The Hospitalist

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Compared to other healthcare-associated infections, catheter-associated urinary tract infections (CAUTIs) cause relatively low rates of mortality and morbidity, but their prevalence nevertheless leads to a considerable cumulative burden.

Hospitalists can impact CAUTI rates by using a simple bundle of interventions. This idea was recently demonstrated by a quality improvement project addressing high CAUTI rates in the hospital setting. The project was summarized in a paper published in The Joint Commission Journal on Quality and Patient Safety.

The project identified a bundle of primary interventions to reduce CAUTI, which consisted of six elements: the “6 Cs” of CAUTI reduction. These include “consider alternatives,” “culture urine only when indication is clear,” and “connect with a securement device.” The interventions were implemented on one ICU with excellent results and subsequently diffused throughout the healthcare facility using multimedia tools. CAUTI rates decreased by 70%.

“The first steps in CAUTI prevention are to ensure that catheters are placed only when necessary, aseptic technique used for placement, and that they are removed when no longer essential,” says lead author Priya Sampathkumar, MD, Mayo Clinic associate professor of medicine. “Once this has been achieved, if CAUTI rates are still high, a secondary bundle of CAUTI prevention can help to reduce CAUTI further.”

About one in four hospitalized patients have a urinary catheter in place.2 “Hospitalists, therefore, can have a significant impact on CAUTI by being mindful about catheter use and catheter management.” Dr. Sampathkumar says.

References

1. Sampathkumar P, Barth JW, Johnson M, et al. Mayo Clinic reduces catheter-associated urinary tract infections. Jt Comm J Qual Patient Saf. 2016;42(6):254-265.
2. Catheter-associated urinary tract infections (CAUTI). Centers for Disease Control and Prevention website. Accessed August 8, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

Although effective palliative care has always been a must-have for patients and caregivers facing serious illness, it hasn’t always been readily available. With the emergence of value-based healthcare models—and their potent incentives to reduce avoidable readmissions—there is renewed hope that such care will be accessible to those who need it.

Palliative and end-of-life care have long been promoted as core skills for hospitalists. The topic has regularly been included at SHM annual meetings and other prominent hospital medicine conferences, in the American Board of Internal Medicine blueprint for recognition of focused practice in hospital medicine, and in a number of influential references for hospitalists. Still, as I look at hospitalist programs around the country, there is a clear need to improve hospitalists’ delivery of palliative and end-of-life care.

Care of patients with chronic illness in their last two years of life accounts for a third of all Medicare spending.1 As hospitalists, we encounter many of these patients as they are hospitalized—and often re-hospitalized. Palliative care, which can improve quality of life and decrease costs for patients while leading to increased satisfaction and better outcomes for caregivers, can help alleviate unneeded and unwanted aggressive interventions like hospitalization.2,3

In its 2014 report, Dying in America, the Institute of Medicine (IOM) identified several areas for improvement, including better advance care planning and payment systems supporting high quality end-of-life care.4 As I write this column in mid 2016, there are two notable achievements since the IOM report: two E&M codes for advance care planning and a substantial and growing number of hospitalist patients in alternative payment models like bundled payments or ACOs.5 I believe we are entering a time when the availability of good palliative care will be accelerated due to broader forces in healthcare that for the first time align incentives between patients’ wishes and how care is paid for.

Palliative Care Skills for Hospitalists

The following are key actions for physicians in addressing palliative care for the hospitalized patient. At the risk of oversimplifying the discipline, I offer a few key actions for hospitalists to keep in mind.

Identify patients who would benefit from palliative care. The surprise question—“Would I be surprised if this patient died in the next year?”—has the ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a “no” answer identified 60% of patients who died within a year.6 The surprise question has previously been shown to be predictive in other cancer and non-cancer populations.7,8

Weisman and Meier suggest using the following in a checklist at the time of hospital admission as “primary criteria to screen for unmet palliative care needs”:9

• The surprise question
• Frequent admissions
• Admission prompted by difficult-to-control physical or psychological symptoms
• Complex care requirements
• Decline in function, feeding intolerance, or unintended decline in weight

Hold a “goals of care” meeting. A notable step forward for supporting conversations between physicians and patients occurred on Jan. 1, when the Centers for Medicare & Medicaid Services (CMS) announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and cover discussions regarding advance care planning issues including discussing advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life-sustaining treatment like the role of hydration or future hospitalizations. (For more information on how to use them, visit the CMS website and search for the FAQ.)

What should hospitalists concentrate on when having “goals of care” conversations with patients and caregivers? Ariadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a serious illness conversation:10

• Patients’ understanding of their illness
• Patients’ preferences for information and for family involvement
• Personal life goals, fears, and anxieties
• Trade-offs they are willing to accept

For hospitalists, an important area to pay particular attention to is the role of future hospitalizations in patients’ wishes for care, as some patients, if offered appropriate symptom control, would prefer to remain at home.

Two other crucial elements of inpatient palliative care—offer psychosocial support and symptom relief and hand off patient to effective post-hospital palliative care—are outside the scope of this article. However, they should be kept in mind and, of course, applied.

Understand the role of the palliative care consultation. Busy hospitalists might reasonably think, “I simply don’t have time to address palliative care in patients who aren’t likely to die during this hospitalization or soon after.” The palliative care consult service, if available, should be accessed when patients are identified as palliative care candidates but the primary hospitalist does not have the time or resources—including specialized knowledge in some cases—to deliver adequate palliative care. Palliative care specialists can also help bridge the gap between inpatient and outpatient palliative care resources.

In sum, the move to value-based payment models and the new advance care planning E&M codes provide a renewed focus—with more aligned incentives—and the opportunity to provide good palliative care to all who need it.

For hospitalists, identifying those who would benefit from palliative care and working with the healthcare team to ensure the care is delivered are at the heart of our professional mission. TH

References

1. End-of-life care. The Darmouth Atlas of Health Care website. Accessed June 23, 2016.
2. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
3. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Int Med. 2008;168(16):1783-1790.
4. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. 2014.
5. BPCI Model 2: Retrospective acute & post acute care episode. Centers for Medicare & Medicaid Services website. Accessed June 24, 2016.
6. Vick JB, Pertsch N, Hutchings M, et al. The utility of the surprise question in identifying patients most at risk of death. J Clin Oncol. 2015;33(suppl):8.
7. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “surprise” question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008;3:1379-1384.
8. Moss AH, Lunney JR, Culp S, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-840.
9. Weissman D, Meier C. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
10. Serious illness care resources. Ariadne Labs website. Accessed June 24, 2016.

• Infectious Disease: Bugs, Drugs, and You: ID Boot Camp for Hospitalists
• Perioperative Medicine: Essential Elements and Latest Advances
• ABIM Maintenance of Certification and Board Review
• Practice Management Success Strategies: Building a Practice That People Want to Be Part Of
• Bedside Procedures for the Hospitalist
• Point-of-Care Ultrasound for the Hospitalist

New to SHM? Receive a FREE membership with your meeting registration. Visit www.hospitalmedicine2017.org to learn more.

• Infectious Disease: Bugs, Drugs, and You: ID Boot Camp for Hospitalists
• Perioperative Medicine: Essential Elements and Latest Advances
• ABIM Maintenance of Certification and Board Review
• Practice Management Success Strategies: Building a Practice That People Want to Be Part Of
• Bedside Procedures for the Hospitalist
• Point-of-Care Ultrasound for the Hospitalist

New to SHM? Receive a FREE membership with your meeting registration. Visit www.hospitalmedicine2017.org to learn more.

• Infectious Disease: Bugs, Drugs, and You: ID Boot Camp for Hospitalists
• Perioperative Medicine: Essential Elements and Latest Advances
• ABIM Maintenance of Certification and Board Review
• Practice Management Success Strategies: Building a Practice That People Want to Be Part Of
• Bedside Procedures for the Hospitalist
• Point-of-Care Ultrasound for the Hospitalist

New to SHM? Receive a FREE membership with your meeting registration. Visit www.hospitalmedicine2017.org to learn more.

G. Alvernaz, Alabama

M. Schloss, Alabama

L. M. Benson, FNP, Arizona

P. Kiesner, Arizona

H. Breen, MD, Arkansas

E. Porter, ACNP, APRN-BC, Arkansas

P. Charugundla, DO, California

J. Leroux, California

R. Liang, DO, California

S. Ramirez, California

A. Sardi, California

K. Waloff, MD, FAAP, California

M. Alami, MD, Colorado

B. Paul, FACP, Colorado

J. Pierce, MD, Colorado

J. Ross, Colorado

C. Schoo, MD, Colorado

R. Ashkar, Connecticut

C. Lodato, Connecticut

R. Nardino, MD, Connecticut

D. No, Connecticut

E. R. H. Pana, MD, Connecticut

J. P. Patel, Connecticut

T. Banks, DO, Delaware

H. Divatia, DO, Delaware

I. Misra, MD, Delaware

D. Baker, ACNP, District of Columbia

G. Baldwin, ACMPE, MS, PA-C, Florida

J. Berquist, Florida

J. Geanes, Florida

J. Mellone, Florida

P. Brown, Georgia

K. Clearo, MD, Georgia

E. Evans, DO, Georgia

F. Fontem, Georgia

N. Gunter, Georgia

Q. L. Ta, FNP, Georgia

J. Kiaffas, BC, Hawaii

K. King, ARNP, Hawaii

Q. J. N. Leo, MBBS, Hawaii

I. Yepishin, DO, Hawaii

P. Costa, MD, Illinois

D. Gibson, MD, Illinois

L. Gimbel, Illinois

E. Lambers, PhD, Illinois

J. Lennon, Illinois

C. Pak, MD, Illinois

J. Yasin, MD, Illinois

F. Zahra, Illinois

T. Adugna, Indiana

N. Akula, FACP, Indiana

M. Aliniazee, MD, Indiana

L. Fick, MD, FACP, Indiana

R. Gotur, AHIP, Indiana

T. Mehta, Indiana

M. Batt, ANP, Iowa

R. Boppana, MD, Iowa

B. Funke, Iowa

C. Gumpert, Iowa

S. Litterer, Iowa

C. Strickler, ANP, Iowa

S. Akidiva, Kansas

T. Core, Kansas

A. Storrer, Kansas

S. Bale, MD, Kentucky

S. Haider, MBBS, Kentucky

A. Hickman, ACNP, Kentucky

A. Depta, Louisiana

M. D. Lindley, MD, MPH, Louisiana

L. Pham, MD, Louisiana

E. Stone, Louisiana

A. Stuart, Louisiana

S. Eleoff Van Durme, MD, MPH, Maryland

P. Guenter, PhD, RN, Maryland

A. Patterson, Maryland

I. Allen, MD, MPH, Massachusetts

R. Berger, MD, Massachusetts

M. Gibbons, MD, Massachusetts

A. C. Kataya, MD, Massachusetts

D. Moran, MD, Massachusetts

J. Sanchez, MD, Massachusetts

R. Hazin, MD, Michigan

L. Johnston, PA-C, Michigan

P. Patel, MD, Michigan

S. Patel, Michigan

J. Hunter, MD, Michigan

J. Coldwell, PA-C, Minnesota

W. Latham, PA-C, Minnesota

S. Tongen, MD, Minnesota

J. Wiederin, MD, Minnesota

V. A. Harrison, MD, FAAP, Mississippi

J. Henry, Mississippi

T. LaGarde, FAAFP, Mississippi

R. Edwards, MD, Missouri

W. El Aneed, MD, Missouri

S. Kolli, MD, Missouri

U. Muthyala, MD, Missouri

T. Thomas, DO, Missouri

C. Cole, PhD, DNP, Montana

K. Lien, MD, FACFM, Montana

N. Lewman, DO, Nevada

M. Makatam-Abrams, MD, New Hampshire

J. Cruz, PharmD, New Jersey

S. Kadiyam, MD, New Jersey

G. Acety, MD, New York

M. Desta, MD, New York

D. Konsky, DO, New York

F. Kumar, MD, New York

S. Ramamoorthy, ANP, New York

R. Ravindran, MD, New York

C. Tauro, MD, New York

P. Vitale, BS, MS, New York

S. Khan, MD, North Carolina

S. Menon, MD, North Carolina

J. Asteriou, MD, Ohio

S. Bearelly, MD, Ohio

K. Clark, MD, Ohio

F. Darmoch, Ohio

L. McKnight, MD, Ohio

A. Pope, APRN-BC, Ohio

D. Abernethy, Oklahoma

I. Liao, MD, Oregon

L. Matlock, FNP, Oregon

M. Bhatta, MD, Pennsylvania

B. Da Silva, MD, Pennsylvania

H. Entero, MD, Pennsylvania

Z. Garbuz, MD, Pennsylvania

B. Goldner, Pennsylvania

J. Goodling, CRNP, Pennsylvania

J. Jablonowski, PA-C, Pennsylvania

S. Kalim, Pennsylvania

J. Kim, Pennsylvania

S. McKimm, DO, Pennsylvania

B. Mosch, Pennsylvania

R. Naik, MBBS, Pennsylvania

V. Patel, MD, Pennsylvania

C. Raffferty, Pennsylvania

S. Ramakrishnan, MD, Pennsylvania

M. Rehr, DO, Pennsylvania

R. Sathi, MD, Pennsylvania

S. Shrestha, MD, Pennsylvania

T. Wigoda, Pennsylvania

B. Yemenu, MD, Pennsylvania

A. Gebru, Rhode Island

J. Freelin, MD, South Carolina

R. Romano Martin, PA-C, South Carolina

D. Njingeh, MD, South Dakota

P. Frost, MD, Tennessee

C. Olechowski, MD, Tennessee

O. Zaka, MD, Tennessee

K. Dowell, MS, Texas

T. Mian, Texas

R. Nuila, Texas

S. Pardinek, Texas

C. Pywell, Texas

K. Sanders, Texas

M. Varwani, MD, Texas

K. Johnson, MD, MPH, Washington

J. A. Levin, MD, Washington

R. Brant, FAAP, West Virginia

E. Hjertstedt, MD, Wisconsin

V. Kumar, Wisconsin

C. A. Valino, MD, Wyoming

E. Nehme, MD, United Arab Emirates

G. Alvernaz, Alabama

M. Schloss, Alabama

L. M. Benson, FNP, Arizona

P. Kiesner, Arizona

H. Breen, MD, Arkansas

E. Porter, ACNP, APRN-BC, Arkansas

P. Charugundla, DO, California

J. Leroux, California

R. Liang, DO, California

S. Ramirez, California

A. Sardi, California

K. Waloff, MD, FAAP, California

M. Alami, MD, Colorado

B. Paul, FACP, Colorado

J. Pierce, MD, Colorado

J. Ross, Colorado

C. Schoo, MD, Colorado

R. Ashkar, Connecticut

C. Lodato, Connecticut

R. Nardino, MD, Connecticut

D. No, Connecticut

E. R. H. Pana, MD, Connecticut

J. P. Patel, Connecticut

T. Banks, DO, Delaware

H. Divatia, DO, Delaware

I. Misra, MD, Delaware

D. Baker, ACNP, District of Columbia

G. Baldwin, ACMPE, MS, PA-C, Florida

J. Berquist, Florida

J. Geanes, Florida

J. Mellone, Florida

P. Brown, Georgia

K. Clearo, MD, Georgia

E. Evans, DO, Georgia

F. Fontem, Georgia

N. Gunter, Georgia

Q. L. Ta, FNP, Georgia

J. Kiaffas, BC, Hawaii

K. King, ARNP, Hawaii

Q. J. N. Leo, MBBS, Hawaii

I. Yepishin, DO, Hawaii

P. Costa, MD, Illinois

D. Gibson, MD, Illinois

L. Gimbel, Illinois

E. Lambers, PhD, Illinois

J. Lennon, Illinois

C. Pak, MD, Illinois

J. Yasin, MD, Illinois

F. Zahra, Illinois

T. Adugna, Indiana

N. Akula, FACP, Indiana

M. Aliniazee, MD, Indiana

L. Fick, MD, FACP, Indiana

R. Gotur, AHIP, Indiana

T. Mehta, Indiana

M. Batt, ANP, Iowa

R. Boppana, MD, Iowa

B. Funke, Iowa

C. Gumpert, Iowa

S. Litterer, Iowa

C. Strickler, ANP, Iowa

S. Akidiva, Kansas

T. Core, Kansas

A. Storrer, Kansas

S. Bale, MD, Kentucky

S. Haider, MBBS, Kentucky

A. Hickman, ACNP, Kentucky

A. Depta, Louisiana

M. D. Lindley, MD, MPH, Louisiana

L. Pham, MD, Louisiana

E. Stone, Louisiana

A. Stuart, Louisiana

S. Eleoff Van Durme, MD, MPH, Maryland

P. Guenter, PhD, RN, Maryland

A. Patterson, Maryland

I. Allen, MD, MPH, Massachusetts

R. Berger, MD, Massachusetts

M. Gibbons, MD, Massachusetts

A. C. Kataya, MD, Massachusetts

D. Moran, MD, Massachusetts

J. Sanchez, MD, Massachusetts

R. Hazin, MD, Michigan

L. Johnston, PA-C, Michigan

P. Patel, MD, Michigan

S. Patel, Michigan

J. Hunter, MD, Michigan

J. Coldwell, PA-C, Minnesota

W. Latham, PA-C, Minnesota

S. Tongen, MD, Minnesota

J. Wiederin, MD, Minnesota

V. A. Harrison, MD, FAAP, Mississippi

J. Henry, Mississippi

T. LaGarde, FAAFP, Mississippi

R. Edwards, MD, Missouri

W. El Aneed, MD, Missouri

S. Kolli, MD, Missouri

U. Muthyala, MD, Missouri

T. Thomas, DO, Missouri

C. Cole, PhD, DNP, Montana

K. Lien, MD, FACFM, Montana

N. Lewman, DO, Nevada

M. Makatam-Abrams, MD, New Hampshire

J. Cruz, PharmD, New Jersey

S. Kadiyam, MD, New Jersey

G. Acety, MD, New York

M. Desta, MD, New York

D. Konsky, DO, New York

F. Kumar, MD, New York

S. Ramamoorthy, ANP, New York

R. Ravindran, MD, New York

C. Tauro, MD, New York

P. Vitale, BS, MS, New York

S. Khan, MD, North Carolina

S. Menon, MD, North Carolina

J. Asteriou, MD, Ohio

S. Bearelly, MD, Ohio

K. Clark, MD, Ohio

F. Darmoch, Ohio

L. McKnight, MD, Ohio

A. Pope, APRN-BC, Ohio

D. Abernethy, Oklahoma

I. Liao, MD, Oregon

L. Matlock, FNP, Oregon

M. Bhatta, MD, Pennsylvania

B. Da Silva, MD, Pennsylvania

H. Entero, MD, Pennsylvania

Z. Garbuz, MD, Pennsylvania

B. Goldner, Pennsylvania

J. Goodling, CRNP, Pennsylvania

J. Jablonowski, PA-C, Pennsylvania

S. Kalim, Pennsylvania

J. Kim, Pennsylvania

S. McKimm, DO, Pennsylvania

B. Mosch, Pennsylvania

R. Naik, MBBS, Pennsylvania

V. Patel, MD, Pennsylvania

C. Raffferty, Pennsylvania

S. Ramakrishnan, MD, Pennsylvania

M. Rehr, DO, Pennsylvania

R. Sathi, MD, Pennsylvania

S. Shrestha, MD, Pennsylvania

T. Wigoda, Pennsylvania

B. Yemenu, MD, Pennsylvania

A. Gebru, Rhode Island

J. Freelin, MD, South Carolina

R. Romano Martin, PA-C, South Carolina

D. Njingeh, MD, South Dakota

P. Frost, MD, Tennessee

C. Olechowski, MD, Tennessee

O. Zaka, MD, Tennessee

K. Dowell, MS, Texas

T. Mian, Texas

R. Nuila, Texas

S. Pardinek, Texas

C. Pywell, Texas

K. Sanders, Texas

M. Varwani, MD, Texas

K. Johnson, MD, MPH, Washington

J. A. Levin, MD, Washington

R. Brant, FAAP, West Virginia

E. Hjertstedt, MD, Wisconsin

V. Kumar, Wisconsin

C. A. Valino, MD, Wyoming

E. Nehme, MD, United Arab Emirates

G. Alvernaz, Alabama

M. Schloss, Alabama

L. M. Benson, FNP, Arizona

P. Kiesner, Arizona

H. Breen, MD, Arkansas

E. Porter, ACNP, APRN-BC, Arkansas

P. Charugundla, DO, California

J. Leroux, California

R. Liang, DO, California

S. Ramirez, California

A. Sardi, California

K. Waloff, MD, FAAP, California

M. Alami, MD, Colorado

B. Paul, FACP, Colorado

J. Pierce, MD, Colorado

J. Ross, Colorado

C. Schoo, MD, Colorado

R. Ashkar, Connecticut

C. Lodato, Connecticut

R. Nardino, MD, Connecticut

D. No, Connecticut

E. R. H. Pana, MD, Connecticut

J. P. Patel, Connecticut

T. Banks, DO, Delaware

H. Divatia, DO, Delaware

I. Misra, MD, Delaware

D. Baker, ACNP, District of Columbia

G. Baldwin, ACMPE, MS, PA-C, Florida

J. Berquist, Florida

J. Geanes, Florida

J. Mellone, Florida

P. Brown, Georgia

K. Clearo, MD, Georgia

E. Evans, DO, Georgia

F. Fontem, Georgia

N. Gunter, Georgia

Q. L. Ta, FNP, Georgia

J. Kiaffas, BC, Hawaii

K. King, ARNP, Hawaii

Q. J. N. Leo, MBBS, Hawaii

I. Yepishin, DO, Hawaii

P. Costa, MD, Illinois

D. Gibson, MD, Illinois

L. Gimbel, Illinois

E. Lambers, PhD, Illinois

J. Lennon, Illinois

C. Pak, MD, Illinois

J. Yasin, MD, Illinois

F. Zahra, Illinois

T. Adugna, Indiana

N. Akula, FACP, Indiana

M. Aliniazee, MD, Indiana

L. Fick, MD, FACP, Indiana

R. Gotur, AHIP, Indiana

T. Mehta, Indiana

M. Batt, ANP, Iowa

R. Boppana, MD, Iowa

B. Funke, Iowa

C. Gumpert, Iowa

S. Litterer, Iowa

C. Strickler, ANP, Iowa

S. Akidiva, Kansas

T. Core, Kansas

A. Storrer, Kansas

S. Bale, MD, Kentucky

S. Haider, MBBS, Kentucky

A. Hickman, ACNP, Kentucky

A. Depta, Louisiana

M. D. Lindley, MD, MPH, Louisiana

L. Pham, MD, Louisiana

E. Stone, Louisiana

A. Stuart, Louisiana

S. Eleoff Van Durme, MD, MPH, Maryland

P. Guenter, PhD, RN, Maryland

A. Patterson, Maryland

I. Allen, MD, MPH, Massachusetts

R. Berger, MD, Massachusetts

M. Gibbons, MD, Massachusetts

A. C. Kataya, MD, Massachusetts

D. Moran, MD, Massachusetts

J. Sanchez, MD, Massachusetts

R. Hazin, MD, Michigan

L. Johnston, PA-C, Michigan

P. Patel, MD, Michigan

S. Patel, Michigan

J. Hunter, MD, Michigan

J. Coldwell, PA-C, Minnesota

W. Latham, PA-C, Minnesota

S. Tongen, MD, Minnesota

J. Wiederin, MD, Minnesota

V. A. Harrison, MD, FAAP, Mississippi

J. Henry, Mississippi

T. LaGarde, FAAFP, Mississippi

R. Edwards, MD, Missouri

W. El Aneed, MD, Missouri

S. Kolli, MD, Missouri

U. Muthyala, MD, Missouri

T. Thomas, DO, Missouri

C. Cole, PhD, DNP, Montana

K. Lien, MD, FACFM, Montana

N. Lewman, DO, Nevada

M. Makatam-Abrams, MD, New Hampshire

J. Cruz, PharmD, New Jersey

S. Kadiyam, MD, New Jersey

G. Acety, MD, New York

M. Desta, MD, New York

D. Konsky, DO, New York

F. Kumar, MD, New York

S. Ramamoorthy, ANP, New York

R. Ravindran, MD, New York

C. Tauro, MD, New York

P. Vitale, BS, MS, New York

S. Khan, MD, North Carolina

S. Menon, MD, North Carolina

J. Asteriou, MD, Ohio

S. Bearelly, MD, Ohio

K. Clark, MD, Ohio

F. Darmoch, Ohio

L. McKnight, MD, Ohio

A. Pope, APRN-BC, Ohio

D. Abernethy, Oklahoma

I. Liao, MD, Oregon

L. Matlock, FNP, Oregon

M. Bhatta, MD, Pennsylvania

B. Da Silva, MD, Pennsylvania

H. Entero, MD, Pennsylvania

Z. Garbuz, MD, Pennsylvania

B. Goldner, Pennsylvania

J. Goodling, CRNP, Pennsylvania

J. Jablonowski, PA-C, Pennsylvania

S. Kalim, Pennsylvania

J. Kim, Pennsylvania

S. McKimm, DO, Pennsylvania

B. Mosch, Pennsylvania

R. Naik, MBBS, Pennsylvania

V. Patel, MD, Pennsylvania

C. Raffferty, Pennsylvania

S. Ramakrishnan, MD, Pennsylvania

M. Rehr, DO, Pennsylvania

R. Sathi, MD, Pennsylvania

S. Shrestha, MD, Pennsylvania

T. Wigoda, Pennsylvania

B. Yemenu, MD, Pennsylvania

A. Gebru, Rhode Island

J. Freelin, MD, South Carolina

R. Romano Martin, PA-C, South Carolina

D. Njingeh, MD, South Dakota

P. Frost, MD, Tennessee

C. Olechowski, MD, Tennessee

O. Zaka, MD, Tennessee

K. Dowell, MS, Texas

T. Mian, Texas

R. Nuila, Texas

S. Pardinek, Texas

C. Pywell, Texas

K. Sanders, Texas

M. Varwani, MD, Texas

K. Johnson, MD, MPH, Washington

J. A. Levin, MD, Washington

R. Brant, FAAP, West Virginia

E. Hjertstedt, MD, Wisconsin

V. Kumar, Wisconsin

C. A. Valino, MD, Wyoming

E. Nehme, MD, United Arab Emirates

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

The pitfalls that can complicate the intersection of social media and patient privacy often come as no surprise when they arise, but digital communications, and social media sites in particular, also have made many positive contributions to the medical profession.

“Social media allows physicians to communicate with each other, to publicize items of interest, to solicit input from colleagues—even people that we don’t know—on a variety of topics,” says Brian Clay, MD, SFHM, interim chief medical informatics officer and associate program director of the internal medicine residency-training program at the University of California at San Diego.

But there is a dark side of social media, too, and some physicians have made significant missteps in social media use. Ryan Greysen, MD, MHS, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, has authored multiple studies on physician violations of online professionalism. In a report published in the March 2012 issue of JAMA, Dr. Greysen and co-authors note that 92% of the executive directors at state medical and osteopathic boards surveyed reported encountering at least one violation of online professionalism.3 Another report in the January 2013 issue of the Annals of Internal Medicine co-authored by Dr. Greysen notes that 71% of state medical boards have investigated physicians for violations of professionalism online.4 The consequences of these errors in judgment can be dire: Should your employer come across it or a colleague report it, you could lose your position and even lose your license.

Professional Guidelines

To avoid these significant and potentially career-ending blunders, the American College of Physicians (ACP)—in conjunction with the Federation of State Medical Boards (FSMB)—published recommendations offering ethical guidance in preserving the patient-physician relationship in context of social media.5 Similarly, the American Medical Association (AMA) published an opinion on professionalism in the use of social media.6 Their guidelines can be summarized in five succinct points.

• Maintain standards of professional ethics in online communications, including respect for patient privacy.

Katherine Chretien, MD, associate professor of medicine at George Washington University in Washington, D.C., a clinical associate professor in medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., and chief of the hospitalist section at the Veterans Affairs Medical Center also in Washington, D.C., warns physicians to use the utmost caution to maintain patient anonymity when publishing case stories online. When publishing clinical vignettes, physician blogs, and other forms of online media, all details that can identify a patient must be completely removed, including all forms of the date (references to “yesterday” or “last week,” for example, can identify the date). Check anything you intend to publish against the HIPPA list of 18 identifiers.7 (See “HIPPA Identifiers” below)

“The safest way to proceed when publishing patient narratives online is to get consent,” Dr. Chretien says. “If consent is not possible, as in cases of incidents that occurred several years ago, change the personal details, such as location, and clearly disclose that you have. Or make the example very general.” For example, instead of discussing how frustrated you became with a patient with asthma who you saw at a particular hospital in a certain year (a clear violation of patient privacy), paint the illustration in broad strokes. Dr. Chretien suggests you might phrase your observations in this way: “One of the frustrations I find when treating asthma patients is …”

It would also be wise to seek advice from colleagues before posting patient information, she notes.

• Do not blur the boundaries between your professional and social spheres.

In a 2011 study, Gabriel Bosslet, MD, assistant professor of clinical medicine and associate director of the fellowship in pulmonary and critical care medicine at Indiana University–Purdue University at Indianapolis, noted that 34% of participating physicians reported receiving a Facebook friend request from a patient or patient’s family member. As Dr. Chretien points out, this is less of a problem for hospitalists than private-practice physicians because the relationship with patients is transitory. The AMA, as well as the ACP and FSMB, note that physicians should not “friend” patients, accept friend requests, or contact patients through social media. Physicians are advised to keep their public and professional online personas separate, even to the point of creating distinct online identities for their personal and professional lives.

• Maintain professionalism in your online persona, and continually monitor your online image to ensure it reflects positively on yourself and the medical profession.

Some physicians fall into the trap of placing questionable postings on their personal pages, including posting content that can be inappropriate for public consumption or venting about patients and employers. Stories or incidents that medical professionals find intriguing or exciting may be disturbing to those outside their community, and medical humor can be offensive.

“[Physicians] assume [their social media page] is their personal space, so they can post whatever they want,” adds Dr. Chretien. “Part of their error is that they believe they are addressing a small group of close friends, but they forget that postings go out to the larger, peripheral audience of all Facebook friends and can often be accessed by the general public.” An ill-considered anecdote can damage not only your own reputation but also the overall perception of the profession. Physicians are always viewed in their professional role, even in social interactions.

• Use email and other forms of electronic communication only in cases of an established physician-patient relationship and only with informed patient consent. Documentation of these communications should be kept in the patient’s medical record.

Any request a physician receives for medical advice through a social media site or email must be handled with caution. The ACP and FSMB state that email and text communications with established patients can be beneficial but should occur only after both parties discuss privacy risks, the appropriate types of information that will be exchanged electronically, and how long patients should expect to wait for a physician response. Patient preference should guide the use of electronic communication with physicians, especially text messaging, says Dr. Greysen.

• Be aware that any postings on the Internet, because of its significant and unprecedented reach, can have future career ramifications. Consequently, physicians are advised to frequently monitor their online presence to control their image.

Dr. Greysen points out that presenting a positive image of physicians in the media is not a new challenge. “Physicians have been publishing books about their experiences for decades. But posting online without oversight, or in the moment without reflection, can be devastating to a physician’s career because the reach of the Internet is exponentially vaster than that of any printed material,” Dr. Greysen says.

Deliver Better Healthcare through Social Media

Perhaps one of the most dramatic ways in which social media is positively impacting healthcare is the FOAM movement, or free open access medical education. Jeanne Farnan, MD, associate professor of medicine at the University of Chicago Department of Medicine and lead author of the ACP and FSMB social media position paper, points to the dynamic collection of resources and tools for ongoing medical education as well as the community that participates in openly sharing knowledge as examples. FOAM resources are predominantly social media based and include blogs, podcasts, tweets, online videos, graphics, web-based applications, text documents, and photographs, many of which are available by following the Twitter feed @FOAMed (see “FOAM Links” below). This FOAM community is dedicated to the belief that high-quality medical education resources and interactions should be free and accessible to all who care for patients and especially to those who educate future physicians.8

Social media also affords physicians the opportunity to be a force in public health policies. “There is an active group of physician and medical student social media users in the blogosphere and on Twitter who use their social media presence for activism, and this presence is intimately tied to how they see themselves as a medical professional,” Dr. Farnan says. “They blog and tweet about medical education issues and other public topics such as access to care and care disparity.”

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company specializing in social media communications, praises the power of social media for raising awareness of public health issues.

“In terms of public health, social media is valuable to better understand how health-related news resonates with the public,” Vangel says. “Two salient examples of major health crises reactions tracked on social media were the Ebola outbreak in Africa and the measles outbreak at Disneyland in California. At times, there was near hysteria over Ebola and vaccine debates, with misinformation spreading quickly. However, many hospitals and physicians tried to get ahead of the hysteria by providing concise, accurate information on different social media platforms, with Facebook often a popular channel to post information.”

Social media sites can also help by making emotional support available at disease-specific sites. These communities address the patient experience of the disease that goes beyond purely medical disease information. Vangel points to several online communities that “host pivotal conversations for patients,” she says. “There are Facebook community pages dedicated to a host of conditions, including diabetes, hypertension, and cystic fibrosis, where patients discuss the challenges of medication compliance, side effects, and even dissatisfaction with healthcare professionals. BabyCenter.com provides message boards about a wide array of topics for people trying to conceive, pregnant women with health conditions, and parents of babies with health issues. CancerForums.net and the health and wellness boards at DelphiForums.com provide support to specific disease populations.”

Vangel encourages physicians to monitor online patient-support sites to better understand the difficulties patients experience while under treatment. These sites can also help physicians recognize and address the gaps in patient understanding about various diseases and explore programs geared toward the populations suffering from a wide range of conditions. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Photos of drinking, grinning aid mission doctors cause uproar. CNN website. Accessed December 2, 2015.
2. Terhune C. Hospital violated patient confidentiality, state says. Los Angeles Times website. Accessed December 3, 2015.
3. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;(307):1141-1142.
4. Greysen SR, Johnson D, Kind T, et al. Online professional investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;(158):124-130.
5. New recommendations offer physicians ethical guidance for preserving trust in patient-physician relationships and the profession when using social media. American College of Physicians website. Accessed July 3, 2015.
6. Opinion 9.124—professionalism in the use of social media. American Medical Association website. Accessed July 3, 2015.
7. HIPPA PHI: list of 18 identifiers and definition of PHI. The Committee for Protection of Human Subjects website. Accessed July 10, 2015.
8. FOAM. Life in the Fastlane website. Accessed September 6, 2015.

HIPPA Identifiers

To maintain patient privacy when specific cases are referenced in an online or printed publication, HIPPA includes a list of 18 items that can identify an individual. These “HIPPA Identifiers,” listed below, must be omitted from any online medical discussions.7

1. Names
2. Geographical entities including street address, city, county, precinct, ZIP, and their equivalent geocodes, except for the initial three digits of a ZIP—in short, anything smaller than a state
3. Dates (except year) directly related to an individual, including birth date, admission date, date of death, etc.
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers including license plate numbers and VINs
13. Device identifiers and serial numbers
14. URLs
15. IP addresses
16. Biometric identifiers, including finger and voice prints
17. Full face (or any comparable image) photographs
18. Any other unique identifying number, characteristic, or code

How Hospitalists Can Use Social Media to Improve Their Institution’s Care

Michelle Vangel, director of insight services with Cision, a Chicago-based public relations company that advises physicians about online promotion, sees social media as an opportunity for hospitalists to benefit their hospital in a number of ways.

“Through online discussions, hospitalists can instill confidence and help patients understand what makes their institution excellent,” she says. “They can openly discuss areas they are working on improving and call attention to any recognition they receive. In order to do this, they need to be responsive to questions from patients and as transparent as possible in their responses.”

According to Vangel, before embarking on a social media plan, hospitalists should develop a clear strategy. In collaboration with colleagues, hospital administration, and communications professionals, they should establish guidelines about the types of topics that can be covered, appropriate social media channels in which to participate, and frequency of posts in advance to help physicians succeed in social media. Physicians must maintain a high standard of professionalism in speaking for their hospital and need to ensure that the message isn’t oversimplified on social media by the character-limit constraints of online channels.

Ryan Greysen, MD, FHM, assistant professor in the division of hospital medicine at the University of California at San Francisco, identifies another benefit hospitals can glean from social media that many other industries have been practicing for some time now. Patients dissatisfied with your hospital’s care can be identified by monitoring the hospital Twitter account for complaints. Hospital representatives can contact these individuals via Twitter and invite them to communicate privately with the hospital about their experience, thereby increasing patient satisfaction rates. TH

—Maybelle Cowan-Lincoln

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.

When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.

“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”

Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?

“I got the idea that we could do better than that,” Dr. Goldman says.

He was right.

Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.

Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

Until Dr. Wachter and Dr. Goldman.

On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).

A burgeoning specialty was given a name.

Its practitioners were called “hospitalists.”

And the rest, as they say, is history.

The Early Days

The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.

But it wasn’t always this way.

The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.

When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.

“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”

Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.

“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”

In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.

“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.

At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’

“And someone raised their hand and said, ‘Who’s the doctor?’

“And I said, ‘You mean who’s the intern?’

“They said, ‘No.’

“I said, ‘Or who’s the ward resident?’

“They said, ‘No.’

“And then, ‘Who is the attending?’

“And they said, ‘Yes.’

“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”

Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.

Community Views

Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.

She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.

She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.

So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.

“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”

Perfect Timing

The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.

“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”

That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.

Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.

The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”

“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”

Growth Spurt

The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.

The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.

“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

Revenue Rules the Day

Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.

“That meant more money in their own pockets because the medical group was taking the risk.”

Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.

“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”

And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.

“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Tech Effect

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?

“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.

“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).

“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”

So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.

“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

Teamwork: An HM Tradition

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.

Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

The Post-Acute Space

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.

“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.

Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.

And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.

“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.

“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”

Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.

Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.

BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.

“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

A Score of Success

Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.

To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.

Again, progress followed quickly.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.

Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.

Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.

“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”

The Future

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.

Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.

“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.

“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.

“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.

“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”

Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.

Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.

“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH

Richard Quinn is a freelance writer in New Jersey.

References

1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.

Year of the Hospitalist: Opinions

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”

—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission

 

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore

 

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago

 

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.

 

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality

 

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.

 

—Richard Quinn

Kris Rehm, MD, is associate professor of clinical pediatrics and director of the Division of Hospital Medicine at the Vanderbilt University School of Medicine in Nashville. Dr. Rehm also serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, chairs the Society of Hospital Medicine’s Pediatrics Committee, and is chair of the 2017 Pediatric Hospital Medicine meeting.

The Hospitalist recently spoke with Dr. Rehm about her career path to pediatric hospital medicine, the impact SHM has had on her career, and how she balances the busy schedule of a hospitalist with her family and personal life.

Question: How did you arrive at a career in pediatric hospital medicine?

Answer: In 2001, as a resident in the Boston Combined Residency Program in pediatrics at Boston Children’s Hospital, I knew that I preferred caring for patients who were acutely ill. I also enjoyed collaborating with subspecialists as we worked to diagnose and treat patients with some of the most complicated disease processes at a tertiary-care center. At this time, hospital medicine was still quite a young specialty.

After my residency, my husband and I moved from Boston to Nashville, and I worked in general pediatrics in the community for three years. In 2005, Vanderbilt was ready to begin a hospital medicine program. It was perfect timing for me, as I had just delivered my first set of twins. (Yes, that’s right—I have two sets of twins!)

I started to work part-time in hospital medicine—what a great opportunity! I was able to work in the acute-care setting, which I loved, with residents, students, and subspecialists that I loved, and also be home with my 1-year-old sons, Jackson and Lucas.

As time passed, I gradually moved from part-time to full-time. In addition, opportunities to advance in administrative leadership have helped me broaden my career, working as the medical director of hospital operations as well as the division director of hospital medicine.

Q: What is the most memorable moment in your career as a pediatric hospitalist?

A: Honestly, the most amazing memories that I have are when those in my division are successful—and that has happened a lot! In our division, we now have the dean of students at the medical school, the two faculty voted as best teachers by our residents last year, and the director of our Quality Academy at Vanderbilt. In fact, earlier this year, a member of our division won the teaching award voted on by residents—the third year in a row for her and our group. I am so proud of those members in my division. … They do incredible things at work and beyond.

While completing our annual reviews this spring, I had a chance to talk with faculty about contributions they have each made in making a diagnosis, comforting a patient, or assisting a family member through a difficult time. Moments like these truly inspire me to keep doing what I do.

Q: What do you find most valuable about your work with SHM?

A: Being involved in a national organization like SHM has opened tremendous doors for me, both personally and professionally. It has helped my academic promotion to associate professor, it has allowed me networking opportunities with leaders in both pediatric and adult hospital medicine, and it has had a tremendous impact on my life as an academic leader in hospital medicine.

The SHM Pediatrics Committee is another example of a truly collaborative group of individuals trying to make a difference every day for the children we care for and the hospital medicine specialty through our professional “home” of SHM. As chair of the Pediatrics Committee, I have had the chance to empower our new committee members who articulate willingness to take leadership to become active, engaged members of the society. Watching Drs. Charlotte Brown and Akshata Hopkins present the top articles in the Pediatric Hospital Medicine talk at HM16 in San Diego was an awesome example.

At the moment, we are jumping into planning for PHM17, and I am honored and excited to serve as chair of this meeting. I have attended annually since 2005, and to watch the meeting grow and take on many issues has been truly unbelievable. The meeting now draws nearly 1,000 pediatric hospitalists and is an invaluable opportunity for attendees to learn from each other.

SHM provides our members with the opportunity to become as engaged as you are able with committees, training opportunities, annual meetings, and more. So jump in!

Q: How do you balance your demanding schedule with your husband, children, and leisure?

A: Raising four young boys, now ages 9 and 12, with my husband and working full-time as a pediatric hospitalist is so challenging but so rewarding. (My husband and I are experts at Outlook invitations to coordinate a busy schedule of sporting events and school functions as well as night shifts for me and travel for him.) As a family, we spend lots of nights at the soccer field or basketball court, and we love to travel, ski, and swim. And personally, I run. That is my time to unwind. I just ask for one hour a day to exercise, which doubles as my therapy.

I run for Nashville Running Company, a local running store. Some of the other ladies and I meet most mornings at 5 a.m. This year, I ran in the St. George Marathon in Utah as well as the L.A. Marathon. Super fun! I’m planning to run the Chicago Marathon this fall, and Boston’s in the spring of 2017.

Q: As we celebrate the 20th anniversary of hospital medicine, how do you see HM evolving over the next 20 years?

A: What an interesting idea to consider! PHM is moving toward a board certification process, which will be exciting for our field. Similar to other specialties, such as pediatric emergency medicine, adolescent medicine, or child abuse pediatrics, it will be wonderful to watch our specialty gain recognition as a boarded specialty.

HM providers are positioned for leadership throughout organizations, and as we strive to provide the highest-value care, I believe we will continue to grow in this regard. PHM providers now serve as department chairs and hospital CEOs, CMOs, and many other leadership positions. At Vanderbilt, we are seeing some other divisions, such as pediatric neurology, hire neurologists who have inpatient versus outpatient interests. We may see this trend continue over time through other fields as well, with physicians providing specialty-specific hospital care expertise in very defined areas. TH

Brett Radler is SHM’s communications specialist.

Kris Rehm, MD, is associate professor of clinical pediatrics and director of the Division of Hospital Medicine at the Vanderbilt University School of Medicine in Nashville. Dr. Rehm also serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, chairs the Society of Hospital Medicine’s Pediatrics Committee, and is chair of the 2017 Pediatric Hospital Medicine meeting.

The Hospitalist recently spoke with Dr. Rehm about her career path to pediatric hospital medicine, the impact SHM has had on her career, and how she balances the busy schedule of a hospitalist with her family and personal life.

Question: How did you arrive at a career in pediatric hospital medicine?

Answer: In 2001, as a resident in the Boston Combined Residency Program in pediatrics at Boston Children’s Hospital, I knew that I preferred caring for patients who were acutely ill. I also enjoyed collaborating with subspecialists as we worked to diagnose and treat patients with some of the most complicated disease processes at a tertiary-care center. At this time, hospital medicine was still quite a young specialty.

After my residency, my husband and I moved from Boston to Nashville, and I worked in general pediatrics in the community for three years. In 2005, Vanderbilt was ready to begin a hospital medicine program. It was perfect timing for me, as I had just delivered my first set of twins. (Yes, that’s right—I have two sets of twins!)

I started to work part-time in hospital medicine—what a great opportunity! I was able to work in the acute-care setting, which I loved, with residents, students, and subspecialists that I loved, and also be home with my 1-year-old sons, Jackson and Lucas.

As time passed, I gradually moved from part-time to full-time. In addition, opportunities to advance in administrative leadership have helped me broaden my career, working as the medical director of hospital operations as well as the division director of hospital medicine.

Q: What is the most memorable moment in your career as a pediatric hospitalist?

A: Honestly, the most amazing memories that I have are when those in my division are successful—and that has happened a lot! In our division, we now have the dean of students at the medical school, the two faculty voted as best teachers by our residents last year, and the director of our Quality Academy at Vanderbilt. In fact, earlier this year, a member of our division won the teaching award voted on by residents—the third year in a row for her and our group. I am so proud of those members in my division. … They do incredible things at work and beyond.

While completing our annual reviews this spring, I had a chance to talk with faculty about contributions they have each made in making a diagnosis, comforting a patient, or assisting a family member through a difficult time. Moments like these truly inspire me to keep doing what I do.

Q: What do you find most valuable about your work with SHM?

A: Being involved in a national organization like SHM has opened tremendous doors for me, both personally and professionally. It has helped my academic promotion to associate professor, it has allowed me networking opportunities with leaders in both pediatric and adult hospital medicine, and it has had a tremendous impact on my life as an academic leader in hospital medicine.

The SHM Pediatrics Committee is another example of a truly collaborative group of individuals trying to make a difference every day for the children we care for and the hospital medicine specialty through our professional “home” of SHM. As chair of the Pediatrics Committee, I have had the chance to empower our new committee members who articulate willingness to take leadership to become active, engaged members of the society. Watching Drs. Charlotte Brown and Akshata Hopkins present the top articles in the Pediatric Hospital Medicine talk at HM16 in San Diego was an awesome example.

At the moment, we are jumping into planning for PHM17, and I am honored and excited to serve as chair of this meeting. I have attended annually since 2005, and to watch the meeting grow and take on many issues has been truly unbelievable. The meeting now draws nearly 1,000 pediatric hospitalists and is an invaluable opportunity for attendees to learn from each other.

SHM provides our members with the opportunity to become as engaged as you are able with committees, training opportunities, annual meetings, and more. So jump in!

Q: How do you balance your demanding schedule with your husband, children, and leisure?

A: Raising four young boys, now ages 9 and 12, with my husband and working full-time as a pediatric hospitalist is so challenging but so rewarding. (My husband and I are experts at Outlook invitations to coordinate a busy schedule of sporting events and school functions as well as night shifts for me and travel for him.) As a family, we spend lots of nights at the soccer field or basketball court, and we love to travel, ski, and swim. And personally, I run. That is my time to unwind. I just ask for one hour a day to exercise, which doubles as my therapy.

I run for Nashville Running Company, a local running store. Some of the other ladies and I meet most mornings at 5 a.m. This year, I ran in the St. George Marathon in Utah as well as the L.A. Marathon. Super fun! I’m planning to run the Chicago Marathon this fall, and Boston’s in the spring of 2017.

Q: As we celebrate the 20th anniversary of hospital medicine, how do you see HM evolving over the next 20 years?

A: What an interesting idea to consider! PHM is moving toward a board certification process, which will be exciting for our field. Similar to other specialties, such as pediatric emergency medicine, adolescent medicine, or child abuse pediatrics, it will be wonderful to watch our specialty gain recognition as a boarded specialty.

HM providers are positioned for leadership throughout organizations, and as we strive to provide the highest-value care, I believe we will continue to grow in this regard. PHM providers now serve as department chairs and hospital CEOs, CMOs, and many other leadership positions. At Vanderbilt, we are seeing some other divisions, such as pediatric neurology, hire neurologists who have inpatient versus outpatient interests. We may see this trend continue over time through other fields as well, with physicians providing specialty-specific hospital care expertise in very defined areas. TH

Brett Radler is SHM’s communications specialist.

Kris Rehm, MD, is associate professor of clinical pediatrics and director of the Division of Hospital Medicine at the Vanderbilt University School of Medicine in Nashville. Dr. Rehm also serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, chairs the Society of Hospital Medicine’s Pediatrics Committee, and is chair of the 2017 Pediatric Hospital Medicine meeting.

The Hospitalist recently spoke with Dr. Rehm about her career path to pediatric hospital medicine, the impact SHM has had on her career, and how she balances the busy schedule of a hospitalist with her family and personal life.

Question: How did you arrive at a career in pediatric hospital medicine?

Answer: In 2001, as a resident in the Boston Combined Residency Program in pediatrics at Boston Children’s Hospital, I knew that I preferred caring for patients who were acutely ill. I also enjoyed collaborating with subspecialists as we worked to diagnose and treat patients with some of the most complicated disease processes at a tertiary-care center. At this time, hospital medicine was still quite a young specialty.

After my residency, my husband and I moved from Boston to Nashville, and I worked in general pediatrics in the community for three years. In 2005, Vanderbilt was ready to begin a hospital medicine program. It was perfect timing for me, as I had just delivered my first set of twins. (Yes, that’s right—I have two sets of twins!)

I started to work part-time in hospital medicine—what a great opportunity! I was able to work in the acute-care setting, which I loved, with residents, students, and subspecialists that I loved, and also be home with my 1-year-old sons, Jackson and Lucas.

As time passed, I gradually moved from part-time to full-time. In addition, opportunities to advance in administrative leadership have helped me broaden my career, working as the medical director of hospital operations as well as the division director of hospital medicine.

Q: What is the most memorable moment in your career as a pediatric hospitalist?

A: Honestly, the most amazing memories that I have are when those in my division are successful—and that has happened a lot! In our division, we now have the dean of students at the medical school, the two faculty voted as best teachers by our residents last year, and the director of our Quality Academy at Vanderbilt. In fact, earlier this year, a member of our division won the teaching award voted on by residents—the third year in a row for her and our group. I am so proud of those members in my division. … They do incredible things at work and beyond.

While completing our annual reviews this spring, I had a chance to talk with faculty about contributions they have each made in making a diagnosis, comforting a patient, or assisting a family member through a difficult time. Moments like these truly inspire me to keep doing what I do.

Q: What do you find most valuable about your work with SHM?

A: Being involved in a national organization like SHM has opened tremendous doors for me, both personally and professionally. It has helped my academic promotion to associate professor, it has allowed me networking opportunities with leaders in both pediatric and adult hospital medicine, and it has had a tremendous impact on my life as an academic leader in hospital medicine.

The SHM Pediatrics Committee is another example of a truly collaborative group of individuals trying to make a difference every day for the children we care for and the hospital medicine specialty through our professional “home” of SHM. As chair of the Pediatrics Committee, I have had the chance to empower our new committee members who articulate willingness to take leadership to become active, engaged members of the society. Watching Drs. Charlotte Brown and Akshata Hopkins present the top articles in the Pediatric Hospital Medicine talk at HM16 in San Diego was an awesome example.

At the moment, we are jumping into planning for PHM17, and I am honored and excited to serve as chair of this meeting. I have attended annually since 2005, and to watch the meeting grow and take on many issues has been truly unbelievable. The meeting now draws nearly 1,000 pediatric hospitalists and is an invaluable opportunity for attendees to learn from each other.

SHM provides our members with the opportunity to become as engaged as you are able with committees, training opportunities, annual meetings, and more. So jump in!

Q: How do you balance your demanding schedule with your husband, children, and leisure?

A: Raising four young boys, now ages 9 and 12, with my husband and working full-time as a pediatric hospitalist is so challenging but so rewarding. (My husband and I are experts at Outlook invitations to coordinate a busy schedule of sporting events and school functions as well as night shifts for me and travel for him.) As a family, we spend lots of nights at the soccer field or basketball court, and we love to travel, ski, and swim. And personally, I run. That is my time to unwind. I just ask for one hour a day to exercise, which doubles as my therapy.

I run for Nashville Running Company, a local running store. Some of the other ladies and I meet most mornings at 5 a.m. This year, I ran in the St. George Marathon in Utah as well as the L.A. Marathon. Super fun! I’m planning to run the Chicago Marathon this fall, and Boston’s in the spring of 2017.

Q: As we celebrate the 20th anniversary of hospital medicine, how do you see HM evolving over the next 20 years?

A: What an interesting idea to consider! PHM is moving toward a board certification process, which will be exciting for our field. Similar to other specialties, such as pediatric emergency medicine, adolescent medicine, or child abuse pediatrics, it will be wonderful to watch our specialty gain recognition as a boarded specialty.

HM providers are positioned for leadership throughout organizations, and as we strive to provide the highest-value care, I believe we will continue to grow in this regard. PHM providers now serve as department chairs and hospital CEOs, CMOs, and many other leadership positions. At Vanderbilt, we are seeing some other divisions, such as pediatric neurology, hire neurologists who have inpatient versus outpatient interests. We may see this trend continue over time through other fields as well, with physicians providing specialty-specific hospital care expertise in very defined areas. TH

Brett Radler is SHM’s communications specialist.

SHM Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently 2,000 hospitalists who have earned the FHM/SFHM designation by demonstrating core values of leadership, teamwork, and quality improvement.

Apply by Sept. 15 to receive an early decision on or before Oct. 28. The regular decision application will remain open through Nov. 30. Apply now at www.hospitalmedicine.org/fellows.

SHM Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently 2,000 hospitalists who have earned the FHM/SFHM designation by demonstrating core values of leadership, teamwork, and quality improvement.

Apply by Sept. 15 to receive an early decision on or before Oct. 28. The regular decision application will remain open through Nov. 30. Apply now at www.hospitalmedicine.org/fellows.

SHM Fellows designation is a prestigious way to differentiate yourself in the rapidly growing profession of hospital medicine. There are currently 2,000 hospitalists who have earned the FHM/SFHM designation by demonstrating core values of leadership, teamwork, and quality improvement.

Apply by Sept. 15 to receive an early decision on or before Oct. 28. The regular decision application will remain open through Nov. 30. Apply now at www.hospitalmedicine.org/fellows.

Nominations for SHM Awards of Excellence, committees, Board of Director seats, and Masters of Hospital Medicine designations are now open. The deadline for award, committee, and board election nominations is Oct. 14. The deadline for MHM submission is Dec. 9. Make your nominations now at www.hospitalmedicine.org:

• Awards of Excellence: www.hospitalmedicine.org/awards

• Board of Directors: www.hospitalmedicine.org/boardelection

• Committee nominations: www.hospitalmedicine.org/committee

• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

Nominations for SHM Awards of Excellence, committees, Board of Director seats, and Masters of Hospital Medicine designations are now open. The deadline for award, committee, and board election nominations is Oct. 14. The deadline for MHM submission is Dec. 9. Make your nominations now at www.hospitalmedicine.org:

• Awards of Excellence: www.hospitalmedicine.org/awards

• Board of Directors: www.hospitalmedicine.org/boardelection

• Committee nominations: www.hospitalmedicine.org/committee

• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

Nominations for SHM Awards of Excellence, committees, Board of Director seats, and Masters of Hospital Medicine designations are now open. The deadline for award, committee, and board election nominations is Oct. 14. The deadline for MHM submission is Dec. 9. Make your nominations now at www.hospitalmedicine.org:

• Awards of Excellence: www.hospitalmedicine.org/awards

• Board of Directors: www.hospitalmedicine.org/boardelection

• Committee nominations: www.hospitalmedicine.org/committee

• Masters of Hospital Medicine: www.hospitalmedicine.org/masters

Learn more by visiting www.hospitalmedicine.org/BOOST and clicking on “BOOST Results” to read the full case study.

Learn more by visiting www.hospitalmedicine.org/BOOST and clicking on “BOOST Results” to read the full case study.

Learn more by visiting www.hospitalmedicine.org/BOOST and clicking on “BOOST Results” to read the full case study.