at all times.

But we also realize in a high-growth practice, some operational details are left to later. So, if you have not done an impact analysis, or if you have one and haven’t updated it in a while, use the urgency of the general economic downturn to get started. You, your group, your hospital, and your patients will be much better off if you are prepared. TH

Dr. Cawley is president of SHM.