It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

It’s been a hectic week, as the Annals of Internal Medicine paper regarding hospitalist outcomes was published.¹ I cannot escape the fallout of the paper showing that the hospitalist model is associated with increased costs of care. The Internet, the phone, my email, the radio, the hallways all are abuzz with excitement about the implications of this paper. Everyone, it seems, has an opinion. The viewpoints range from “the article is methodologically flawed” to “yeah, but that data is old and things are different now,” to “I knew the model was bunk” to “it’s time to bring back the traditional model of care.”

Moreover, nobody is afraid to share.

Wherever you stand on this continuum, it isn’t hard to find a supporting opinion. NPR covered it, newspapers reported it, and bloggers blogged it. Thousands of words were typed, printed, tweeted, spoken. However, one word seemed conspicuously absent. That word? Thanks.

The Study

The study authors examined more than 58,000 admissions at 454 hospitals and compared the impact of hospitalist versus PCP care on in-hospital and post-discharge outcomes. Predictably, hospital length of stay (LOS) was shorter (0.64 days) and less costly ($282) with the hospitalist model. This has been shown, albeit generally with more robust outcomes, in nearly all-previous studies. Importantly, however, this study lifted the veil on what happens after discharge—and the findings have rocked the foundation of the HM field.

Hospitalist patients were less likely to follow up with their PCP, more likely to go to a skilled nursing facility, more likely to return to the ED, and had higher rates of 30-day readmission. All of this post-discharge care came with a price tag—$332 more than the PCP model—making the bundled in- and outpatient costs of care about $50 more per patient in the hospitalist model.

And this is where the controversy—and the words—begins. Connecting the earlier discharge, the added SNF utilization, and the higher readmission rate could only mean only one thing to those that favor the traditional model—a cost shift. Clearly hospitalists, motivated by saving money, are shifting the financial costs just beyond the hospital confines, discharging patients so early that they require nursing home and, ultimately, more ED visits and hospital care.

On the other side of the ledger, HM supporters have pointed out that the patients in the two arms were not the same. The HM patients were more likely to be admitted from a nursing home, more comorbid, poorer, and more likely to be admitted on a weekend—all valid points, which are hard to control for in an observational study. They argue that patients in an SNF are, of course, less likely to see their PCP than patients at home and, therefore, more likely to be sent to an ED (and admitted) when issues arise. Perhaps, the argument goes, in this scenario the system is actually working. Without indicators of quality of life and functional status, it’s hard to know that HM patients didn’t do better. Sure, there were more readmissions and it cost more, but perhaps that’s the cost of better, longer-term outcomes.

My take: Let’s move beyond debating the study merits and its implications. HM is here to stay. No matter how much we conjure Osler, we aren’t going back to the traditional model. In the debate we miss the point. Rome is afire; it’s time to stop fiddling.

So, let’s put our preconceived biases, the potential methodological flaws, the conspiratorial overtones, the vitriolic banter, and the fruitless debates behind us. This study was generally well done. It focuses on a (perhaps, the) crucial issue for HM. And its findings are plausible. For that I say “thanks”: for exposing this issue so we can tackle it head on by moving in at least three distinct directions—quality, training, and retraining.

Now let’s put down the fiddle and pick up the extinguisher.

$50: The Price of Quality?

First, I hope this study finally pushes our field beyond the cost discussion. We simply can and should not be a field that is about saving money. Yes, it is great to save money. But more important, we have to enhance the quality and safety of hospital (and post-hospital) care.

The piece missing from the Annals paper is any significant look at quality metrics, beyond perhaps readmission. It is possible, and maybe probable, that hospitalists in this study reduced complications, avoided harm, and improved inpatient mortality. Perhaps this, and not a zeal for too-early discharges, is what fueled the lower hospital cost and shorter LOS.

How much is that worth? It’s hard to say, but I’d venture much more than the $50 more per patient associated with the hospitalist model. Quality, even at higher costs, needs to be our primary focus moving forward. We must improve the quality of care to levels that, if necessary, Medicare would happily pay more for. This must be our singular goal. I’d also argue that we include the post-discharge period in our quality reach.

More QI, Less MEN

We cannot continue to train square pegs and struggle to cram them into round holes. We need more systems thinkers. We do a tremendous job teaching our students and residents about the interplay of pathophysiology and pharmacology, but spend very little time with the interplay between our patients and the system. We simply must triage process improvement, quality, safety, and efficiency training closer to the top of our medical curricula.

As such, it shouldn’t be that surprising that two groups of providers with the exact same background and training should have similar outcomes as seen in this study. The reality is that these providers came from very similar training backgrounds. Yes, they have chosen different practice models, but we all learned how to treat pneumonia and heart failure. It’s not about the model as much as what you do with the model. Cohorting patients to providers who just care for hospitalized patients will lead to efficiencies, but if we want to fundamentally improve patient outcomes, both during and after their hospital stay, we need to train hospitalists to transform that model through systematic process improvement.

And I firmly believe that hospitalists should lead this sea change. Our teaching brethren are perfectly positioned to develop hospitalist-focused training models that better prepare future hospitalists to fundamentally improve not just transitions of care but indeed all systems of care. Training that emphasizes systems thinking, mentored process improvement, and patient safety across the continuum of care.

BOOSTing Outcomes

This paper highlights HM’s Achilles’ heel. It has always been transitions of care—specifically, communication with PCPs. HM is by its very nature a fractured care model. And that discontinuity results in information drop on transitions. A PCP who knows a patient and admits and follows them after discharge is better positioned to reduce readmissions because there is no information drop in that model. The success of the HM model hinges on hospitalists efficiently and effectively approximating that level of knowledge transfer to PCPs. And to be honest, we don’t need an NIH-funded study to tell us that we have not been doing a great job with this.

This is not necessarily from a lack of effort but rather because we lack systems that simplify information transfer on transitions. It is incumbent these systems be built. It is incumbent we lead this. Whether you choose Project BOOST, Project RED, or a homegrown solution, it is no longer acceptable to ignore the transitions of care issue.

And with that I’ve just typed my 1,319th word about an article that has already commanded too many words. Don’t get me wrong, the discussion is important, and for that we must thank the study’s authors. But it’s time to move beyond the discussion, the debate, the words.

It’s time to turn words into deeds.

Dr. Glasheen is physician editor of The Hospitalist.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152-159.

As regular readers of The Hospitalist are aware, essentially every specialty in medicine is adopting the hospitalist model to some degree. After the “legacy” specialties of medicine and pediatrics, the model has more recently been embraced enthusiastically by neurologists, obstetricians, and general surgeons. But even fields like dermatology and ENT have put a hospitalist version of their specialties in place in at least a few places.

Did you know there is a Society for Dermatology Hospitalists? Did you know that the Neurohospitalist Society has its own journal? Did you know OB hospitalists have a really neat website, and the Society of OB/GYN Hospitalists is scheduled to have its first annual meeting in Boulder, Colo., Sept. 23-25?

It’ll make your head spin if you think about it too long. All of this raises a number of issues, including the need for more precise terminology to describe these fields and their practitioners.

The Need for Better Terminology

For example, now that we have neurohospitalists and psychiatric hospitalists, is it time to start attaching a modifier or prefix every time we use the word “hospitalist,” including when referring to “medical” hospitalists? I don’t think so. For the time being, I propose that when used alone, the word “hospitalist” still refers to a doctor who provides general medical care for adult inpatients. But I think any other use of the word does require a modifier, as in “peds hospitalist” or “GI hospitalist.”

(I think my view makes sense, but then, I’ve tried for years to ensure nocternist, with an E—NOCTernal intERNIST)—is the preferred spelling over nocternist, with a U. But Google returns nine hits for the former and 365,000 for the latter. Looks like I lost that one.)

Terminology for general and trauma surgeons is tricky. There is an emerging field of acute-care surgery, distinct from general surgery, which some argue passionately is nothing like a hospitalist model, and they tend to be offended if one uses the latter term. So, for now, we’ll need to use both “acute-care surgeon” and “surgical hospitalist” carefully. Although there are meaningful distinctions between acute-care surgery and a “standard” general surgery practice devoted to the hospital, there is an awful lot of overlap in the Venn diagrams of their expertise and what they do. But for now, it looks like we should expect both “acute-care surgeon” and “surgical hospitalist” to appear commonly, and the context will determine whether the terms could be used interchangeably.

While “obstetric hospitalist,” or “OB hospitalist,” is a perfectly useful term, I think it is great when laborist is substituted, at least in informal communication.

We still need a way to speak of all of these clinical roles (I don’t think we can properly call them specialties yet). I propose that we refer to all of them as specialties within the realm of “hospital-focused practice.” I’ve borrowed this term from the American Board of Internal Medicine’s Recognition of Focused Practice in Hospital Medicine, the new pathway to Maintenance of Certification.

And what about those doctors in each specialty who continue to practice in the traditional inpatient and outpatient model? Let’s call them “traditionalists.”

Hospital-Focused Practice

A rational vocabulary is only one of many significant issues raised by the growth of hospital-focused disciplines. In January, I participated in an SHM-convened, and AHA-supported, meeting of 11 practitioners who were hospitalists in neurology, obstetrics, general surgery, medicine, pediatrics, and ENT. (Sadly, the invited dermatology hospitalist couldn’t make it.) The meeting was filled with interest and sharing of lessons learned in each field. We discussed questions, and I have provided a very brief answer to each based on the conversation during the meeting and my own work with practices across many different specialties that have adopted the hospitalist model:

What are the reasons each specialty is turning to this model, and what is its prevalence? Hospitalists have appeared in a specialty largely to fill the void left by the traditionalists who no longer want to care for unattached patients admitted through the ED, or who want to leave the hospital altogether for a solely outpatient practice.

What are typical staffing models, night coverage arrangements, and provider career sustainability? These vary a lot by specialty, but laborists typically work 24-hour, in-house shifts. Surgical hospitalists usually work 12-hour shifts if they are in-house all the time, or 24-hour shifts if they take call from home. Neurohospitalists essentially always take call from home (did you even have to ask?).

Career longevity is still a matter of speculation, but the majority of those who have transitioned from traditional to hospitalist practice in their field are convinced they will have a longer career than if they hadn’t made the switch.

What are the effects of this practice model on clinical quality, patient outcomes, healthcare economics, and liability? It will be really difficult to get convincing research data on the quality effects of the hospitalist model in many fields. After more than 15 years in operation, research about the quality effects of the medical hospitalist model is not robust enough to satisfy some. But OB hospitalists may be the exception here. There is hope that their continuous, on-site presence will reduce complications from emergencies, and in doing so might reduce malpractice risk.

What is the prevalent financial model? The experience across a lot of healthcare settings to this point is that professional fee revenue alone usually is not enough to support a hospitalist practice model in any specialty. Just like medical and pediatric hospitalist models, the hospital in which the doctors practice usually provides additional financial support.

Hospitals usually are willing to do this because they are able to reallocate dollars spent paying for numerous specialty doctors to take ED call with poor performance, and instead use those dollars to support a hospitalist practice in that specialty that promises a better return on the investment.

Join us in November for a meeting to understand the implications of hospital-focused practice. Those of us at the January meeting of specialty hospitalists thought that it would be valuable to convene a much larger meeting to think about issues like those above and others. At the Nov. 4 meeting in Las Vegas, we plan to hear from such national figures as CMS’ chief medical officer, physicians practicing in a hospitalist model, and hospital and healthcare executives. The meeting will be structured to promote interaction and communication from attendees.

I hope to see you in Las Vegas. We have a lot to learn from one another.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

As regular readers of The Hospitalist are aware, essentially every specialty in medicine is adopting the hospitalist model to some degree. After the “legacy” specialties of medicine and pediatrics, the model has more recently been embraced enthusiastically by neurologists, obstetricians, and general surgeons. But even fields like dermatology and ENT have put a hospitalist version of their specialties in place in at least a few places.

Did you know there is a Society for Dermatology Hospitalists? Did you know that the Neurohospitalist Society has its own journal? Did you know OB hospitalists have a really neat website, and the Society of OB/GYN Hospitalists is scheduled to have its first annual meeting in Boulder, Colo., Sept. 23-25?

It’ll make your head spin if you think about it too long. All of this raises a number of issues, including the need for more precise terminology to describe these fields and their practitioners.

The Need for Better Terminology

For example, now that we have neurohospitalists and psychiatric hospitalists, is it time to start attaching a modifier or prefix every time we use the word “hospitalist,” including when referring to “medical” hospitalists? I don’t think so. For the time being, I propose that when used alone, the word “hospitalist” still refers to a doctor who provides general medical care for adult inpatients. But I think any other use of the word does require a modifier, as in “peds hospitalist” or “GI hospitalist.”

(I think my view makes sense, but then, I’ve tried for years to ensure nocternist, with an E—NOCTernal intERNIST)—is the preferred spelling over nocternist, with a U. But Google returns nine hits for the former and 365,000 for the latter. Looks like I lost that one.)

Terminology for general and trauma surgeons is tricky. There is an emerging field of acute-care surgery, distinct from general surgery, which some argue passionately is nothing like a hospitalist model, and they tend to be offended if one uses the latter term. So, for now, we’ll need to use both “acute-care surgeon” and “surgical hospitalist” carefully. Although there are meaningful distinctions between acute-care surgery and a “standard” general surgery practice devoted to the hospital, there is an awful lot of overlap in the Venn diagrams of their expertise and what they do. But for now, it looks like we should expect both “acute-care surgeon” and “surgical hospitalist” to appear commonly, and the context will determine whether the terms could be used interchangeably.

While “obstetric hospitalist,” or “OB hospitalist,” is a perfectly useful term, I think it is great when laborist is substituted, at least in informal communication.

We still need a way to speak of all of these clinical roles (I don’t think we can properly call them specialties yet). I propose that we refer to all of them as specialties within the realm of “hospital-focused practice.” I’ve borrowed this term from the American Board of Internal Medicine’s Recognition of Focused Practice in Hospital Medicine, the new pathway to Maintenance of Certification.

And what about those doctors in each specialty who continue to practice in the traditional inpatient and outpatient model? Let’s call them “traditionalists.”

Hospital-Focused Practice

A rational vocabulary is only one of many significant issues raised by the growth of hospital-focused disciplines. In January, I participated in an SHM-convened, and AHA-supported, meeting of 11 practitioners who were hospitalists in neurology, obstetrics, general surgery, medicine, pediatrics, and ENT. (Sadly, the invited dermatology hospitalist couldn’t make it.) The meeting was filled with interest and sharing of lessons learned in each field. We discussed questions, and I have provided a very brief answer to each based on the conversation during the meeting and my own work with practices across many different specialties that have adopted the hospitalist model:

What are the reasons each specialty is turning to this model, and what is its prevalence? Hospitalists have appeared in a specialty largely to fill the void left by the traditionalists who no longer want to care for unattached patients admitted through the ED, or who want to leave the hospital altogether for a solely outpatient practice.

What are typical staffing models, night coverage arrangements, and provider career sustainability? These vary a lot by specialty, but laborists typically work 24-hour, in-house shifts. Surgical hospitalists usually work 12-hour shifts if they are in-house all the time, or 24-hour shifts if they take call from home. Neurohospitalists essentially always take call from home (did you even have to ask?).

Career longevity is still a matter of speculation, but the majority of those who have transitioned from traditional to hospitalist practice in their field are convinced they will have a longer career than if they hadn’t made the switch.

What are the effects of this practice model on clinical quality, patient outcomes, healthcare economics, and liability? It will be really difficult to get convincing research data on the quality effects of the hospitalist model in many fields. After more than 15 years in operation, research about the quality effects of the medical hospitalist model is not robust enough to satisfy some. But OB hospitalists may be the exception here. There is hope that their continuous, on-site presence will reduce complications from emergencies, and in doing so might reduce malpractice risk.

What is the prevalent financial model? The experience across a lot of healthcare settings to this point is that professional fee revenue alone usually is not enough to support a hospitalist practice model in any specialty. Just like medical and pediatric hospitalist models, the hospital in which the doctors practice usually provides additional financial support.

Hospitals usually are willing to do this because they are able to reallocate dollars spent paying for numerous specialty doctors to take ED call with poor performance, and instead use those dollars to support a hospitalist practice in that specialty that promises a better return on the investment.

Join us in November for a meeting to understand the implications of hospital-focused practice. Those of us at the January meeting of specialty hospitalists thought that it would be valuable to convene a much larger meeting to think about issues like those above and others. At the Nov. 4 meeting in Las Vegas, we plan to hear from such national figures as CMS’ chief medical officer, physicians practicing in a hospitalist model, and hospital and healthcare executives. The meeting will be structured to promote interaction and communication from attendees.

I hope to see you in Las Vegas. We have a lot to learn from one another.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

As regular readers of The Hospitalist are aware, essentially every specialty in medicine is adopting the hospitalist model to some degree. After the “legacy” specialties of medicine and pediatrics, the model has more recently been embraced enthusiastically by neurologists, obstetricians, and general surgeons. But even fields like dermatology and ENT have put a hospitalist version of their specialties in place in at least a few places.

Did you know there is a Society for Dermatology Hospitalists? Did you know that the Neurohospitalist Society has its own journal? Did you know OB hospitalists have a really neat website, and the Society of OB/GYN Hospitalists is scheduled to have its first annual meeting in Boulder, Colo., Sept. 23-25?

It’ll make your head spin if you think about it too long. All of this raises a number of issues, including the need for more precise terminology to describe these fields and their practitioners.

The Need for Better Terminology

For example, now that we have neurohospitalists and psychiatric hospitalists, is it time to start attaching a modifier or prefix every time we use the word “hospitalist,” including when referring to “medical” hospitalists? I don’t think so. For the time being, I propose that when used alone, the word “hospitalist” still refers to a doctor who provides general medical care for adult inpatients. But I think any other use of the word does require a modifier, as in “peds hospitalist” or “GI hospitalist.”

(I think my view makes sense, but then, I’ve tried for years to ensure nocternist, with an E—NOCTernal intERNIST)—is the preferred spelling over nocternist, with a U. But Google returns nine hits for the former and 365,000 for the latter. Looks like I lost that one.)

Terminology for general and trauma surgeons is tricky. There is an emerging field of acute-care surgery, distinct from general surgery, which some argue passionately is nothing like a hospitalist model, and they tend to be offended if one uses the latter term. So, for now, we’ll need to use both “acute-care surgeon” and “surgical hospitalist” carefully. Although there are meaningful distinctions between acute-care surgery and a “standard” general surgery practice devoted to the hospital, there is an awful lot of overlap in the Venn diagrams of their expertise and what they do. But for now, it looks like we should expect both “acute-care surgeon” and “surgical hospitalist” to appear commonly, and the context will determine whether the terms could be used interchangeably.

While “obstetric hospitalist,” or “OB hospitalist,” is a perfectly useful term, I think it is great when laborist is substituted, at least in informal communication.

We still need a way to speak of all of these clinical roles (I don’t think we can properly call them specialties yet). I propose that we refer to all of them as specialties within the realm of “hospital-focused practice.” I’ve borrowed this term from the American Board of Internal Medicine’s Recognition of Focused Practice in Hospital Medicine, the new pathway to Maintenance of Certification.

And what about those doctors in each specialty who continue to practice in the traditional inpatient and outpatient model? Let’s call them “traditionalists.”

Hospital-Focused Practice

A rational vocabulary is only one of many significant issues raised by the growth of hospital-focused disciplines. In January, I participated in an SHM-convened, and AHA-supported, meeting of 11 practitioners who were hospitalists in neurology, obstetrics, general surgery, medicine, pediatrics, and ENT. (Sadly, the invited dermatology hospitalist couldn’t make it.) The meeting was filled with interest and sharing of lessons learned in each field. We discussed questions, and I have provided a very brief answer to each based on the conversation during the meeting and my own work with practices across many different specialties that have adopted the hospitalist model:

What are the reasons each specialty is turning to this model, and what is its prevalence? Hospitalists have appeared in a specialty largely to fill the void left by the traditionalists who no longer want to care for unattached patients admitted through the ED, or who want to leave the hospital altogether for a solely outpatient practice.

What are typical staffing models, night coverage arrangements, and provider career sustainability? These vary a lot by specialty, but laborists typically work 24-hour, in-house shifts. Surgical hospitalists usually work 12-hour shifts if they are in-house all the time, or 24-hour shifts if they take call from home. Neurohospitalists essentially always take call from home (did you even have to ask?).

Career longevity is still a matter of speculation, but the majority of those who have transitioned from traditional to hospitalist practice in their field are convinced they will have a longer career than if they hadn’t made the switch.

What are the effects of this practice model on clinical quality, patient outcomes, healthcare economics, and liability? It will be really difficult to get convincing research data on the quality effects of the hospitalist model in many fields. After more than 15 years in operation, research about the quality effects of the medical hospitalist model is not robust enough to satisfy some. But OB hospitalists may be the exception here. There is hope that their continuous, on-site presence will reduce complications from emergencies, and in doing so might reduce malpractice risk.

What is the prevalent financial model? The experience across a lot of healthcare settings to this point is that professional fee revenue alone usually is not enough to support a hospitalist practice model in any specialty. Just like medical and pediatric hospitalist models, the hospital in which the doctors practice usually provides additional financial support.

Hospitals usually are willing to do this because they are able to reallocate dollars spent paying for numerous specialty doctors to take ED call with poor performance, and instead use those dollars to support a hospitalist practice in that specialty that promises a better return on the investment.

Join us in November for a meeting to understand the implications of hospital-focused practice. Those of us at the January meeting of specialty hospitalists thought that it would be valuable to convene a much larger meeting to think about issues like those above and others. At the Nov. 4 meeting in Las Vegas, we plan to hear from such national figures as CMS’ chief medical officer, physicians practicing in a hospitalist model, and hospital and healthcare executives. The meeting will be structured to promote interaction and communication from attendees.

I hope to see you in Las Vegas. We have a lot to learn from one another.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

What I am curious about are the current issues around using length of stay (LOS) or cost/case or the like as part of compensation packages. I have had discussions with several other folks, and I think I am getting the picture. However, it sounds like there has been some new interpretation of the laws around gainsharing, and that is what I am curious about.

K.S., Ohio

Dr. Hospitalist responds:

Tough question, and let me start by saying that I’m not a healthcare lawyer: This stuff is tricky. I’ll do my best to explain the current situation as I understand it, but I’m no expert on this.

So gainsharing, as generally defined in healthcare, is where a hospital and a group of physicians design a contract around services for which the two sides can share in any savings. Physicians are paid fee-for-service by Medicare, thus they are reimbursed per unit of work, with no incentive for cost control. Hospitals are paid on a per-case (or per-procedure) basis, so cost control means a lot to them: Because they get a set payment, any savings generated, they get to keep. Ideally, this means that better performance leads to more efficient care, less waste, and better outcomes. Unfortunately, that’s not always what happens, especially in the view of the federal government (you know, the guys who issue the bright orange jumpsuits for you to wear when you break the law).

Gainsharing has an interesting history as interpreted by the Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS). Back in 1999, the OIG explicitly stopped any gainsharing models between physicians and hospitals based on concerns that these contracts might reduce the care provided to patients. The opinion was that there might be a “race to the bottom” in terms of cutting expenses (read: services).

Since then, there has been only incremental movement forward in the form of demonstration projects. One project looked at two very specific procedures: cardiac catheterization and coronary artery bypass grafting (CABG). The results showed that gainsharing could be beneficial to the hospital-physician relationship, and, more important, not harmful to the patient. There has since been some movement toward gainsharing, but only in the context of specific procedures, with very clear safeguards around it, including an independent auditor. Nothing to this point has suggested that a cost per case or adjusted LOS gainsharing agreement would pass muster with the OIG.

So, at this point in time, I would caution against any contract that contained explicit references connecting compensation to a change in hospital costs, such as reducing LOS or cost per case. The new accountable-care organization (ACO) model might be a different prism through which to view this, but it’s a world apart from an individual physician or hospitalist group contract (see “A Chilly Reception,” August 2011, p. 23).

For contractual compensation, I think that quality metrics can fill a need, and there are lots of ways to be creative here. You could set a target around something measurable (appropriate DVT prophylaxis is just one example) and tie dollars to that specific performance. The key is avoiding any language that would imply additional physician compensation for a reduction in patient services.

Might things change in the future? Your guess is as good as mine.

Hollywood, Fla.-based Hospital Physician Partners (HPP) was an ED business when opportunity came knocking: Hospital administrators started asking, “Can you provide us with some hospitalists to go with our emergency-room doctors?”

Today, HPP is firmly in the HM business—and all signs point toward more hospitals hiring companies to handle both emergency care and inpatient care.

“In many ways, we expanded our efforts into hospitalist medicine as a result of requests from our hospital partners,” says Ed Weinberg, HPP’s chief operating officer. “Their needs were such that they asked us to provide hospital medicine services. So from that, it became clear that it was an area that was really growing. And that is something we are pursuing as vigorously as we are emergency medicine.”

HPP handling both emergency care and hospital medicine can help with the transition of patients from the ED to a hospital bed upstairs, he says.

“That’s where our efficiencies are, because we have physicians working who are carrying out the same philosophy,” he says.

Out of HPP’s 120 contracts, 15 are in hospital medicine. But the HM contract numbers are growing quickly, Weinberg notes.

EmCare has about 400 emergency-medicine programs and more than 50 HM programs, according to Mark Hamm, CEO of EmCare Inpatient Services. He says that it can be much more cost effective to contract with one company for both hospitalist and ED services, something hospitals find attractive.

EmCare service agreements range from completely separate emergency and HM staffs to small, rural hospitals where ED physicians also do rounds. Some hospitals “just don’t have the money for a full-time hospitalist and don’t really need one,” Hamm says.

The patient transitions tend to go more smoothly when both types of care are provided by EmCare, he adds. If they’re not, there can be slowdowns.

“Our goal is to quickly and appropriately move patients through the system,” he says. “If we have a hospitalist provider that’s not really on the same page, that can create bottlenecks. But it’s a blip. Our goal is to sit down, even if it’s not an EmCare hospitalist, to sit down with that director and say, ‘Hey look, let’s be the leader here, let’s work together and appropriately expedite these patients.’ We do the same thing on the hospitalist side.”

Inpatient care promises to be a big part of their future business, the executives agreed.

“Hospital medicine,” Weinberg says, “is growing by leaps and bounds.”

Hollywood, Fla.-based Hospital Physician Partners (HPP) was an ED business when opportunity came knocking: Hospital administrators started asking, “Can you provide us with some hospitalists to go with our emergency-room doctors?”

Today, HPP is firmly in the HM business—and all signs point toward more hospitals hiring companies to handle both emergency care and inpatient care.

“In many ways, we expanded our efforts into hospitalist medicine as a result of requests from our hospital partners,” says Ed Weinberg, HPP’s chief operating officer. “Their needs were such that they asked us to provide hospital medicine services. So from that, it became clear that it was an area that was really growing. And that is something we are pursuing as vigorously as we are emergency medicine.”

HPP handling both emergency care and hospital medicine can help with the transition of patients from the ED to a hospital bed upstairs, he says.

“That’s where our efficiencies are, because we have physicians working who are carrying out the same philosophy,” he says.

Out of HPP’s 120 contracts, 15 are in hospital medicine. But the HM contract numbers are growing quickly, Weinberg notes.

EmCare has about 400 emergency-medicine programs and more than 50 HM programs, according to Mark Hamm, CEO of EmCare Inpatient Services. He says that it can be much more cost effective to contract with one company for both hospitalist and ED services, something hospitals find attractive.

EmCare service agreements range from completely separate emergency and HM staffs to small, rural hospitals where ED physicians also do rounds. Some hospitals “just don’t have the money for a full-time hospitalist and don’t really need one,” Hamm says.

The patient transitions tend to go more smoothly when both types of care are provided by EmCare, he adds. If they’re not, there can be slowdowns.

“Our goal is to quickly and appropriately move patients through the system,” he says. “If we have a hospitalist provider that’s not really on the same page, that can create bottlenecks. But it’s a blip. Our goal is to sit down, even if it’s not an EmCare hospitalist, to sit down with that director and say, ‘Hey look, let’s be the leader here, let’s work together and appropriately expedite these patients.’ We do the same thing on the hospitalist side.”

Inpatient care promises to be a big part of their future business, the executives agreed.

“Hospital medicine,” Weinberg says, “is growing by leaps and bounds.”

Hollywood, Fla.-based Hospital Physician Partners (HPP) was an ED business when opportunity came knocking: Hospital administrators started asking, “Can you provide us with some hospitalists to go with our emergency-room doctors?”

Today, HPP is firmly in the HM business—and all signs point toward more hospitals hiring companies to handle both emergency care and inpatient care.

“In many ways, we expanded our efforts into hospitalist medicine as a result of requests from our hospital partners,” says Ed Weinberg, HPP’s chief operating officer. “Their needs were such that they asked us to provide hospital medicine services. So from that, it became clear that it was an area that was really growing. And that is something we are pursuing as vigorously as we are emergency medicine.”

HPP handling both emergency care and hospital medicine can help with the transition of patients from the ED to a hospital bed upstairs, he says.

“That’s where our efficiencies are, because we have physicians working who are carrying out the same philosophy,” he says.

Out of HPP’s 120 contracts, 15 are in hospital medicine. But the HM contract numbers are growing quickly, Weinberg notes.

EmCare has about 400 emergency-medicine programs and more than 50 HM programs, according to Mark Hamm, CEO of EmCare Inpatient Services. He says that it can be much more cost effective to contract with one company for both hospitalist and ED services, something hospitals find attractive.

EmCare service agreements range from completely separate emergency and HM staffs to small, rural hospitals where ED physicians also do rounds. Some hospitals “just don’t have the money for a full-time hospitalist and don’t really need one,” Hamm says.

The patient transitions tend to go more smoothly when both types of care are provided by EmCare, he adds. If they’re not, there can be slowdowns.

“Our goal is to quickly and appropriately move patients through the system,” he says. “If we have a hospitalist provider that’s not really on the same page, that can create bottlenecks. But it’s a blip. Our goal is to sit down, even if it’s not an EmCare hospitalist, to sit down with that director and say, ‘Hey look, let’s be the leader here, let’s work together and appropriately expedite these patients.’ We do the same thing on the hospitalist side.”

Inpatient care promises to be a big part of their future business, the executives agreed.

“Hospital medicine,” Weinberg says, “is growing by leaps and bounds.”

Hospitalist David Mitchell, MD, PhD, was moonlighting in an Ohio hospital when a nurse called him about a gravely ill older patient who was experiencing shortness of breath. Should she administer the diuretic Lasix to help clear his lung congestion?

Dr. Mitchell, now a hospitalist at Sibley Memorial Hospital in Washington, D.C., and a member of SHM’s Performance Standards Committee, decided to see the patient in person and review his charts. He found that the patient had severe dementia, hadn’t walked in months, and was declining despite more than two weeks in the hospital and daily visits by three specialists.

Dr. Mitchell called the patient’s son and explained the situation, then asked whether the son thought his father would want to continue receiving aggressive therapy. “The son said, ‘Oh, no. He would never want to continue like this.’ So we stopped all the treatments, and he died by the next day,” Dr. Mitchell says.

To him, the anecdote highlights how far medicine has to go in providing personalized palliative care that honors the wishes of patients and their families. It also demonstrates how ignoring those wishes and failing to communicate can contribute to the huge costs associated with end-of-life medical care. Every day, the three specialists seeing the patient were recommending the same course of therapy. “But nobody was being the quarterback and saying, ‘Hey, listen. This is not working,’ ” Dr. Mitchell says.

Hospitalists, he says, are in an ideal position to step up and play a pivotal role in providing the kind of patient-centered care that could improve both quality and cost. So far, however, Dr. Mitchell says he’s seen wide variation in how hospitalists communicate with a patient’s family about end-of-life decisions. “For the ones who do have these conversations, the family is almost always glad that somebody finally said, ‘Do we have to do these tests? Do we have to continue to try to save his life?’ ” Dr. Mitchell says.

Time constraints, he says, are the main reason why hospitalists don’t have such conversations more often. “The communication dies when you’re busy.” And the remedy? Dr. Mitchell says the only thing that will help shift the focus from seeing as many patients as possible to making sure every encounter is a high-quality, efficient one is payment reform in the form of bundled payments to hospitals and physicians. In theory, professional standards can encourage more uniformity, he says. “But when it hits the trenches, it’s the payment that speaks.”

Hospitalist David Mitchell, MD, PhD, was moonlighting in an Ohio hospital when a nurse called him about a gravely ill older patient who was experiencing shortness of breath. Should she administer the diuretic Lasix to help clear his lung congestion?

Dr. Mitchell, now a hospitalist at Sibley Memorial Hospital in Washington, D.C., and a member of SHM’s Performance Standards Committee, decided to see the patient in person and review his charts. He found that the patient had severe dementia, hadn’t walked in months, and was declining despite more than two weeks in the hospital and daily visits by three specialists.

Dr. Mitchell called the patient’s son and explained the situation, then asked whether the son thought his father would want to continue receiving aggressive therapy. “The son said, ‘Oh, no. He would never want to continue like this.’ So we stopped all the treatments, and he died by the next day,” Dr. Mitchell says.

To him, the anecdote highlights how far medicine has to go in providing personalized palliative care that honors the wishes of patients and their families. It also demonstrates how ignoring those wishes and failing to communicate can contribute to the huge costs associated with end-of-life medical care. Every day, the three specialists seeing the patient were recommending the same course of therapy. “But nobody was being the quarterback and saying, ‘Hey, listen. This is not working,’ ” Dr. Mitchell says.

Hospitalists, he says, are in an ideal position to step up and play a pivotal role in providing the kind of patient-centered care that could improve both quality and cost. So far, however, Dr. Mitchell says he’s seen wide variation in how hospitalists communicate with a patient’s family about end-of-life decisions. “For the ones who do have these conversations, the family is almost always glad that somebody finally said, ‘Do we have to do these tests? Do we have to continue to try to save his life?’ ” Dr. Mitchell says.

Time constraints, he says, are the main reason why hospitalists don’t have such conversations more often. “The communication dies when you’re busy.” And the remedy? Dr. Mitchell says the only thing that will help shift the focus from seeing as many patients as possible to making sure every encounter is a high-quality, efficient one is payment reform in the form of bundled payments to hospitals and physicians. In theory, professional standards can encourage more uniformity, he says. “But when it hits the trenches, it’s the payment that speaks.”

Hospitalist David Mitchell, MD, PhD, was moonlighting in an Ohio hospital when a nurse called him about a gravely ill older patient who was experiencing shortness of breath. Should she administer the diuretic Lasix to help clear his lung congestion?

Dr. Mitchell, now a hospitalist at Sibley Memorial Hospital in Washington, D.C., and a member of SHM’s Performance Standards Committee, decided to see the patient in person and review his charts. He found that the patient had severe dementia, hadn’t walked in months, and was declining despite more than two weeks in the hospital and daily visits by three specialists.

Dr. Mitchell called the patient’s son and explained the situation, then asked whether the son thought his father would want to continue receiving aggressive therapy. “The son said, ‘Oh, no. He would never want to continue like this.’ So we stopped all the treatments, and he died by the next day,” Dr. Mitchell says.

To him, the anecdote highlights how far medicine has to go in providing personalized palliative care that honors the wishes of patients and their families. It also demonstrates how ignoring those wishes and failing to communicate can contribute to the huge costs associated with end-of-life medical care. Every day, the three specialists seeing the patient were recommending the same course of therapy. “But nobody was being the quarterback and saying, ‘Hey, listen. This is not working,’ ” Dr. Mitchell says.

Hospitalists, he says, are in an ideal position to step up and play a pivotal role in providing the kind of patient-centered care that could improve both quality and cost. So far, however, Dr. Mitchell says he’s seen wide variation in how hospitalists communicate with a patient’s family about end-of-life decisions. “For the ones who do have these conversations, the family is almost always glad that somebody finally said, ‘Do we have to do these tests? Do we have to continue to try to save his life?’ ” Dr. Mitchell says.

Time constraints, he says, are the main reason why hospitalists don’t have such conversations more often. “The communication dies when you’re busy.” And the remedy? Dr. Mitchell says the only thing that will help shift the focus from seeing as many patients as possible to making sure every encounter is a high-quality, efficient one is payment reform in the form of bundled payments to hospitals and physicians. In theory, professional standards can encourage more uniformity, he says. “But when it hits the trenches, it’s the payment that speaks.”

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