Doctor and patient

Credit: NIH

The US House and Senate have passed a bill that will delay for another year the 24% cut in Medicare reimbursements that was set to take effect April 1 as part of the sustainable growth rate (SGR) formula.

Leaders from the House and Senate recently agreed on a plan to permanently replace the SGR, but they could not agree on a way to pay for it.

The current bill delays the cuts to Medicare reimbursements and extends other expiring healthcare provisions, such as higher payment rates for rural hospitals and ambulance rides in rural areas.

In total, this is expected to cost $21 billion. It will be paid for by cuts to healthcare providers, but half of the cuts won’t take effect for 10 years.

The SGR calls for annual, automatic cuts in Medicare payments to physicians, but these cuts have accumulated over the years. This marks the seventeenth temporary “patch” to the SGR.

For more details on this year’s fix, see the bill: Protecting Access to Medicare Act of 2014 (H.R. 4302).

Doctor and patient

Credit: NIH

The US House and Senate have passed a bill that will delay for another year the 24% cut in Medicare reimbursements that was set to take effect April 1 as part of the sustainable growth rate (SGR) formula.

Leaders from the House and Senate recently agreed on a plan to permanently replace the SGR, but they could not agree on a way to pay for it.

The current bill delays the cuts to Medicare reimbursements and extends other expiring healthcare provisions, such as higher payment rates for rural hospitals and ambulance rides in rural areas.

In total, this is expected to cost $21 billion. It will be paid for by cuts to healthcare providers, but half of the cuts won’t take effect for 10 years.

The SGR calls for annual, automatic cuts in Medicare payments to physicians, but these cuts have accumulated over the years. This marks the seventeenth temporary “patch” to the SGR.

For more details on this year’s fix, see the bill: Protecting Access to Medicare Act of 2014 (H.R. 4302).

Doctor and patient

Credit: NIH

The US House and Senate have passed a bill that will delay for another year the 24% cut in Medicare reimbursements that was set to take effect April 1 as part of the sustainable growth rate (SGR) formula.

Leaders from the House and Senate recently agreed on a plan to permanently replace the SGR, but they could not agree on a way to pay for it.

The current bill delays the cuts to Medicare reimbursements and extends other expiring healthcare provisions, such as higher payment rates for rural hospitals and ambulance rides in rural areas.

In total, this is expected to cost $21 billion. It will be paid for by cuts to healthcare providers, but half of the cuts won’t take effect for 10 years.

The SGR calls for annual, automatic cuts in Medicare payments to physicians, but these cuts have accumulated over the years. This marks the seventeenth temporary “patch” to the SGR.

For more details on this year’s fix, see the bill: Protecting Access to Medicare Act of 2014 (H.R. 4302).

DNA helices

Credit: NIGMS

NASHVILLE—New research suggests we may need to use more sensitive methods to analyze patients with cytogenetically normal acute myeloid leukemia or myelodysplastic syndrome (CN-AML/MDS).

Using “highly sensitive” microarray technology, researchers found a distinct pattern of genetic abnormalities in 22 patients diagnosed with CN-AML/MDS.

The team identified 3 overlapping regions of homozygosity in 3 genes, 2 of which are known to be involved in carcinogenesis.

This suggests that using karyotyping or FISH, or simply looking for known mutations, is not sufficient for evaluating patients with CN-AML/MDS, according to Ravindra Kolhe, MD, PhD, of the Medical College of Georgia at Georgia Regents University.

“The technology we currently use can’t identify specifically what’s wrong,” Dr Kolhe said. “We have to use more sensitive tests to give patients the proper answer.”

Dr Kolhe presented this finding, and the research to support it, at the American College of Medical Genetics and Genomics Annual Clinical Genetics Meeting.

He and his colleagues analyzed 22 patients. Seventeen had AML, and 5 had MDS, including 1 with refractory anemia with excess blasts-2. All patients had normal karyotype and FISH and had greater than 20% blasts in the bone marrow.

The researchers analyzed samples from these patients using a high-resolution, single-nucleotide polymorphism (SNP) microarray called CytoScanHD.

According to the company that markets this technology (Affymetrix, Inc.), the assay includes 750,000 SNPs with over 99% accuracy to detect accurate breakpoint estimation, loss of heterozygosity determination, regions identical-by-descent, maternal contamination, and low-level mosaicism.

For Dr Kolhe and his colleagues, the assay revealed small, previously undetectable changes in patients thought to be cytogenetically normal.

Specifically, the researchers identified 3 overlapping regions of homozygosity in all 22 cases—chromosome 1p34.3, chromosome 1p32.3, and chromosome 16q22.1 in the SFPQ, EPS15, and CTCF genes, respectively.

SFPQ and CTCF are already known to be involved in carcinogenesis, and Dr Kolhe and his colleagues are now investigating the role of EPS15 in leukemogenesis.

The researchers also identified additional abnormalities and are investigating these as well. They are sequencing the genes to identify homozygous or compound heterozygous mutations, performing expression studies to confirm that these mutations are leukemic, and conducting experiments in knockout mice to demonstrate that these genes produce the same leukemia phenotype.

The materials and reagents for this study were provided by Affymetrix. The test design, experimentation, data collection, analysis, and interpretation were done independently by the researchers.

DNA helices

Credit: NIGMS

NASHVILLE—New research suggests we may need to use more sensitive methods to analyze patients with cytogenetically normal acute myeloid leukemia or myelodysplastic syndrome (CN-AML/MDS).

Using “highly sensitive” microarray technology, researchers found a distinct pattern of genetic abnormalities in 22 patients diagnosed with CN-AML/MDS.

The team identified 3 overlapping regions of homozygosity in 3 genes, 2 of which are known to be involved in carcinogenesis.

This suggests that using karyotyping or FISH, or simply looking for known mutations, is not sufficient for evaluating patients with CN-AML/MDS, according to Ravindra Kolhe, MD, PhD, of the Medical College of Georgia at Georgia Regents University.

“The technology we currently use can’t identify specifically what’s wrong,” Dr Kolhe said. “We have to use more sensitive tests to give patients the proper answer.”

Dr Kolhe presented this finding, and the research to support it, at the American College of Medical Genetics and Genomics Annual Clinical Genetics Meeting.

He and his colleagues analyzed 22 patients. Seventeen had AML, and 5 had MDS, including 1 with refractory anemia with excess blasts-2. All patients had normal karyotype and FISH and had greater than 20% blasts in the bone marrow.

The researchers analyzed samples from these patients using a high-resolution, single-nucleotide polymorphism (SNP) microarray called CytoScanHD.

According to the company that markets this technology (Affymetrix, Inc.), the assay includes 750,000 SNPs with over 99% accuracy to detect accurate breakpoint estimation, loss of heterozygosity determination, regions identical-by-descent, maternal contamination, and low-level mosaicism.

For Dr Kolhe and his colleagues, the assay revealed small, previously undetectable changes in patients thought to be cytogenetically normal.

Specifically, the researchers identified 3 overlapping regions of homozygosity in all 22 cases—chromosome 1p34.3, chromosome 1p32.3, and chromosome 16q22.1 in the SFPQ, EPS15, and CTCF genes, respectively.

SFPQ and CTCF are already known to be involved in carcinogenesis, and Dr Kolhe and his colleagues are now investigating the role of EPS15 in leukemogenesis.

The researchers also identified additional abnormalities and are investigating these as well. They are sequencing the genes to identify homozygous or compound heterozygous mutations, performing expression studies to confirm that these mutations are leukemic, and conducting experiments in knockout mice to demonstrate that these genes produce the same leukemia phenotype.

The materials and reagents for this study were provided by Affymetrix. The test design, experimentation, data collection, analysis, and interpretation were done independently by the researchers.

DNA helices

Credit: NIGMS

NASHVILLE—New research suggests we may need to use more sensitive methods to analyze patients with cytogenetically normal acute myeloid leukemia or myelodysplastic syndrome (CN-AML/MDS).

Using “highly sensitive” microarray technology, researchers found a distinct pattern of genetic abnormalities in 22 patients diagnosed with CN-AML/MDS.

The team identified 3 overlapping regions of homozygosity in 3 genes, 2 of which are known to be involved in carcinogenesis.

This suggests that using karyotyping or FISH, or simply looking for known mutations, is not sufficient for evaluating patients with CN-AML/MDS, according to Ravindra Kolhe, MD, PhD, of the Medical College of Georgia at Georgia Regents University.

“The technology we currently use can’t identify specifically what’s wrong,” Dr Kolhe said. “We have to use more sensitive tests to give patients the proper answer.”

Dr Kolhe presented this finding, and the research to support it, at the American College of Medical Genetics and Genomics Annual Clinical Genetics Meeting.

He and his colleagues analyzed 22 patients. Seventeen had AML, and 5 had MDS, including 1 with refractory anemia with excess blasts-2. All patients had normal karyotype and FISH and had greater than 20% blasts in the bone marrow.

The researchers analyzed samples from these patients using a high-resolution, single-nucleotide polymorphism (SNP) microarray called CytoScanHD.

According to the company that markets this technology (Affymetrix, Inc.), the assay includes 750,000 SNPs with over 99% accuracy to detect accurate breakpoint estimation, loss of heterozygosity determination, regions identical-by-descent, maternal contamination, and low-level mosaicism.

For Dr Kolhe and his colleagues, the assay revealed small, previously undetectable changes in patients thought to be cytogenetically normal.

Specifically, the researchers identified 3 overlapping regions of homozygosity in all 22 cases—chromosome 1p34.3, chromosome 1p32.3, and chromosome 16q22.1 in the SFPQ, EPS15, and CTCF genes, respectively.

SFPQ and CTCF are already known to be involved in carcinogenesis, and Dr Kolhe and his colleagues are now investigating the role of EPS15 in leukemogenesis.

The researchers also identified additional abnormalities and are investigating these as well. They are sequencing the genes to identify homozygous or compound heterozygous mutations, performing expression studies to confirm that these mutations are leukemic, and conducting experiments in knockout mice to demonstrate that these genes produce the same leukemia phenotype.

The materials and reagents for this study were provided by Affymetrix. The test design, experimentation, data collection, analysis, and interpretation were done independently by the researchers.

A Rough Patch

I was the medical director of a hospitalist group in the Southeast that had been hospital-owned for eight years and grew to more than 20 full-time providers. New hospital administrators took over and, faced with staffing and compensation issues, outsourced the program. Within a year, all but one of the HMG employees (physicians, nurse practitioners, and physician assistants) resigned. As expected, the exodus put a strain on the program, patient care, and community. After a shakeup in administration, the management company pulled out. The hospital now runs the HM program. Is this occurrence just an outlier or are thes kind of situations becoming common to our field?

—Dr. Nore-grets

Dr. Hospitalist responds:

While I’m saddened at the disruption of so many lives (hospital executives, physicians, advanced practice providers, other clinical staff, and patients), I must say I’m not surprised by the outcome. Hospital medicine continues to be a rapidly growing specialty; approximately 70% of all hospitals in the U.S. have a hospitalist program. It’s only 17 years old, and as with all adolescents still finding their way, disputes are common.

Like most good stories, there are usually two sides. Hospitals have a board to satisfy, large numbers of employees (professional and non-professional), varying revenue streams to contend with, and an annual budget. There are many different groups vying for a larger slice of the pie—and the pie is only so big. No matter how we see it, some administrators believe physicians are overpaid and are not hard workers. There may not be much empathy for the docs, who work "only 182 days a year," asking for more time off, paid vacations, smaller patient loads, and more money.

Physicians see their student loans stretched out for 30 years, hospitals on building sprees, heavy patient loads, complex administrative tasks, and a lack of appreciation for the myriad intangible and non-billable services they render every day. Not being able to take a paid vacation like most workers in this country seems unfair to many. Even though most hospitalists still work 12-hour shifts, we resist being labeled "shift workers" because of the negative and non-professional inference.

It appears your hospitalist group had concerns about staffing and pay, and instead of effectively dealing with their concerns, the hospital’s administrators decided to outsource the program. While most national firms that hire hospitalists are well intentioned, they (like most hospitals) are driven by profit and sometimes bring in transient and inexperienced physicians. The eight-year-old group, while still relatively young, likely had members who had established both personal and professional relationships with many of the physicians and other clinical staff. These relationships, when built on trust, mutual respect, and competence, are the foundation of good clinical care. It is no surprise they were not able to adequately replace the clinicians who resigned.

The issues of pay and staffing are common points of contention among hospitalist and hospital administrators. The mode of compensation most often used is based on hospitalist productivity and is heavily subsidized by the hospital. While this model has served us well, the passage of the Affordable Care Act will change how healthcare systems are reimbursed. There will likely be many instances of bundled payments tied to inpatient care, but also an opportunity for hospitalists to further expand their roles into improving the quality of care and efficiency of delivery. The formation of accountable care organizations will offer even more opportunities for physician leadership and organizational assistance. The more hospitalists become imbedded in and invaluable to the hospital, the less likely we are placed on the chopping block when budget cuts happen or leadership changes (as in your case).

Until the reimbursement model changes, both groups need to understand the other’s position and use some basis for comparative analysis. I find the information from SHM surveys serves as a good basis to initiate discussion and allows for transparency. As in any negotiation, a shared sense of responsibility, goodwill, and commitment is necessary to find a just solution.

Because HM continues its rapid growth and hospitalists are in such high demand, many in the group are not tolerant of what they perceive as unfair treatment or pay. The principles of supply and demand economics are at work and have so far benefitted hospitalists well. We must balance our desire for just pay and fair staffing models with our responsibility as clinicians to care for the injured and heal the sick.

A Rough Patch

I was the medical director of a hospitalist group in the Southeast that had been hospital-owned for eight years and grew to more than 20 full-time providers. New hospital administrators took over and, faced with staffing and compensation issues, outsourced the program. Within a year, all but one of the HMG employees (physicians, nurse practitioners, and physician assistants) resigned. As expected, the exodus put a strain on the program, patient care, and community. After a shakeup in administration, the management company pulled out. The hospital now runs the HM program. Is this occurrence just an outlier or are thes kind of situations becoming common to our field?

—Dr. Nore-grets

Dr. Hospitalist responds:

While I’m saddened at the disruption of so many lives (hospital executives, physicians, advanced practice providers, other clinical staff, and patients), I must say I’m not surprised by the outcome. Hospital medicine continues to be a rapidly growing specialty; approximately 70% of all hospitals in the U.S. have a hospitalist program. It’s only 17 years old, and as with all adolescents still finding their way, disputes are common.

Like most good stories, there are usually two sides. Hospitals have a board to satisfy, large numbers of employees (professional and non-professional), varying revenue streams to contend with, and an annual budget. There are many different groups vying for a larger slice of the pie—and the pie is only so big. No matter how we see it, some administrators believe physicians are overpaid and are not hard workers. There may not be much empathy for the docs, who work "only 182 days a year," asking for more time off, paid vacations, smaller patient loads, and more money.

Physicians see their student loans stretched out for 30 years, hospitals on building sprees, heavy patient loads, complex administrative tasks, and a lack of appreciation for the myriad intangible and non-billable services they render every day. Not being able to take a paid vacation like most workers in this country seems unfair to many. Even though most hospitalists still work 12-hour shifts, we resist being labeled "shift workers" because of the negative and non-professional inference.

It appears your hospitalist group had concerns about staffing and pay, and instead of effectively dealing with their concerns, the hospital’s administrators decided to outsource the program. While most national firms that hire hospitalists are well intentioned, they (like most hospitals) are driven by profit and sometimes bring in transient and inexperienced physicians. The eight-year-old group, while still relatively young, likely had members who had established both personal and professional relationships with many of the physicians and other clinical staff. These relationships, when built on trust, mutual respect, and competence, are the foundation of good clinical care. It is no surprise they were not able to adequately replace the clinicians who resigned.

The issues of pay and staffing are common points of contention among hospitalist and hospital administrators. The mode of compensation most often used is based on hospitalist productivity and is heavily subsidized by the hospital. While this model has served us well, the passage of the Affordable Care Act will change how healthcare systems are reimbursed. There will likely be many instances of bundled payments tied to inpatient care, but also an opportunity for hospitalists to further expand their roles into improving the quality of care and efficiency of delivery. The formation of accountable care organizations will offer even more opportunities for physician leadership and organizational assistance. The more hospitalists become imbedded in and invaluable to the hospital, the less likely we are placed on the chopping block when budget cuts happen or leadership changes (as in your case).

Until the reimbursement model changes, both groups need to understand the other’s position and use some basis for comparative analysis. I find the information from SHM surveys serves as a good basis to initiate discussion and allows for transparency. As in any negotiation, a shared sense of responsibility, goodwill, and commitment is necessary to find a just solution.

Because HM continues its rapid growth and hospitalists are in such high demand, many in the group are not tolerant of what they perceive as unfair treatment or pay. The principles of supply and demand economics are at work and have so far benefitted hospitalists well. We must balance our desire for just pay and fair staffing models with our responsibility as clinicians to care for the injured and heal the sick.

A Rough Patch

I was the medical director of a hospitalist group in the Southeast that had been hospital-owned for eight years and grew to more than 20 full-time providers. New hospital administrators took over and, faced with staffing and compensation issues, outsourced the program. Within a year, all but one of the HMG employees (physicians, nurse practitioners, and physician assistants) resigned. As expected, the exodus put a strain on the program, patient care, and community. After a shakeup in administration, the management company pulled out. The hospital now runs the HM program. Is this occurrence just an outlier or are thes kind of situations becoming common to our field?

—Dr. Nore-grets

Dr. Hospitalist responds:

While I’m saddened at the disruption of so many lives (hospital executives, physicians, advanced practice providers, other clinical staff, and patients), I must say I’m not surprised by the outcome. Hospital medicine continues to be a rapidly growing specialty; approximately 70% of all hospitals in the U.S. have a hospitalist program. It’s only 17 years old, and as with all adolescents still finding their way, disputes are common.

Like most good stories, there are usually two sides. Hospitals have a board to satisfy, large numbers of employees (professional and non-professional), varying revenue streams to contend with, and an annual budget. There are many different groups vying for a larger slice of the pie—and the pie is only so big. No matter how we see it, some administrators believe physicians are overpaid and are not hard workers. There may not be much empathy for the docs, who work "only 182 days a year," asking for more time off, paid vacations, smaller patient loads, and more money.

Physicians see their student loans stretched out for 30 years, hospitals on building sprees, heavy patient loads, complex administrative tasks, and a lack of appreciation for the myriad intangible and non-billable services they render every day. Not being able to take a paid vacation like most workers in this country seems unfair to many. Even though most hospitalists still work 12-hour shifts, we resist being labeled "shift workers" because of the negative and non-professional inference.

It appears your hospitalist group had concerns about staffing and pay, and instead of effectively dealing with their concerns, the hospital’s administrators decided to outsource the program. While most national firms that hire hospitalists are well intentioned, they (like most hospitals) are driven by profit and sometimes bring in transient and inexperienced physicians. The eight-year-old group, while still relatively young, likely had members who had established both personal and professional relationships with many of the physicians and other clinical staff. These relationships, when built on trust, mutual respect, and competence, are the foundation of good clinical care. It is no surprise they were not able to adequately replace the clinicians who resigned.

The issues of pay and staffing are common points of contention among hospitalist and hospital administrators. The mode of compensation most often used is based on hospitalist productivity and is heavily subsidized by the hospital. While this model has served us well, the passage of the Affordable Care Act will change how healthcare systems are reimbursed. There will likely be many instances of bundled payments tied to inpatient care, but also an opportunity for hospitalists to further expand their roles into improving the quality of care and efficiency of delivery. The formation of accountable care organizations will offer even more opportunities for physician leadership and organizational assistance. The more hospitalists become imbedded in and invaluable to the hospital, the less likely we are placed on the chopping block when budget cuts happen or leadership changes (as in your case).

Until the reimbursement model changes, both groups need to understand the other’s position and use some basis for comparative analysis. I find the information from SHM surveys serves as a good basis to initiate discussion and allows for transparency. As in any negotiation, a shared sense of responsibility, goodwill, and commitment is necessary to find a just solution.

Because HM continues its rapid growth and hospitalists are in such high demand, many in the group are not tolerant of what they perceive as unfair treatment or pay. The principles of supply and demand economics are at work and have so far benefitted hospitalists well. We must balance our desire for just pay and fair staffing models with our responsibility as clinicians to care for the injured and heal the sick.

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

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

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

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

Dear Ms. Bernstein:

I’m writing this letter to let you know about some of the things happening in hospital medicine, to ensure we are always improving the care we provide.

While we talked on New Year’s Eve, you reluctantly told me that you and many of your friends were not happy with the move toward hospital care being provided by hospitalists, rather than the PCP you know. I didn’t respond because we were having a nice lunch and I didn’t want to distract you from praising my kids and talking about your grandbaby and her sibling on the way. So I thought I’d respond by writing this open letter to you on the chance it might also be thought provoking for some of my hospitalist colleagues.

I think your reluctance to share with me the unflattering opinion you and many of your friends have of the hospitalist model of care stemmed from a desire not to offend me rather than any uncertainty in your conclusion. It isn’t difficult to find others, both healthcare providers and consumers, who share your opinion.

As I’ve told you before, outside of my own parents, you and Mr. B. are among the people who had the most influence on my upbringing, and your opinion still matters to me. So I’m writing this hoping to change your view, at least a little.

Updated Numbers of Hospitalists

Our field is now larger than many other specialties, and we are experiencing ever-increasing pressure to “get it right.” A 2012 survey of hospitals conducted by the American Hospital Association found more than 38,000 doctors who identify themselves as hospitalists. This number has been increasing rapidly for more than a decade. The Society of Hospital Medicine (SHM) estimates that the number has grown to more than 44,000 in 2014, and that there are hospitalists in 72% of U.S. hospitals—90% at hospitals with over 200 beds. In 1996, there were fewer than 1,000 hospitalists.

The rapid growth in our field has brought challenges, and we’re lucky to have attracted many dedicated and talented people who are helping all of us make strides to do better, both by providing better technical care (e.g. ensuring careful assessments and ordering the best tests and treatments) and by doing so in a way that ensures patients and their families are highly satisfied.

Tools to Support Ongoing Improvements in Hospitalist Practice

There are many outlets hospitalists can turn to for education on essentially any aspect of their practice. Several years ago, the SHM published “The Core Competencies in Hospital Medicine: A Framework for Curriculum Development,” a publication that continues to be valuable in guiding hospitalists’ professional scope of clinical skills as well as educational curricula for training programs and continuing education. SHM and other organizations generate a great deal of educational content for hospitalists, which is available in many forms, including in-person conferences, webinars, and written materials. And there are several scientific journals that have significant content for hospitalists, including SHM’s own Journal of Hospital Medicine.

Our field encourages and recognizes ongoing commitment to hospitalists’ growth and development in a number of ways. When it is time for a doctor to renew his/her board certification, the American Board of Internal Medicine (ABIM) offers the option to pursue “Focused Practice in Hospital Medicine.” And SHM’s designation of Fellow, Senior Fellow and Master in Hospital Medicine recognizes those who have “demonstrated a commitment to hospital medicine, system change, and quality improvement principles.” Many in our field have achieved one or both of these distinctions, and countless others are pursuing them now.

Through its foundation, the ABIM developed a campaign known as “Choosing Wisely” to “promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” SHM joined in this effort by developing separate criteria for hospitalists who care for adults or children.

New Tool Encourages High Performance

In February, an SHM workgroup published “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists,” a document meant to serve as a road map for hospitalist groups to follow to improve their performance. I’m particularly interested in this, since I have spent much of my career thinking about and working with hospitalist groups to improve the way they perform, and I helped develop the characteristics and co-authored the document. But the real value of the document comes from the input of hundreds of people within and outside of SHM who provided thoughtful advice and feedback to identify those attributes of hospitalist groups that are most likely to ensure success.

The document describes 47 characteristics grouped into 10 different categories (“principles”). Some of the principles that you as a patient might be most interested in are ones specifying that a hospitalist group:

— Implements a practice model that is patient- and family-centered, is team-based, and emphasizes care coordination and effective communication.

— Supports care coordination across care settings; and

— Plays a leadership role in addressing key clinical issues in the hospital and/or health system: teaching, quality, safety, efficiency, and the patient/family experience.

Current State of Hospital Medicine

If you’ve had a less than satisfactory experience with care by a hospitalist, the things I’ve described here might not improve your opinion of hospitalists, or that of your friends. But maybe you can take some measure of comfort in knowing that our field as a whole is working hard to continuously improve all aspects of what we do. We’re serious about being good at what we do.

And, since this is published in a magazine read by hospitalists, maybe some of them will be reminded of the many ways our field encourages, supports, and recognizes their professional development.

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

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

There has been a fair amount of media coverage lately about “medical deserts.”¹ What exactly is a medical desert, and how big of a problem do they pose for hospital medicine? Wikipedia defines a desert as “a barren area of land where little precipitation occurs and consequently living conditions are hostile for plant and animal life.”² There are definitely areas in the U.S., both urban and rural, lacking adequate emergency and inpatient medical care.

Based on the latest American Hospital Association (AHA) statistics, there are still >5,700 registered hospitals in the U.S. with almost one million staffed beds combined, which accommodate >36 million admissions every year.³ However, of all U.S. hospitals, only about 35% are located in rural areas, and these tend to be the ones most likely affected by declining reimbursements and tight operating margins.¹

Here is some evidence:

— A recent study in the Annals of Emergency Medicine found that only half of the population in the state of Pennsylvania had access to appropriate care within 60 minutes for four time-sensitive conditions (i.e., STEMI, stroke, septic shock, and cardiac arrest).⁴

— Another study from the Office of Rural Health Policy estimates that approximately 20% of all residential areas do not have rapid access to an acute care medical facility.¹

— A recent online story about medical deserts described the devastating case of an 18-month-old girl who died of asphyxiation when a grape became lodged in her throat; their local county’s only hospital with an emergency room had closed months earlier, leaving the closest ED more than 20 miles away.¹ This particular hospital, Shelby Regional Medical Center, was a 54-bed hospital in Center, Texas, which suddenly closed in July 2013 amid allegations of fraud from CMS. In addition, a nearby 49-bed Texas hospital (Renaissance Hospital Groves), owned and operated by the same company, had closed in May 2013.

But the list of hospital closures in the past year goes on:

• Lakeside Memorial Hospital in Brockport, N.Y. (61-bed hospital);
• Earl K. Long Medical Center in Baton Rouge, La. (116-bed hospital);
• Stewart-Webster Hospital in Richland, Ga. (25-bed, critical access hospital);
• Calhoun Memorial Hospital in Arlington, Ga. (85-bed hospital);
• Charlton Memorial Hospital in Folkston, Ga. (25-bed hospital);
• The Los Angeles-based Pacific Health Corporation closed all four of its hospitals in California: Anaheim General Hospital (142 beds), Bellflower Medical Center (142 beds), Los Angeles Metropolitan Medical Center (212 beds), and Newport Specialty Hospital (177 beds).

As the CEO of Calhoun Memorial Hospital stated at the closure of his hospital: “It’s a sad day for the community it’s just a sign of the times.”⁵

Staff, Service Reductions

These hospital closures do not even start to address the nearly ubiquitous reductions in staff and services that many hospitals are resorting to, including workforce reductions experienced by many high-profile academic medical centers like Wake Forest, Denver Health, Emory Health, and Vanderbilt University Medical Centers. According to the Bureau of Labor Statistics, hospitals cut 4,400 jobs in July 2013 alone, while the U.S. overall added 162,000 jobs.¹

These acute medical care deserts are primarily a result of declining reimbursements from Medicare and Medicaid, combined with a lack of newly insured Americans, a group that was expected to increase at a much faster pace than it has. The introduction of high-dollar withholds tethered to pay-for-performance programs, such as value-based purchasing and readmission reduction penalties, has also contributed to the financial instability in some hospitals.

In addition, the reduction in disproportionate share hospital (DSH) payments has occurred long before any substantial increase in funded patients through the Affordable Care Act health exchanges. Particularly hard-hit are hospitals in the states that have still elected not to expand Medicaid (primarily in the Southeast and Midwest). And forecasters have every reason to believe that these medical deserts will expand, unless limping hospitals are merged and/or acquired by larger hospital systems.

Should You Be Concerned?

These statistics probably should raise some concern for hospitalists and hospital medicine groups, as the number of hospital-employed physicians is already relatively high (26% according to a recent survey) and rises every year, including an increase of 6% from 2012 to 2013 alone.⁶ In order to survive in these tenuous conditions, healthcare systems, including hospitalists, will have to be much more involved in the “spectrum of care,” including population health, as opposed to only being involved in discrete acute care episodes. There undoubtedly will be a heavy reliance on telemedicine, seamless electronic medical records, and alternative treatment settings to bridge the gap between medical oases and medical deserts. All of these acute medical care extensions will very likely involve hospitalists.

For the most part, as long as the specialty of hospital medicine keeps its ear to the ground on what is coming, ensuring that we can all be flexible and responsive in meeting the needs of the population we serve, our specialty will be prepped and ready for the “sign of the times.” That way, even when medical deserts do appear, they are not “hostile for life” but are reasonably connected to a suitable oasis.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Williams JP. What happens when a town’s only hospital shuts down? U.S. News and World Report online. November 8, 2013. Available at: http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/11/08/what-happens-when-the-only-hospital-closes. Accessed March 5, 2014.
2. Wikipedia. Desert. Available at: http://en.wikipedia.org/wiki/Desert. Accessed March 5, 2014.
3. American Hospital Association. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 5, 2014.
4. Salhi RA, Edwards JM, Gaieski DF, Band RA, Abella BS, Carr BG. Access to Care for patients with time-sensitive conditions in Pennsylvania [published online ahead of print December 21, 2013]. Ann Emerg Med.
5. Parks JM. Calhoun Memorial Hospital shuts down. Albany Herald online. February 4, 2013. Available at: http://www.albanyherald.com/news/2013/feb/04/calhoun-memorial-hospital-shuts-down. Accessed March 5, 2014.
6. Vaidya A. Survey: number of hospital-employed physicians up 6%. Becker’s Hospital Review online. June 18, 2013. Available at: http://www.beckershospitalreview.com/hospital-physician-relationships/survey-number-of-hospital-employed-physicians-up-6.html. Accessed March 5, 2014.

“When the time is ripe for certain things, they appear at different places in the manner of violets coming to light in early spring.” —Farkas Bolyai, to his son, Janos, urging him to claim the invention of non-Euclidean geometry without delay.

In February, I was at a 20th anniversary party for the hospital medicine program from Park Nicollet Methodist Hospital in St Louis Park, Minn., listening to the original founders of the group giving speeches and telling stories of how their program began. For them, it all began at an internal medicine retreat in 1993, with ideas being tossed about on how to be more efficient and deliver better care for their patients. This was three years before Bob Wachter and Lee Goldman delivered their sounding board article to the New England Journal of Medicine describing some early programs and, more importantly, giving those new practitioners a name: “hospitalist.”¹ The very same Park Nicollet program I was now helping to celebrate 20 years of success was called out in that article as one of four early groups in our country experimenting with hospitalists.

As I listened to the speeches, it occurred to me that the hospitalists standing up at the front of the room telling their war stories and reminiscing about the early days weren’t actually hospitalists at all back when they were thinking this new model up. They were primary care physicians struggling to meet the demands of the care environment at the time, coming up with unique solutions to the problems of the times without anyone telling them how or showing them the way. Back then, a few brave souls in the group stepped forward and said they would take on the majority of inpatient coverage, and suddenly, just like that, there were hospitalists, their given name still three years in the future, but hospitalists nevertheless.

Now this early program wasn’t the very first program, but it was part of a trend repeating at hospitals and within medical groups all over America. Slowly growing, slowly spreading, and under the radar, a social movement was afoot.

What Is a Social Movement?

Wikipedia says: Social movements are a type of group action. In sociology, a group action is a situation in which a large number of agents take action simultaneously in order to achieve a common goal; their actions are usually coordinated.

In those early days, the proto-hospitalists around the country were not coordinated or acting together, but that would come soon enough.

What were the factors that gave birth to this nascent social movement? Why was the same solution beginning to pop up all over the country in seemingly unconnected instances? The zeitgeist of the times had a lot to do with this, and it can all be boiled down to three things: time, money, and the “X” factor.

In the late 1980s and early 90s, managed care was making inroads into healthcare as a struggling country tried to wrestle with exploding costs. Capitated managed care systems attempted to control costs and improve health by managing cases preferentially, using PCPs with a directive to limit resource utilization.² They were the “gatekeepers” to more expensive care options like specialists and hospitalization. They were tasked with managing larger panels of patients, conducting shorter visits, and seeing more patients per day. In the other type of managed care of the time (non-capitated), physician practices, to stay in the game, were negotiating large discounts for their services. Then, to maintain their income, they had to see larger numbers of patients, either in the same amount of time or, as was usually the case, in time added to their workday.²

Just when the country was starting to count on primary care to be the lynchpin for the new healthcare model, medical students were turning away from primary care in record numbers. Internal-medicine matches were near all-time lows. PCPs in practice were facing growing time and money crunches, and the medical students they were counting on to help out were choosing other fields. The cavalry of new doctors needed to bolster the ranks of those already struggling to keep up simply wasn’t coming.

Finally, unassigned care for hospitalized patients, which had always been a responsibility of local doctors, had frequently been a condition of hospital privileging, and was often seen by the doctors as a way to give back to their hospital and community, was now something that added even more time, work, and financial pressure to their growing burdens.

So, these doctors, just like the doctors in the Park Nicollet Medical Group, began to brainstorm new ways to improve efficiency and see if they could get on top of the changes happening around them. One such idea was to create rounder systems. These systems would have each doctor in the practice take a week away from clinic and care for all of the practice’s patients in the hospital. This way, only one doctor would have to spend time away from those ever-busier clinic practices during the week. By giving up the continuity of the individual rounder and trading it for the continuity of the group, these groups gained efficiencies for everyone in the practice. This was the first small, but critical, step toward hospital medicine. It would have been hard to get to hospitalists without PCPs taking that first mental leap.

Often, it was one or more of these rounders who decided, for various reasons—boredom with ambulatory care, dislike of the more frantic pace of clinic, or simply a realization that they enjoyed or excelled at hospital care—that maybe they would just take on all of the hospital care for their group. This is what happened at Park Nicollet, and what started happening all across the country. The tinder was assembled and stacked, ready for something else to happen.

The Spark

Word of these new types of models and practices began to spread and was even talked about inside the pages of some journals. It took a few years, but somebody noticed and finally put it all together into an article that was published in the most famous medical journal in the world. In that 1996 New England Journal of Medicine article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Wachter and Goldman gave a name to the strange creatures willingly giving up half of what they had been trained to do and devoting all their time to an inpatient practice.¹ “Hospitalists,” they called them, and when the rest of the country read that article, the movement was no longer under the radar; it had a name. The spark had been ignited. What would become the fastest growing medical specialty in history was ready to take off.

But a spark needs more than tinder to truly ignite. Fuel and oxygen are necessary to give it life.

I’ll talk about that in my next column…

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335(7):514-517.
2. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34-S40.

“When the time is ripe for certain things, they appear at different places in the manner of violets coming to light in early spring.” —Farkas Bolyai, to his son, Janos, urging him to claim the invention of non-Euclidean geometry without delay.

In February, I was at a 20th anniversary party for the hospital medicine program from Park Nicollet Methodist Hospital in St Louis Park, Minn., listening to the original founders of the group giving speeches and telling stories of how their program began. For them, it all began at an internal medicine retreat in 1993, with ideas being tossed about on how to be more efficient and deliver better care for their patients. This was three years before Bob Wachter and Lee Goldman delivered their sounding board article to the New England Journal of Medicine describing some early programs and, more importantly, giving those new practitioners a name: “hospitalist.”¹ The very same Park Nicollet program I was now helping to celebrate 20 years of success was called out in that article as one of four early groups in our country experimenting with hospitalists.

As I listened to the speeches, it occurred to me that the hospitalists standing up at the front of the room telling their war stories and reminiscing about the early days weren’t actually hospitalists at all back when they were thinking this new model up. They were primary care physicians struggling to meet the demands of the care environment at the time, coming up with unique solutions to the problems of the times without anyone telling them how or showing them the way. Back then, a few brave souls in the group stepped forward and said they would take on the majority of inpatient coverage, and suddenly, just like that, there were hospitalists, their given name still three years in the future, but hospitalists nevertheless.

Now this early program wasn’t the very first program, but it was part of a trend repeating at hospitals and within medical groups all over America. Slowly growing, slowly spreading, and under the radar, a social movement was afoot.

What Is a Social Movement?

Wikipedia says: Social movements are a type of group action. In sociology, a group action is a situation in which a large number of agents take action simultaneously in order to achieve a common goal; their actions are usually coordinated.

In those early days, the proto-hospitalists around the country were not coordinated or acting together, but that would come soon enough.

What were the factors that gave birth to this nascent social movement? Why was the same solution beginning to pop up all over the country in seemingly unconnected instances? The zeitgeist of the times had a lot to do with this, and it can all be boiled down to three things: time, money, and the “X” factor.

In the late 1980s and early 90s, managed care was making inroads into healthcare as a struggling country tried to wrestle with exploding costs. Capitated managed care systems attempted to control costs and improve health by managing cases preferentially, using PCPs with a directive to limit resource utilization.² They were the “gatekeepers” to more expensive care options like specialists and hospitalization. They were tasked with managing larger panels of patients, conducting shorter visits, and seeing more patients per day. In the other type of managed care of the time (non-capitated), physician practices, to stay in the game, were negotiating large discounts for their services. Then, to maintain their income, they had to see larger numbers of patients, either in the same amount of time or, as was usually the case, in time added to their workday.²

Just when the country was starting to count on primary care to be the lynchpin for the new healthcare model, medical students were turning away from primary care in record numbers. Internal-medicine matches were near all-time lows. PCPs in practice were facing growing time and money crunches, and the medical students they were counting on to help out were choosing other fields. The cavalry of new doctors needed to bolster the ranks of those already struggling to keep up simply wasn’t coming.

Finally, unassigned care for hospitalized patients, which had always been a responsibility of local doctors, had frequently been a condition of hospital privileging, and was often seen by the doctors as a way to give back to their hospital and community, was now something that added even more time, work, and financial pressure to their growing burdens.

So, these doctors, just like the doctors in the Park Nicollet Medical Group, began to brainstorm new ways to improve efficiency and see if they could get on top of the changes happening around them. One such idea was to create rounder systems. These systems would have each doctor in the practice take a week away from clinic and care for all of the practice’s patients in the hospital. This way, only one doctor would have to spend time away from those ever-busier clinic practices during the week. By giving up the continuity of the individual rounder and trading it for the continuity of the group, these groups gained efficiencies for everyone in the practice. This was the first small, but critical, step toward hospital medicine. It would have been hard to get to hospitalists without PCPs taking that first mental leap.

Often, it was one or more of these rounders who decided, for various reasons—boredom with ambulatory care, dislike of the more frantic pace of clinic, or simply a realization that they enjoyed or excelled at hospital care—that maybe they would just take on all of the hospital care for their group. This is what happened at Park Nicollet, and what started happening all across the country. The tinder was assembled and stacked, ready for something else to happen.

The Spark

Word of these new types of models and practices began to spread and was even talked about inside the pages of some journals. It took a few years, but somebody noticed and finally put it all together into an article that was published in the most famous medical journal in the world. In that 1996 New England Journal of Medicine article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Wachter and Goldman gave a name to the strange creatures willingly giving up half of what they had been trained to do and devoting all their time to an inpatient practice.¹ “Hospitalists,” they called them, and when the rest of the country read that article, the movement was no longer under the radar; it had a name. The spark had been ignited. What would become the fastest growing medical specialty in history was ready to take off.

But a spark needs more than tinder to truly ignite. Fuel and oxygen are necessary to give it life.

I’ll talk about that in my next column…

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335(7):514-517.
2. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34-S40.

“When the time is ripe for certain things, they appear at different places in the manner of violets coming to light in early spring.” —Farkas Bolyai, to his son, Janos, urging him to claim the invention of non-Euclidean geometry without delay.

In February, I was at a 20th anniversary party for the hospital medicine program from Park Nicollet Methodist Hospital in St Louis Park, Minn., listening to the original founders of the group giving speeches and telling stories of how their program began. For them, it all began at an internal medicine retreat in 1993, with ideas being tossed about on how to be more efficient and deliver better care for their patients. This was three years before Bob Wachter and Lee Goldman delivered their sounding board article to the New England Journal of Medicine describing some early programs and, more importantly, giving those new practitioners a name: “hospitalist.”¹ The very same Park Nicollet program I was now helping to celebrate 20 years of success was called out in that article as one of four early groups in our country experimenting with hospitalists.

As I listened to the speeches, it occurred to me that the hospitalists standing up at the front of the room telling their war stories and reminiscing about the early days weren’t actually hospitalists at all back when they were thinking this new model up. They were primary care physicians struggling to meet the demands of the care environment at the time, coming up with unique solutions to the problems of the times without anyone telling them how or showing them the way. Back then, a few brave souls in the group stepped forward and said they would take on the majority of inpatient coverage, and suddenly, just like that, there were hospitalists, their given name still three years in the future, but hospitalists nevertheless.

Now this early program wasn’t the very first program, but it was part of a trend repeating at hospitals and within medical groups all over America. Slowly growing, slowly spreading, and under the radar, a social movement was afoot.

What Is a Social Movement?

Wikipedia says: Social movements are a type of group action. In sociology, a group action is a situation in which a large number of agents take action simultaneously in order to achieve a common goal; their actions are usually coordinated.

In those early days, the proto-hospitalists around the country were not coordinated or acting together, but that would come soon enough.

What were the factors that gave birth to this nascent social movement? Why was the same solution beginning to pop up all over the country in seemingly unconnected instances? The zeitgeist of the times had a lot to do with this, and it can all be boiled down to three things: time, money, and the “X” factor.

In the late 1980s and early 90s, managed care was making inroads into healthcare as a struggling country tried to wrestle with exploding costs. Capitated managed care systems attempted to control costs and improve health by managing cases preferentially, using PCPs with a directive to limit resource utilization.² They were the “gatekeepers” to more expensive care options like specialists and hospitalization. They were tasked with managing larger panels of patients, conducting shorter visits, and seeing more patients per day. In the other type of managed care of the time (non-capitated), physician practices, to stay in the game, were negotiating large discounts for their services. Then, to maintain their income, they had to see larger numbers of patients, either in the same amount of time or, as was usually the case, in time added to their workday.²

Just when the country was starting to count on primary care to be the lynchpin for the new healthcare model, medical students were turning away from primary care in record numbers. Internal-medicine matches were near all-time lows. PCPs in practice were facing growing time and money crunches, and the medical students they were counting on to help out were choosing other fields. The cavalry of new doctors needed to bolster the ranks of those already struggling to keep up simply wasn’t coming.

Finally, unassigned care for hospitalized patients, which had always been a responsibility of local doctors, had frequently been a condition of hospital privileging, and was often seen by the doctors as a way to give back to their hospital and community, was now something that added even more time, work, and financial pressure to their growing burdens.

So, these doctors, just like the doctors in the Park Nicollet Medical Group, began to brainstorm new ways to improve efficiency and see if they could get on top of the changes happening around them. One such idea was to create rounder systems. These systems would have each doctor in the practice take a week away from clinic and care for all of the practice’s patients in the hospital. This way, only one doctor would have to spend time away from those ever-busier clinic practices during the week. By giving up the continuity of the individual rounder and trading it for the continuity of the group, these groups gained efficiencies for everyone in the practice. This was the first small, but critical, step toward hospital medicine. It would have been hard to get to hospitalists without PCPs taking that first mental leap.

Often, it was one or more of these rounders who decided, for various reasons—boredom with ambulatory care, dislike of the more frantic pace of clinic, or simply a realization that they enjoyed or excelled at hospital care—that maybe they would just take on all of the hospital care for their group. This is what happened at Park Nicollet, and what started happening all across the country. The tinder was assembled and stacked, ready for something else to happen.

The Spark

Word of these new types of models and practices began to spread and was even talked about inside the pages of some journals. It took a few years, but somebody noticed and finally put it all together into an article that was published in the most famous medical journal in the world. In that 1996 New England Journal of Medicine article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Wachter and Goldman gave a name to the strange creatures willingly giving up half of what they had been trained to do and devoting all their time to an inpatient practice.¹ “Hospitalists,” they called them, and when the rest of the country read that article, the movement was no longer under the radar; it had a name. The spark had been ignited. What would become the fastest growing medical specialty in history was ready to take off.

But a spark needs more than tinder to truly ignite. Fuel and oxygen are necessary to give it life.

I’ll talk about that in my next column…

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335(7):514-517.
2. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34-S40.

Dr. Steve Narang

CEO, Banner Health’s Good Samaritan Medical Center, Phoenix

Path to the C-suite: Medical school at Northwestern University; residency at Johns Hopkins; pediatric hospitalist at Children’s Hospital of New Orleans; medical director of Pediatric Hospitalists of Louisiana; master’s in healthcare management from Harvard; chief medical officer at Banner Health’s Cardon Children’s Medical Center

As a resident at Johns Hopkins in pediatrics, Dr. Narang wasn’t always pleased by what he saw—too many process errors and patient safety gaps, and too much waste. Healthcare resources were not being spent in the right way, he discovered.

“I was struck by [the fact] that we spent a lot of our resources in publishing more articles about what’s new, and what the coolest drug is,” he says. “I saw very little of that [relating to] what does this mean in terms of value?”

He became a hospitalist because he saw it as a role in which he could “really touch everything” if he chose to do so and work within the system to improve it.

“The hospital could use a partner,” he says. “One of the biggest challenges we have in healthcare is hospitals and physicians are often not working together to add value, and they’re subtracting from value, and they’re competing with each other.”

If doctors make the effort to learn the management aspects of working in a hospital, they can put themselves in a great position to take on big leadership roles, Dr. Narang says. He says hospitals are seeing the value in having physicians in those roles.

“If you can find the right leader and it happens to be a physician, if it happens to be a physician who can speak that language—and find a sweet spot for independent physicians, employed physicians, and hospitalists to deliver value, which we have to now I think it’s the best way to go,” he says. “I think you’re going to see a trend moving forward to this as more physicians become more interested in this track.” —TC

Being a hospitalist was a key strength of my background. Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

—Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix

Dr. Brian Harte

President, South Pointe Hospital, Warrenville Heights, Ohio

Path to the C-suite: Resident at University of California San Francisco; private practice hospitalist in Marin County, near San Francisco; hospitalist at Cleveland Clinic; program director of hospital medicine at Cleveland Clinic’s Euclid Hospital; chief operating officer at Cleveland Clinic’s Hillcrest Hospital For about two hours a day, Dr. Harte makes his way through South Pointe Hospital—to see and to be seen. Before he started doing this as president of the hospital, he underestimated how important it was to stay visible to everyone—nurses, doctors, housekeeping, and so on.

“The impression that makes surprised me,” he says.

He’ll ask what people need to do their jobs better. He’ll also pop into patients’ rooms, introduce himself, and ask how their experiences have been. Then he takes that feedback and incorporates it into his planning.

Dr. Harte says he likes to have an “open and transparent” relationship with physicians and lists his credibility, both as a physician and a person, as a top attribute for a leader. For those embarking on leadership roles in a hospital, he says it’s a must to have a “strong mentor that you can go to.”

He also says a supportive environment is critical.

“You must work in an organization that is a resource to help you succeed, because when you move out of the purely clinical or clinical administrative jobs like division chair, department chair, program director, even CMO or VPMA [vice president of medical affairs], those are doctor jobs,” he says. “When you really become a doctor doing administrative work, unless it’s in your background and in your skill set, I think it’s important to work in an organization that is going to support you in your continued growth.

“Because these are jobs that I think you grow into.” —TC

I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment. You have pockets of enormous expertise that sometimes function like silos. Being a hospitalist actually trains you well for those things.

—Brian Harte, MD, SFHM, president, South Pointe Hospital, Warrenville Heights, Ohio, SHM board member

Dr. Nasim Afsar

Associate Chief Medical Officer, UCLA Hospitals, Los Angeles

Path to the C-suite: Residency at UCLA; advanced training program in quality improvement at Intermountain Healthcare Dr. Afsar wasn’t aiming for a top administrative job in a hospital. But, during her time spent working as a hospitalist, she started noticing trouble within the system. Eventually, she wanted to try to solve problems in a way that would have a ripple effect. Inspired, she ventured into quality improvement.

“I’m very passionate about helping the patient in front of me, whether it’s helping them get better or helping them during a really challenging time of their life,” she says. “But there’s something about feeling that the improvements that you make will not just impact the person in front of you, but the thousands of patients that come after them.”

Part of her job is instilling in other healthcare providers the sense that they themselves are agents of change. One big difference in her administrative job and clinical work is how to gauge success.

“The job is a lot harder than it seems. In our clinical world, I know what constitutes a good job. I know that when I’m on service, I get up early in the morning, I come in, I pre-round on my patients extensively, I read up on a couple of different things, I go out onto the wards with my team,” she explains. “This type of leadership role, I think, is more challenging. Initiatives that you do to improve care in one area could have detrimental or challenging impacts on another set of stakeholders or care area. You’re constantly navigating the system.” —TC

By nature when you’re a hospitalist, you are a problem solver. You don’t shy away from problems that you don’t understand.

—Nasim Afsar, MD, SFHM, associate chief medical officer, UCLA Hospitals, Los Angeles, SHM board member

Dr. Patrick Torcson

Chief Integration Officer, St. Tammany Parish Hospital, Covington, La.

Path to the C-Suite: Residency at Ochsner Clinic in New Orleans; private internist; director of hospital medicine at St. Tammany Parish Hospital Dr. Torcson recently became his hospital’s first chief integration officer, a job in which he promotes clinical quality and service quality using information technology.

But it was never about a promotion, he says.

“It’s really been more about just trying to provide quality care and make contributions to fixing a broken healthcare system,” he says. “Staying focused on that personal journey has really brought me to where I am.”

A good leader within a hospital is a “systems-level thinker,” not one focusing on a specific agenda. And, prioritizing important items is crucial to success, he notes.

“We all have a limited amount of energy. If you can pick three to five things that are really important and prioritize them and they turn out to be important, that’s going to facilitate your success,” he says.

He can’t emphasize “clinical credibility” enough. That’s where it all begins, he says.

“Your leadership is facilitated if you’re seen as someone that takes good care of your patients,” being the doctor that other doctors would want themselves and their families to go to. “That’s huge.”

Also, he says, running out and getting a master’s degree in business management and then applying for positions around the country is probably not the best approach to seeking out leadership positions, he says.

“I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something,” he points out. “Leadership is home-grown, and you work your way up.” —TC

I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something. Leadership is home-grown, and you work your way up.

—Patrick Torcson, MD, MMM, FACP, SFHM, vice president and chief integration officer, St. Tammany Parish Hospital, Covington, La., SHM board member

Dr. Steve Narang

CEO, Banner Health’s Good Samaritan Medical Center, Phoenix

Path to the C-suite: Medical school at Northwestern University; residency at Johns Hopkins; pediatric hospitalist at Children’s Hospital of New Orleans; medical director of Pediatric Hospitalists of Louisiana; master’s in healthcare management from Harvard; chief medical officer at Banner Health’s Cardon Children’s Medical Center

As a resident at Johns Hopkins in pediatrics, Dr. Narang wasn’t always pleased by what he saw—too many process errors and patient safety gaps, and too much waste. Healthcare resources were not being spent in the right way, he discovered.

“I was struck by [the fact] that we spent a lot of our resources in publishing more articles about what’s new, and what the coolest drug is,” he says. “I saw very little of that [relating to] what does this mean in terms of value?”

He became a hospitalist because he saw it as a role in which he could “really touch everything” if he chose to do so and work within the system to improve it.

“The hospital could use a partner,” he says. “One of the biggest challenges we have in healthcare is hospitals and physicians are often not working together to add value, and they’re subtracting from value, and they’re competing with each other.”

If doctors make the effort to learn the management aspects of working in a hospital, they can put themselves in a great position to take on big leadership roles, Dr. Narang says. He says hospitals are seeing the value in having physicians in those roles.

“If you can find the right leader and it happens to be a physician, if it happens to be a physician who can speak that language—and find a sweet spot for independent physicians, employed physicians, and hospitalists to deliver value, which we have to now I think it’s the best way to go,” he says. “I think you’re going to see a trend moving forward to this as more physicians become more interested in this track.” —TC

Being a hospitalist was a key strength of my background. Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

—Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix

Dr. Brian Harte

President, South Pointe Hospital, Warrenville Heights, Ohio

Path to the C-suite: Resident at University of California San Francisco; private practice hospitalist in Marin County, near San Francisco; hospitalist at Cleveland Clinic; program director of hospital medicine at Cleveland Clinic’s Euclid Hospital; chief operating officer at Cleveland Clinic’s Hillcrest Hospital For about two hours a day, Dr. Harte makes his way through South Pointe Hospital—to see and to be seen. Before he started doing this as president of the hospital, he underestimated how important it was to stay visible to everyone—nurses, doctors, housekeeping, and so on.

“The impression that makes surprised me,” he says.

He’ll ask what people need to do their jobs better. He’ll also pop into patients’ rooms, introduce himself, and ask how their experiences have been. Then he takes that feedback and incorporates it into his planning.

Dr. Harte says he likes to have an “open and transparent” relationship with physicians and lists his credibility, both as a physician and a person, as a top attribute for a leader. For those embarking on leadership roles in a hospital, he says it’s a must to have a “strong mentor that you can go to.”

He also says a supportive environment is critical.

“You must work in an organization that is a resource to help you succeed, because when you move out of the purely clinical or clinical administrative jobs like division chair, department chair, program director, even CMO or VPMA [vice president of medical affairs], those are doctor jobs,” he says. “When you really become a doctor doing administrative work, unless it’s in your background and in your skill set, I think it’s important to work in an organization that is going to support you in your continued growth.

“Because these are jobs that I think you grow into.” —TC

I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment. You have pockets of enormous expertise that sometimes function like silos. Being a hospitalist actually trains you well for those things.

—Brian Harte, MD, SFHM, president, South Pointe Hospital, Warrenville Heights, Ohio, SHM board member

Dr. Nasim Afsar

Associate Chief Medical Officer, UCLA Hospitals, Los Angeles

Path to the C-suite: Residency at UCLA; advanced training program in quality improvement at Intermountain Healthcare Dr. Afsar wasn’t aiming for a top administrative job in a hospital. But, during her time spent working as a hospitalist, she started noticing trouble within the system. Eventually, she wanted to try to solve problems in a way that would have a ripple effect. Inspired, she ventured into quality improvement.

“I’m very passionate about helping the patient in front of me, whether it’s helping them get better or helping them during a really challenging time of their life,” she says. “But there’s something about feeling that the improvements that you make will not just impact the person in front of you, but the thousands of patients that come after them.”

Part of her job is instilling in other healthcare providers the sense that they themselves are agents of change. One big difference in her administrative job and clinical work is how to gauge success.

“The job is a lot harder than it seems. In our clinical world, I know what constitutes a good job. I know that when I’m on service, I get up early in the morning, I come in, I pre-round on my patients extensively, I read up on a couple of different things, I go out onto the wards with my team,” she explains. “This type of leadership role, I think, is more challenging. Initiatives that you do to improve care in one area could have detrimental or challenging impacts on another set of stakeholders or care area. You’re constantly navigating the system.” —TC

By nature when you’re a hospitalist, you are a problem solver. You don’t shy away from problems that you don’t understand.

—Nasim Afsar, MD, SFHM, associate chief medical officer, UCLA Hospitals, Los Angeles, SHM board member

Dr. Patrick Torcson

Chief Integration Officer, St. Tammany Parish Hospital, Covington, La.

Path to the C-Suite: Residency at Ochsner Clinic in New Orleans; private internist; director of hospital medicine at St. Tammany Parish Hospital Dr. Torcson recently became his hospital’s first chief integration officer, a job in which he promotes clinical quality and service quality using information technology.

But it was never about a promotion, he says.

“It’s really been more about just trying to provide quality care and make contributions to fixing a broken healthcare system,” he says. “Staying focused on that personal journey has really brought me to where I am.”

A good leader within a hospital is a “systems-level thinker,” not one focusing on a specific agenda. And, prioritizing important items is crucial to success, he notes.

“We all have a limited amount of energy. If you can pick three to five things that are really important and prioritize them and they turn out to be important, that’s going to facilitate your success,” he says.

He can’t emphasize “clinical credibility” enough. That’s where it all begins, he says.

“Your leadership is facilitated if you’re seen as someone that takes good care of your patients,” being the doctor that other doctors would want themselves and their families to go to. “That’s huge.”

Also, he says, running out and getting a master’s degree in business management and then applying for positions around the country is probably not the best approach to seeking out leadership positions, he says.

“I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something,” he points out. “Leadership is home-grown, and you work your way up.” —TC

I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something. Leadership is home-grown, and you work your way up.

—Patrick Torcson, MD, MMM, FACP, SFHM, vice president and chief integration officer, St. Tammany Parish Hospital, Covington, La., SHM board member

Dr. Steve Narang

CEO, Banner Health’s Good Samaritan Medical Center, Phoenix

Path to the C-suite: Medical school at Northwestern University; residency at Johns Hopkins; pediatric hospitalist at Children’s Hospital of New Orleans; medical director of Pediatric Hospitalists of Louisiana; master’s in healthcare management from Harvard; chief medical officer at Banner Health’s Cardon Children’s Medical Center

As a resident at Johns Hopkins in pediatrics, Dr. Narang wasn’t always pleased by what he saw—too many process errors and patient safety gaps, and too much waste. Healthcare resources were not being spent in the right way, he discovered.

“I was struck by [the fact] that we spent a lot of our resources in publishing more articles about what’s new, and what the coolest drug is,” he says. “I saw very little of that [relating to] what does this mean in terms of value?”

He became a hospitalist because he saw it as a role in which he could “really touch everything” if he chose to do so and work within the system to improve it.

“The hospital could use a partner,” he says. “One of the biggest challenges we have in healthcare is hospitals and physicians are often not working together to add value, and they’re subtracting from value, and they’re competing with each other.”

If doctors make the effort to learn the management aspects of working in a hospital, they can put themselves in a great position to take on big leadership roles, Dr. Narang says. He says hospitals are seeing the value in having physicians in those roles.

“If you can find the right leader and it happens to be a physician, if it happens to be a physician who can speak that language—and find a sweet spot for independent physicians, employed physicians, and hospitalists to deliver value, which we have to now I think it’s the best way to go,” he says. “I think you’re going to see a trend moving forward to this as more physicians become more interested in this track.” —TC

Being a hospitalist was a key strength of my background. Hospitalists are so well-positioned…to get truly at the intersection of operations and find value in a complex puzzle. Hospitalists are able to do that.

—Steve Narang, MD, a pediatrician, hospitalist, and the then-CMO at Banner Health’s Cardon Children’s Medical Center in Phoenix

Dr. Brian Harte

President, South Pointe Hospital, Warrenville Heights, Ohio

Path to the C-suite: Resident at University of California San Francisco; private practice hospitalist in Marin County, near San Francisco; hospitalist at Cleveland Clinic; program director of hospital medicine at Cleveland Clinic’s Euclid Hospital; chief operating officer at Cleveland Clinic’s Hillcrest Hospital For about two hours a day, Dr. Harte makes his way through South Pointe Hospital—to see and to be seen. Before he started doing this as president of the hospital, he underestimated how important it was to stay visible to everyone—nurses, doctors, housekeeping, and so on.

“The impression that makes surprised me,” he says.

He’ll ask what people need to do their jobs better. He’ll also pop into patients’ rooms, introduce himself, and ask how their experiences have been. Then he takes that feedback and incorporates it into his planning.

Dr. Harte says he likes to have an “open and transparent” relationship with physicians and lists his credibility, both as a physician and a person, as a top attribute for a leader. For those embarking on leadership roles in a hospital, he says it’s a must to have a “strong mentor that you can go to.”

He also says a supportive environment is critical.

“You must work in an organization that is a resource to help you succeed, because when you move out of the purely clinical or clinical administrative jobs like division chair, department chair, program director, even CMO or VPMA [vice president of medical affairs], those are doctor jobs,” he says. “When you really become a doctor doing administrative work, unless it’s in your background and in your skill set, I think it’s important to work in an organization that is going to support you in your continued growth.

“Because these are jobs that I think you grow into.” —TC

I think one of the things that makes hospitalists fairly natural fits for the hospital leadership positions is that a hospital is a very complicated environment. You have pockets of enormous expertise that sometimes function like silos. Being a hospitalist actually trains you well for those things.

—Brian Harte, MD, SFHM, president, South Pointe Hospital, Warrenville Heights, Ohio, SHM board member

Dr. Nasim Afsar

Associate Chief Medical Officer, UCLA Hospitals, Los Angeles

Path to the C-suite: Residency at UCLA; advanced training program in quality improvement at Intermountain Healthcare Dr. Afsar wasn’t aiming for a top administrative job in a hospital. But, during her time spent working as a hospitalist, she started noticing trouble within the system. Eventually, she wanted to try to solve problems in a way that would have a ripple effect. Inspired, she ventured into quality improvement.

“I’m very passionate about helping the patient in front of me, whether it’s helping them get better or helping them during a really challenging time of their life,” she says. “But there’s something about feeling that the improvements that you make will not just impact the person in front of you, but the thousands of patients that come after them.”

Part of her job is instilling in other healthcare providers the sense that they themselves are agents of change. One big difference in her administrative job and clinical work is how to gauge success.

“The job is a lot harder than it seems. In our clinical world, I know what constitutes a good job. I know that when I’m on service, I get up early in the morning, I come in, I pre-round on my patients extensively, I read up on a couple of different things, I go out onto the wards with my team,” she explains. “This type of leadership role, I think, is more challenging. Initiatives that you do to improve care in one area could have detrimental or challenging impacts on another set of stakeholders or care area. You’re constantly navigating the system.” —TC

By nature when you’re a hospitalist, you are a problem solver. You don’t shy away from problems that you don’t understand.

—Nasim Afsar, MD, SFHM, associate chief medical officer, UCLA Hospitals, Los Angeles, SHM board member

Dr. Patrick Torcson

Chief Integration Officer, St. Tammany Parish Hospital, Covington, La.

Path to the C-Suite: Residency at Ochsner Clinic in New Orleans; private internist; director of hospital medicine at St. Tammany Parish Hospital Dr. Torcson recently became his hospital’s first chief integration officer, a job in which he promotes clinical quality and service quality using information technology.

But it was never about a promotion, he says.

“It’s really been more about just trying to provide quality care and make contributions to fixing a broken healthcare system,” he says. “Staying focused on that personal journey has really brought me to where I am.”

A good leader within a hospital is a “systems-level thinker,” not one focusing on a specific agenda. And, prioritizing important items is crucial to success, he notes.

“We all have a limited amount of energy. If you can pick three to five things that are really important and prioritize them and they turn out to be important, that’s going to facilitate your success,” he says.

He can’t emphasize “clinical credibility” enough. That’s where it all begins, he says.

“Your leadership is facilitated if you’re seen as someone that takes good care of your patients,” being the doctor that other doctors would want themselves and their families to go to. “That’s huge.”

Also, he says, running out and getting a master’s degree in business management and then applying for positions around the country is probably not the best approach to seeking out leadership positions, he says.

“I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something,” he points out. “Leadership is home-grown, and you work your way up.” —TC

I don’t think many people are put in a position where you’re just asked to pull a sword out of a stone and you’re suddenly chief of something. Leadership is home-grown, and you work your way up.

—Patrick Torcson, MD, MMM, FACP, SFHM, vice president and chief integration officer, St. Tammany Parish Hospital, Covington, La., SHM board member

Dr. Hunter

Jairy Hunter III, MD, MBA, SFHM, was restless and wondering if office-based practice was the right career choice for him. He’d already worked as an ED tech during medical school, as an emergency physician for a few years after that, and as a family practitioner for a little more than five years.

Lucky for him, hospital medicine was taking root in his neck of the woods.

“Looking back, I realize that, at that point, I was interested in doing something different, and in becoming a leader in a new setting,” says Dr. Hunter, one of the newest members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist.

More than a decade later, Dr. Hunter is doing what he loves—acting as the “go-to guy” for coordination of care. He’s gravitated toward a career in leadership, serving 10 years as medical director of a hospitalist group in his native Charleston, S.C. and, since September 2012, as associate executive medical director for case management and care transitions at the Medical University of South Carolina (MUSC), also in Charleston. His titles include assistant professor in the department of family medicine at MUSC.

“We are the ‘details’ people,” he says. “The people who know how to get things done and maneuver efficiently through hospital systems.”

Question: What’s the biggest change you’ve seen in HM in your career?

Answer: Specialties like hospital medicine have become a sort of training ground for physicians in leadership. A lot of us were "thrust" into these positions, so to speak, with little background or training in how to be a leader. For example, I thought in order to be a physician leader, I had to work harder than everyone else, and I had to be the best doctor in the group. Let me tell you, most people will fail those tests almost every time! I think we are seeing many more hospitalists move into administrative roles along career paths like mine. It seems to be a natural fit, and I think that's very exciting.

Q: What do you dislike most about the job?

A: The disjointed scheduling patterns that many programs have in place. I feel too many programs think it’s too hard to create scheduling formats that foster longevity. I also dislike the fact that some hospitalists are on their way to somewhere else, such as fellowship or other careers. They don’t involve themselves in making the hospital better, improving the patient experience, or taking ownership of the job as a group member.

Q: What’s the best advice you ever received?

A: Say “yes” as often as possible. That’s also the best advice I received when I became a dad.

Q: Why is it important for group leaders to continue seeing patients?

A: To maintain the sense of shared experience and to sustain credibility amongst your hospitalist and medical staff colleagues. In addition, medicine is our calling. We should never be so far away from it as to lose touch with patients and what we do best.

Q: Outside of patient care, what are your career interests?

A: I’m very interested in physicians in leadership. I recently changed from a large, for-profit entity to an academic medical center, so I’ve increased the amount of teaching from basically zero to about 25% of my time. I found that I really enjoy interacting with young physicians. My current role has responsibility for a number of administrative projects—specifically, several dealing with readmissions, EHR implementation, and collaborating with our outpatient physician affiliates. I find the business side of medicine interesting and surprisingly exciting, in that we are now challenged with figuring out how to maintain and improve quality care and efficient patient flow, while economic constraints are a reality.

Q: What is your biggest professional challenge?

A: Finding avenues and opportunities for advancing my career in leadership. In the organization I formerly worked for, there were few opportunities for physicians to move upward. There was very little space for advancement. Earning an advanced degree, putting my CV out on the wire, and having the courage to break with an entity where I had worked for 15-plus years was a challenge.

Q: What is your biggest professional reward?

A: Learning under a number of mentors (physicians and non-physicians, clinical and business-oriented), working with over 100 hospitalists in my career, and being able to mentor them as well. Having been given an opportunity as an administrative leader and being trusted to create solutions and collaborate with a lot of groups in my current job, using my experience as a physician and my interest in the business of healthcare, has been extremely rewarding.

Q: What does it mean to be designated a Senior Fellow in Hospital Medicine?

A: I felt gratified to receive recognition for my career path and commitment to a vision that has developed into a thriving, essential force in medicine. Hopefully, I have contributed—and will continue to contribute—to that growth in some small way.

Q: When you aren’t working, what is important to you?

A: Family, photography, music, technology, and gadgets.

Q: Where do you see yourself in 10 years?

A: I currently am enjoying a new role and testing new responsibilities and opportunities for growth as they are presented. I’ve discovered an interest in teaching, both of perceptive young physicians and physicians-in-training. I have terrific mentors who continue to provide constructive feedback and guidance. I want to see where this leads. I find that I really enjoy mentoring and working with young people.

Q: If you weren’t a doctor, what would you be doing right now?

A: I’d either be a professional photographer or a writer—maybe a graphic designer.

Q: What’s the best book you’ve read recently?

A: Special Topics in Calamity Physics by Marisha Pessl. It is hilarious and witty and offers a unique writing style and unexpected turns. Richard Ford’s latest book, Canada. Anything by Ford is a “must."

Q: How many Apple products do you interface with in a given week?

A: About 20.

Q: What’s next in your iTunes queue?

A: Probably something by Matthew Sweet I have a threshold of about five minutes before I usually work my love for his music into a conversation.

Richard Quinn is a freelance writer in New Jersey.

Dr. Hunter

Jairy Hunter III, MD, MBA, SFHM, was restless and wondering if office-based practice was the right career choice for him. He’d already worked as an ED tech during medical school, as an emergency physician for a few years after that, and as a family practitioner for a little more than five years.

Lucky for him, hospital medicine was taking root in his neck of the woods.

“Looking back, I realize that, at that point, I was interested in doing something different, and in becoming a leader in a new setting,” says Dr. Hunter, one of the newest members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist.

More than a decade later, Dr. Hunter is doing what he loves—acting as the “go-to guy” for coordination of care. He’s gravitated toward a career in leadership, serving 10 years as medical director of a hospitalist group in his native Charleston, S.C. and, since September 2012, as associate executive medical director for case management and care transitions at the Medical University of South Carolina (MUSC), also in Charleston. His titles include assistant professor in the department of family medicine at MUSC.

“We are the ‘details’ people,” he says. “The people who know how to get things done and maneuver efficiently through hospital systems.”

Question: What’s the biggest change you’ve seen in HM in your career?

Answer: Specialties like hospital medicine have become a sort of training ground for physicians in leadership. A lot of us were "thrust" into these positions, so to speak, with little background or training in how to be a leader. For example, I thought in order to be a physician leader, I had to work harder than everyone else, and I had to be the best doctor in the group. Let me tell you, most people will fail those tests almost every time! I think we are seeing many more hospitalists move into administrative roles along career paths like mine. It seems to be a natural fit, and I think that's very exciting.

Q: What do you dislike most about the job?

A: The disjointed scheduling patterns that many programs have in place. I feel too many programs think it’s too hard to create scheduling formats that foster longevity. I also dislike the fact that some hospitalists are on their way to somewhere else, such as fellowship or other careers. They don’t involve themselves in making the hospital better, improving the patient experience, or taking ownership of the job as a group member.

Q: What’s the best advice you ever received?

A: Say “yes” as often as possible. That’s also the best advice I received when I became a dad.

Q: Why is it important for group leaders to continue seeing patients?

A: To maintain the sense of shared experience and to sustain credibility amongst your hospitalist and medical staff colleagues. In addition, medicine is our calling. We should never be so far away from it as to lose touch with patients and what we do best.

Q: Outside of patient care, what are your career interests?

A: I’m very interested in physicians in leadership. I recently changed from a large, for-profit entity to an academic medical center, so I’ve increased the amount of teaching from basically zero to about 25% of my time. I found that I really enjoy interacting with young physicians. My current role has responsibility for a number of administrative projects—specifically, several dealing with readmissions, EHR implementation, and collaborating with our outpatient physician affiliates. I find the business side of medicine interesting and surprisingly exciting, in that we are now challenged with figuring out how to maintain and improve quality care and efficient patient flow, while economic constraints are a reality.

Q: What is your biggest professional challenge?

A: Finding avenues and opportunities for advancing my career in leadership. In the organization I formerly worked for, there were few opportunities for physicians to move upward. There was very little space for advancement. Earning an advanced degree, putting my CV out on the wire, and having the courage to break with an entity where I had worked for 15-plus years was a challenge.

Q: What is your biggest professional reward?

A: Learning under a number of mentors (physicians and non-physicians, clinical and business-oriented), working with over 100 hospitalists in my career, and being able to mentor them as well. Having been given an opportunity as an administrative leader and being trusted to create solutions and collaborate with a lot of groups in my current job, using my experience as a physician and my interest in the business of healthcare, has been extremely rewarding.

Q: What does it mean to be designated a Senior Fellow in Hospital Medicine?

A: I felt gratified to receive recognition for my career path and commitment to a vision that has developed into a thriving, essential force in medicine. Hopefully, I have contributed—and will continue to contribute—to that growth in some small way.

Q: When you aren’t working, what is important to you?

A: Family, photography, music, technology, and gadgets.

Q: Where do you see yourself in 10 years?

A: I currently am enjoying a new role and testing new responsibilities and opportunities for growth as they are presented. I’ve discovered an interest in teaching, both of perceptive young physicians and physicians-in-training. I have terrific mentors who continue to provide constructive feedback and guidance. I want to see where this leads. I find that I really enjoy mentoring and working with young people.

Q: If you weren’t a doctor, what would you be doing right now?

A: I’d either be a professional photographer or a writer—maybe a graphic designer.

Q: What’s the best book you’ve read recently?

A: Special Topics in Calamity Physics by Marisha Pessl. It is hilarious and witty and offers a unique writing style and unexpected turns. Richard Ford’s latest book, Canada. Anything by Ford is a “must."

Q: How many Apple products do you interface with in a given week?

A: About 20.

Q: What’s next in your iTunes queue?

A: Probably something by Matthew Sweet I have a threshold of about five minutes before I usually work my love for his music into a conversation.

Richard Quinn is a freelance writer in New Jersey.

Dr. Hunter

Jairy Hunter III, MD, MBA, SFHM, was restless and wondering if office-based practice was the right career choice for him. He’d already worked as an ED tech during medical school, as an emergency physician for a few years after that, and as a family practitioner for a little more than five years.

Lucky for him, hospital medicine was taking root in his neck of the woods.

“Looking back, I realize that, at that point, I was interested in doing something different, and in becoming a leader in a new setting,” says Dr. Hunter, one of the newest members of Team Hospitalist, the volunteer editorial advisory group for The Hospitalist.

More than a decade later, Dr. Hunter is doing what he loves—acting as the “go-to guy” for coordination of care. He’s gravitated toward a career in leadership, serving 10 years as medical director of a hospitalist group in his native Charleston, S.C. and, since September 2012, as associate executive medical director for case management and care transitions at the Medical University of South Carolina (MUSC), also in Charleston. His titles include assistant professor in the department of family medicine at MUSC.

“We are the ‘details’ people,” he says. “The people who know how to get things done and maneuver efficiently through hospital systems.”

Question: What’s the biggest change you’ve seen in HM in your career?

Answer: Specialties like hospital medicine have become a sort of training ground for physicians in leadership. A lot of us were "thrust" into these positions, so to speak, with little background or training in how to be a leader. For example, I thought in order to be a physician leader, I had to work harder than everyone else, and I had to be the best doctor in the group. Let me tell you, most people will fail those tests almost every time! I think we are seeing many more hospitalists move into administrative roles along career paths like mine. It seems to be a natural fit, and I think that's very exciting.

Q: What do you dislike most about the job?

A: The disjointed scheduling patterns that many programs have in place. I feel too many programs think it’s too hard to create scheduling formats that foster longevity. I also dislike the fact that some hospitalists are on their way to somewhere else, such as fellowship or other careers. They don’t involve themselves in making the hospital better, improving the patient experience, or taking ownership of the job as a group member.

Q: What’s the best advice you ever received?

A: Say “yes” as often as possible. That’s also the best advice I received when I became a dad.

Q: Why is it important for group leaders to continue seeing patients?

A: To maintain the sense of shared experience and to sustain credibility amongst your hospitalist and medical staff colleagues. In addition, medicine is our calling. We should never be so far away from it as to lose touch with patients and what we do best.

Q: Outside of patient care, what are your career interests?

A: I’m very interested in physicians in leadership. I recently changed from a large, for-profit entity to an academic medical center, so I’ve increased the amount of teaching from basically zero to about 25% of my time. I found that I really enjoy interacting with young physicians. My current role has responsibility for a number of administrative projects—specifically, several dealing with readmissions, EHR implementation, and collaborating with our outpatient physician affiliates. I find the business side of medicine interesting and surprisingly exciting, in that we are now challenged with figuring out how to maintain and improve quality care and efficient patient flow, while economic constraints are a reality.

Q: What is your biggest professional challenge?

A: Finding avenues and opportunities for advancing my career in leadership. In the organization I formerly worked for, there were few opportunities for physicians to move upward. There was very little space for advancement. Earning an advanced degree, putting my CV out on the wire, and having the courage to break with an entity where I had worked for 15-plus years was a challenge.

Q: What is your biggest professional reward?

A: Learning under a number of mentors (physicians and non-physicians, clinical and business-oriented), working with over 100 hospitalists in my career, and being able to mentor them as well. Having been given an opportunity as an administrative leader and being trusted to create solutions and collaborate with a lot of groups in my current job, using my experience as a physician and my interest in the business of healthcare, has been extremely rewarding.

Q: What does it mean to be designated a Senior Fellow in Hospital Medicine?

A: I felt gratified to receive recognition for my career path and commitment to a vision that has developed into a thriving, essential force in medicine. Hopefully, I have contributed—and will continue to contribute—to that growth in some small way.

Q: When you aren’t working, what is important to you?

A: Family, photography, music, technology, and gadgets.

Q: Where do you see yourself in 10 years?

A: I currently am enjoying a new role and testing new responsibilities and opportunities for growth as they are presented. I’ve discovered an interest in teaching, both of perceptive young physicians and physicians-in-training. I have terrific mentors who continue to provide constructive feedback and guidance. I want to see where this leads. I find that I really enjoy mentoring and working with young people.

Q: If you weren’t a doctor, what would you be doing right now?

A: I’d either be a professional photographer or a writer—maybe a graphic designer.

Q: What’s the best book you’ve read recently?

A: Special Topics in Calamity Physics by Marisha Pessl. It is hilarious and witty and offers a unique writing style and unexpected turns. Richard Ford’s latest book, Canada. Anything by Ford is a “must."

Q: How many Apple products do you interface with in a given week?

A: About 20.

Q: What’s next in your iTunes queue?

A: Probably something by Matthew Sweet I have a threshold of about five minutes before I usually work my love for his music into a conversation.

Richard Quinn is a freelance writer in New Jersey.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.