The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

What’s up with the dress code in hospitals these days? Some of my colleagues wear white coats, some wear ties, some have short-sleeved shirts. Some even wear scrubs in the daytime, and they swear they are right as to “the most clinically appropriate attire.” Any thoughts?

Attirely Concerned in Los Angeles

Dr. Hospitalist responds:

There are a lot of suggestions out there regarding attire. The United Kingdom’s National Health Service is probably most famous for instituting a “bare below elbows” (BBE for short) dress code in 2007.

Although lots of studies have shown bacterial colonization on the items doctors wear or carry (e.g. pagers, pens, neckties, coats, scrubs), none of them truly show causality. The Journal of Hospital Medicine just published a study on scrubs versus white coats, which showed no real difference in contamination.¹

Even the BBE policy was meant to promote hand-washing more than anything else. On that point, there is little disagreement, as there is a substantial amount of data to show that good hand hygiene is a patient-care imperative. We all should spend more time thinking about “clean in/clean out” when it comes to patient rooms than deciding which article of clothing carries the fewest bacteria.

There is another issue at play here, though, and that is the question of how hospitalists are expected to dress. Certainly, there is some regional variation. I don’t think you’ll find that physicians at the Mayo Clinic in Rochester, Minn., are going to dress the same as physicians in San Diego or Hawaii.

So, setting aside the cultural expectations for your region, I do think it’s a good idea for your group to agree on some standards. These policies might vary from white coats for everyone to scrubs after hours, or that blue jeans are OK only on weekends.

Why bother?

Well, for starters, a little consistency will promote the professionalism of your group, and it also sets some baseline expectations for everyone involved. Think about how many healthcare providers wander into a patient’s room during the day: You want to be readily identifiable as the treating physician. No, it’s not just how you dress (a voice, a name badge, and putting your name on the white board also count), but it is part of the picture.

As a hospitalist, not only are you a professional, but, by definition, you are going to meet patients with whom you have no prior relationship. Like it or not, perception matters, and when you need to quickly gain the trust of a patient (and a family) to make urgent clinical decisions, being dressed professionally will help. Looking like a slob won’t.

My advice? First, wash your hands where the patient can see you. If you have to use that gel 40 times a day, you might as well make a show of it. Two, dress professionally within the parameters that your group outlines.

Beyond that, I don’t think you need to autoclave your peripherals and go through a decontamination room just yet.

Reference

1. Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: A randomized controlled trial. J Hosp Med. 2011;6(4):177-182.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

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. 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.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

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. 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.

Many hospitalist practices are started by “traditionalists”: primary-care physicians (PCPs) active in the outpatient and hospital settings. The practice typically grows due in large part to the leadership of the founders. Ultimately, the practice is made up of both the founders and a cadre of part- or full-time hospitalists who don’t work in the outpatient setting. And sometimes they have different incentives and ideas about how the practice should operate.

When these individuals disagree, which group should break the tie—the founding “hybrid” or “rotating” doctors who work part time on the hospitalist service or the doctors who work only as hospitalists?

This is a reasonably common issue for “medical” hospitalist groups, and in many cases is becoming an issue for groups in other specialties that adopt the hospitalist model, such as surgical hospitalists, laborists, etc.

A Common Scenario

Let me illustrate this issue with a composite of several former consulting clients. Let’s say this is a hospitalist practice that serves a 250-bed community hospital. One large private internal medicine group adopted a “rotating hospitalist” model there in the late 1990s. One of the internists provided the daytime hospital coverage for all the group’s patients one week out of every six. Their hospital volume grew quickly. They were asked to take on responsibility for admitting an increasing portion of the unassigned patients, provide care for patients referred by other PCPs who wanted to drop out of hospital work, and increasingly were asked to consult on patients admitted by surgeons.

When faced with this situation, many PCP groups decided to exit the hospital themselves and turn that work over to hospitalists. This group stuck it out. At first, the one doctor in the group covering the hospital each week kept up with the growing volume by simply working harder and longer every day. Eventually, the group sought financial help from the hospital to hire hospitalists who didn’t have outpatient responsibilities.

Years passed, and this PCP group transitioned to employment by the hospital, just like the full-time hospitalists. And by this time, the hospitalist practice was seen as distinct from the original PCP group. About 80% of the staffing was provided by hospitalists who didn’t work in the outpatient setting, the remainder by PCPs who essentially founded the practice. The PCPs chose to continue providing hospital care, both because they found it professionally satisfying and their compensation formula made it attractive for generating production in the hospital.

Tensions arose between the hospitalists and the “hybrids.” The hybrids refused to work night shifts and generally were unable to fill in for unplanned absences by the hospitalists. And because of the PCPs’ compensation formula, and possibly the work ethic of more senior doctors, they favored managing larger patient volumes and decreasing weekend staffing significantly to allow more weekends off in total for everyone. The hospitalists had other ideas about these things, and they were unhappy that the PCPs would have first say about when they could work hospital shifts, thereby decreasing the hospitalists’ scheduling flexibility.

The hospitalists were all within a few years of their residency training, and most of the PCPs were midcareer. This created a social divide, making it that much more difficult for the two groups to work through the issues. While the hybrid doctors saw the hospitalists as good clinicians, and vice versa, each group said: “The other guys are difficult to work with. They don’t understand what it is like for us.”

Need for Paradigm Shift

At many sites, the doctors and their administrative counterparts get stuck in a stalemate and have the same, unhappy conversations repeatedly. These conversations are really gripe sessions more than anything else.

I think the best solution is for everyone to acknowledge the valuable contribution of the hybrid doctors in founding and leading the hospitalist practice through years of growth, but also to begin seeing the hospitalist practice as being owned and governed primarily by the hospitalists who do most of the work. For most issues in which the two factions can’t agree, the hospitalists should have the tie-breaking vote.

While this approach reduces the autonomy of the hybrid doctors to make operational decisions, it doesn’t mean they have zero influence. In fact, the practice usually has a critical need for the hybrid doctors to continue providing some of the staffing. This usually means that the practice will need to ensure it puts together a package of compensation and available shifts on the schedule to ensure the hybrids want to remain active in the practice.

In most cases, all involved should ensure that those hybrid doctors who want to remain active in the hospital, and perform well in the hospitalist practice, should have the opportunity to do so indefinitely.

Compensation Methods for Hybrids

Even if the hybrids and hospitalists are able to harmoniously agree on things like work schedules, the hybrid doctors often have compensation schemes such that when working in the hospital, they have different financial incentives from the hospitalists. (I’m using “hybrid” to describe physicians who work in both inpatient and outpatient settings, usually more time in the office practice.) A common situation is that the production (i.e. wRVUs) generated in the hospital counts toward their office productivity. So the hybrids and the hospitalists will have different ideas about how hard they want to work.

The solution here is to divorce the office and hospital compensation schemes. There should be no connection between the compensation in the two settings, and both should be designed to ensure a competitive amount of money and performance incentives appropriate for that setting. Such methods usually mean that a day of work in the office will result in a different-sized paycheck than what comes with a day of work in the hospital.

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. 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.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.¹

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.²

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.^3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.⁵

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.

For those of you who were kind enough to catch my column in last month’s issue of The Hospitalist (see “What Is Your Value,” p. 56), you spent a few minutes reading my thoughts on the value of hospitalists. I mentioned the fact that the U.S. is moving rapidly toward a value-based system of purchasing healthcare, and that all healthcare providers, including hospitalists, increasingly will be judged on the value of care they deliver to their patients and the healthcare system. (Remember, value=quality/cost.)

Hospitalists, like all other healthcare providers, can increase their “value” by improving the quality of care they provide and decreasing the cost of healthcare delivery. Seems simple enough, right? Take better care of patients and do so while minimizing unnecessary costs. (If you have figured out how to do this, I want to learn from you!)

As a doctor and as the leader of the hospitalist group at Beth Israel Deaconess Medical Center in Boston, I have given this topic considerable thought. How do I become a “high value” provider? How do I help my hospitalist colleagues become “high value” hospitalists? Another persistent thought that has crossed my mind is: “How do I know that I am not already a high-value hospitalist?”

Maybe all of my hospitalist colleagues at Beth Israel Deaconess Medical Center are high-value providers. Seems fair enough, right? Maybe each of us is providing “high quality” care and doing so while minimizing unnecessary costs.

I mean, who really wants to think of themselves as low-quality doctors spending a considerable amount of unnecessary resources?

Like many of you, it became evident to me that the first step to improving quality and/or decreasing cost is to define “quality” and “cost.”

The First Step

Although it might seem difficult for the individual hospitalist to know the cost of a patient’s hospitalization, such information is available, and your hospital administrator might be willing to share such information with you and your group. But when it comes to quality of care, I think most patients would expect that doctors should understand the definition of “high-quality care.”

So, what is the definition of “high-quality care?” Try asking this question of patients and doctors, and you are likely to get very different answers. Not surprised? Try asking this question just to doctors, and you are likely to get some different answers. (For fun, you could try this exercise with your hospitalist colleagues; I have.)

Honestly, none of us should be alarmed if a group of doctors cannot easily define “high-quality care.” Not being able to do so does not mean these are “bad” doctors. While it may not be easy to define high-quality care, I suspect most of us recognize it when we see it.

The process of defining the quality of care involves capturing the essence of what we see. For example, can we agree that prescribing aspirin for patients with acute coronary syndrome is optimal care? If so, it stands to reason that a patient with acute coronary syndrome who did not receive aspirin received suboptimal care.

This is how a group of hospitalists can go about creating a quality standard. If you are a hospitalist or HM group leader who is interested in improving the quality of care you and your colleagues are providing to your patients, defining a quality standard is the critical first step to process improvement. Do not limit yourself to clinical processes. Although clinical processes are important, so are communication and documentation processes.

For example, most of us, as hospitalists, believe that communication with outpatient providers is important to the provision of high-quality inpatient care. How often do your hospitalists communicate with patients’ primary-care providers? Is this a quality standard for your hospitalist group? What about the documentation of a patient’s code status at the time of admission or documentation of a patient’s functional status in the discharge summary?

If you believe these are important, your group should include these as quality standards. You should be measuring them and reporting the results to individual providers.

Start with Definition

At this point, some of us might be tempted to get ahead of ourselves and worry about what standards we can or cannot measure, but I urge you to complete this first step of defining “high-quality care” before worrying about anything else. (In other words, don’t start running before you can walk.)

Another suggestion: Please don’t try to do too much all at once. Nobody is going to argue that patients with acute coronary syndrome should not receive aspirin. Reaching consensus on other quality standards might not be as easy. But do not get bogged down trying to create too many quality standards all at once. Start with a few and get yourself and your colleagues accustomed to the process.

Remember, when it comes to doctors, we have centuries of history of not knowing exactly what we are doing. I hope it won’t take centuries to fix this problem, but I also know we are not going to fix this in a few days or weeks. Small victories along the way are important if we hope to succeed.

Once you and your hospitalist colleagues arrive at a mutually agreed upon quality standard, the next step is performance measurement. I honestly believe performance measurement is easy when we spend the time understanding and agreeing to the most appropriate quality standards for our hospitalist groups.

I am interested in learning about your efforts to define the quality standards for your hospitalist group. Feel free to email me at [email protected].

Dr. Li is president of SHM.