A new report that hints stress factors like case volume and academic status of a hospital do not explain the wide disparities in defibrillation response times in hospitals has at least one hospitalist convinced HM leaders can help solve the problem.

Traditional hospital pressures do not predict whether patients with cardiac arrest are likely to experience delays in receiving defibrillation, according to a July 27 report in the Archives of Internal Medicine (2009;169(14):1260-1261). Such factors as the number of beds and where the cardiac unit was located were found to have more impact, the study found.

“This is a very simple thing,” says hospitalist Jason Persoff, MD, FHM, assistant professor of medicine at the Mayo Clinic in Jacksonville, Fla. "What are the barriers to shocking the patient? This doesn’t require huge committees. The question is, 'Why isn’t this happening?' … This paper is a call to arms."

According to the study, rates of delayed defibrillation, which were defined as longer than the two-minute standard, ranged from 2.4% to 50.9%. The authors state that standardizing defibrillation times to meet the two-minute standard set by the American Hospital Association could be a quality initiative focus for HM groups.

“Now that we’ve identified the problem, that helps us identify how to move forward,” Dr. Persoff says. “We are in dire need of improving our system when it comes to cardiac care. The hospitalists are in the best position to do that because we are able to work closest with the nurses.”

Jane Kelly-Cummings, RN, CPHQ, SHM's senior director of quality initiatives, agrees there is room for improvement in the survival rate of in-hospital cardiac patients. "In order to make those improvements, hospitals will need to make changes to their cardiac resuscitation processes and procedures," she says. "Hospitalists are integral and central players on cardiac resuscitation teams at a great majority of hospitals with hospital medicine programs. They act as change agents at these and many other facilities."

For more information on HM's role in cardiac resuscitation of hospitalized patients, visit the Emergency Procedures section of the "Core Competencies in Hospital Medicine."a

A new report that hints stress factors like case volume and academic status of a hospital do not explain the wide disparities in defibrillation response times in hospitals has at least one hospitalist convinced HM leaders can help solve the problem.

Traditional hospital pressures do not predict whether patients with cardiac arrest are likely to experience delays in receiving defibrillation, according to a July 27 report in the Archives of Internal Medicine (2009;169(14):1260-1261). Such factors as the number of beds and where the cardiac unit was located were found to have more impact, the study found.

“This is a very simple thing,” says hospitalist Jason Persoff, MD, FHM, assistant professor of medicine at the Mayo Clinic in Jacksonville, Fla. "What are the barriers to shocking the patient? This doesn’t require huge committees. The question is, 'Why isn’t this happening?' … This paper is a call to arms."

According to the study, rates of delayed defibrillation, which were defined as longer than the two-minute standard, ranged from 2.4% to 50.9%. The authors state that standardizing defibrillation times to meet the two-minute standard set by the American Hospital Association could be a quality initiative focus for HM groups.

“Now that we’ve identified the problem, that helps us identify how to move forward,” Dr. Persoff says. “We are in dire need of improving our system when it comes to cardiac care. The hospitalists are in the best position to do that because we are able to work closest with the nurses.”

Jane Kelly-Cummings, RN, CPHQ, SHM's senior director of quality initiatives, agrees there is room for improvement in the survival rate of in-hospital cardiac patients. "In order to make those improvements, hospitals will need to make changes to their cardiac resuscitation processes and procedures," she says. "Hospitalists are integral and central players on cardiac resuscitation teams at a great majority of hospitals with hospital medicine programs. They act as change agents at these and many other facilities."

For more information on HM's role in cardiac resuscitation of hospitalized patients, visit the Emergency Procedures section of the "Core Competencies in Hospital Medicine."a

A new report that hints stress factors like case volume and academic status of a hospital do not explain the wide disparities in defibrillation response times in hospitals has at least one hospitalist convinced HM leaders can help solve the problem.

Traditional hospital pressures do not predict whether patients with cardiac arrest are likely to experience delays in receiving defibrillation, according to a July 27 report in the Archives of Internal Medicine (2009;169(14):1260-1261). Such factors as the number of beds and where the cardiac unit was located were found to have more impact, the study found.

“This is a very simple thing,” says hospitalist Jason Persoff, MD, FHM, assistant professor of medicine at the Mayo Clinic in Jacksonville, Fla. "What are the barriers to shocking the patient? This doesn’t require huge committees. The question is, 'Why isn’t this happening?' … This paper is a call to arms."

According to the study, rates of delayed defibrillation, which were defined as longer than the two-minute standard, ranged from 2.4% to 50.9%. The authors state that standardizing defibrillation times to meet the two-minute standard set by the American Hospital Association could be a quality initiative focus for HM groups.

“Now that we’ve identified the problem, that helps us identify how to move forward,” Dr. Persoff says. “We are in dire need of improving our system when it comes to cardiac care. The hospitalists are in the best position to do that because we are able to work closest with the nurses.”

Jane Kelly-Cummings, RN, CPHQ, SHM's senior director of quality initiatives, agrees there is room for improvement in the survival rate of in-hospital cardiac patients. "In order to make those improvements, hospitals will need to make changes to their cardiac resuscitation processes and procedures," she says. "Hospitalists are integral and central players on cardiac resuscitation teams at a great majority of hospitals with hospital medicine programs. They act as change agents at these and many other facilities."

For more information on HM's role in cardiac resuscitation of hospitalized patients, visit the Emergency Procedures section of the "Core Competencies in Hospital Medicine."a

Clinical question: Does tailoring the duration of anticoagulation based on the persistence of residual thrombus following conventional duration therapy reduce rates of recurrent venous thromboembolism (VTE) in adults with proximal deep-venous thrombosis (DVT)?

Background: The optimal duration of oral anticoagulation therapy in adults with proximal DVT remains uncertain. This study was designed to ascertain if tailoring the duration of therapy based on ultrasonographic findings improves outcomes through a reduction in recurrent VTE.

Study design: Parallel, open-label, randomized trial with independent and blinded assessment of study outcomes.

Setting: Nine university and hospital centers in Italy.

Synopsis: Five hundred thirty-eight patients with proximal DVT who completed three months of anticoagulation were randomly assigned to fixed-duration or flexible-duration therapy. Patients in the fixed-duration group with provoked DVT received no further therapy; those with unprovoked DVT received an additional three months of anticoagulation. Patients in the flexible-duration group had no further therapy if ultrasonography demonstrated recanalized veins, and received further therapy (up to nine to 21 months for provoked and unprovoked DVT, respectively) if persistent thrombi were demonstrated. Patients were followed over three years for the primary outcomes of recurrent VTE and major bleeding events.

Significantly fewer recurrent VTE occurred in the ultrasound guided, flexible-duration treatment group (11.9% vs. 17.2%; HR 0.64; 95% CI 0.39 to 0.99). There was no significant difference in major bleeding events between the two groups.

Limitations of this study include the lack of a double-blind design and the relatively small sample size.

Bottom line: Tailoring the duration of anticoagulation in adults with proximal DVT based on ultrasonographic demonstration of residual thrombi reduces rates of recurrent VTE without increasing major bleeding events.

Citation: Prandoni P, Prins MH, Lensing AW, et al. Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial. Ann Intern Med. 2009;150(9):577-585.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

Clinical question: Does tailoring the duration of anticoagulation based on the persistence of residual thrombus following conventional duration therapy reduce rates of recurrent venous thromboembolism (VTE) in adults with proximal deep-venous thrombosis (DVT)?

Background: The optimal duration of oral anticoagulation therapy in adults with proximal DVT remains uncertain. This study was designed to ascertain if tailoring the duration of therapy based on ultrasonographic findings improves outcomes through a reduction in recurrent VTE.

Study design: Parallel, open-label, randomized trial with independent and blinded assessment of study outcomes.

Setting: Nine university and hospital centers in Italy.

Synopsis: Five hundred thirty-eight patients with proximal DVT who completed three months of anticoagulation were randomly assigned to fixed-duration or flexible-duration therapy. Patients in the fixed-duration group with provoked DVT received no further therapy; those with unprovoked DVT received an additional three months of anticoagulation. Patients in the flexible-duration group had no further therapy if ultrasonography demonstrated recanalized veins, and received further therapy (up to nine to 21 months for provoked and unprovoked DVT, respectively) if persistent thrombi were demonstrated. Patients were followed over three years for the primary outcomes of recurrent VTE and major bleeding events.

Significantly fewer recurrent VTE occurred in the ultrasound guided, flexible-duration treatment group (11.9% vs. 17.2%; HR 0.64; 95% CI 0.39 to 0.99). There was no significant difference in major bleeding events between the two groups.

Limitations of this study include the lack of a double-blind design and the relatively small sample size.

Bottom line: Tailoring the duration of anticoagulation in adults with proximal DVT based on ultrasonographic demonstration of residual thrombi reduces rates of recurrent VTE without increasing major bleeding events.

Citation: Prandoni P, Prins MH, Lensing AW, et al. Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial. Ann Intern Med. 2009;150(9):577-585.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

Clinical question: Does tailoring the duration of anticoagulation based on the persistence of residual thrombus following conventional duration therapy reduce rates of recurrent venous thromboembolism (VTE) in adults with proximal deep-venous thrombosis (DVT)?

Background: The optimal duration of oral anticoagulation therapy in adults with proximal DVT remains uncertain. This study was designed to ascertain if tailoring the duration of therapy based on ultrasonographic findings improves outcomes through a reduction in recurrent VTE.

Study design: Parallel, open-label, randomized trial with independent and blinded assessment of study outcomes.

Setting: Nine university and hospital centers in Italy.

Synopsis: Five hundred thirty-eight patients with proximal DVT who completed three months of anticoagulation were randomly assigned to fixed-duration or flexible-duration therapy. Patients in the fixed-duration group with provoked DVT received no further therapy; those with unprovoked DVT received an additional three months of anticoagulation. Patients in the flexible-duration group had no further therapy if ultrasonography demonstrated recanalized veins, and received further therapy (up to nine to 21 months for provoked and unprovoked DVT, respectively) if persistent thrombi were demonstrated. Patients were followed over three years for the primary outcomes of recurrent VTE and major bleeding events.

Significantly fewer recurrent VTE occurred in the ultrasound guided, flexible-duration treatment group (11.9% vs. 17.2%; HR 0.64; 95% CI 0.39 to 0.99). There was no significant difference in major bleeding events between the two groups.

Limitations of this study include the lack of a double-blind design and the relatively small sample size.

Bottom line: Tailoring the duration of anticoagulation in adults with proximal DVT based on ultrasonographic demonstration of residual thrombi reduces rates of recurrent VTE without increasing major bleeding events.

Citation: Prandoni P, Prins MH, Lensing AW, et al. Residual thrombosis on ultrasonography to guide the duration of anticoagulation in patients with deep venous thrombosis: a randomized trial. Ann Intern Med. 2009;150(9):577-585.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

AMANE KANEKO

Think Twice Before Accepting an Expert Witness Offer

A medical malpractice attorney recently contacted me, asking if I would be interested in reviewing a case. They are looking for a hospitalist “expert witness.” I’ve never done this before and don’t know if I’m qualified. Can you tell me about the benefits and risks of being a medical expert witness?

R. Jones, MD

Miami

Dr. Hospitalist responds: Most physicians complete medical school and postgraduate training without firsthand knowledge of our legal system. Unfortunately, a number of physicians become defendants in medical lawsuits during their professional careers. I hear with increasing frequency about hospitalists being sued for alleged medical malpractice. I am not surprised. This is not an indictment against hospital HM, but more a matter of probability. There are at least tenfold more hospitalists today than 10 years ago.

To be clear, I am not an attorney, nor do I have any formal legal training. I suggest you speak with an attorney if you have questions about the law.

Laws vary from state to state, but for the most part, plaintiff attorneys and defense attorneys retain expert witnesses to help them determine the merits of a lawsuit. Did the defendant have a duty to treat the patient? Was there a breach of the standard of care? What were the damages, and were they due to the defendant’s actions or lack of action?

Understand that our judicial system holds that a physician in the same field as the defendant is the most qualified to determine whether the defendant met the standard of care. Standard of care is what is reasonably expected of a physician in that field given the circumstances. So if the defendant is a hospitalist, the attorneys are looking for an expert witness who is also a hospitalist. Seems like a reasonable system, right? Individuals are judged by their peers. But the system is far from perfect.

Critics point out the system is inherently flawed when we rely on “experts” to help us determine the standard of care. Aside from working in a given field of medicine, there are no specific qualifications to be an expert witness. Unfortunately, not all experts are experts, and not all experts are completely honest. And there can be a lot of money at stake. Plaintiffs attorneys and defense attorneys, along with expert witnesses for both sides, stand to profit from lawsuits. All of this drives up the cost of medical malpractice premiums.

I will not tell you not to become an expert witness. Until we see real, sustainable tort reform, we have to live with the system. If I am sued, my defense attorney would seek an expert witness’s opinion. If a patient is hurt because of alleged negligence, the patient’s attorney would seek the opinion of an expert witness. So we need honest physicians to provide honest opinions as expert witnesses. This goes for defendants and plaintiffs.

Many expert witnesses find gratification in knowing they helped a patient or a physician. As I mentioned previously, an expert-witness gig can be financially lucrative, but it is not without its drawbacks. Expert witnesses are subject to the code of ethics set forth by the medical society and state board of registration in medicine. Any sworn testimony you provide is discoverable. It is easier than you might think for others (e.g., opposition attorneys) to believe you have contradicted yourself when you give your opinion on the same subject in more than one case. As an expert witness, know that you will be cross-examined by an attorney, either in deposition or at trial. Testifying under oath can be a grueling experience.

Most expert witnesses are reputable physicians in their fields. You should feel honored for being asked to participate as an expert witness, but think carefully before you accept the offer. Understand what is being asked of you before you take on this responsibility. TH

AMANE KANEKO

Think Twice Before Accepting an Expert Witness Offer

A medical malpractice attorney recently contacted me, asking if I would be interested in reviewing a case. They are looking for a hospitalist “expert witness.” I’ve never done this before and don’t know if I’m qualified. Can you tell me about the benefits and risks of being a medical expert witness?

R. Jones, MD

Miami

Dr. Hospitalist responds: Most physicians complete medical school and postgraduate training without firsthand knowledge of our legal system. Unfortunately, a number of physicians become defendants in medical lawsuits during their professional careers. I hear with increasing frequency about hospitalists being sued for alleged medical malpractice. I am not surprised. This is not an indictment against hospital HM, but more a matter of probability. There are at least tenfold more hospitalists today than 10 years ago.

To be clear, I am not an attorney, nor do I have any formal legal training. I suggest you speak with an attorney if you have questions about the law.

Laws vary from state to state, but for the most part, plaintiff attorneys and defense attorneys retain expert witnesses to help them determine the merits of a lawsuit. Did the defendant have a duty to treat the patient? Was there a breach of the standard of care? What were the damages, and were they due to the defendant’s actions or lack of action?

Understand that our judicial system holds that a physician in the same field as the defendant is the most qualified to determine whether the defendant met the standard of care. Standard of care is what is reasonably expected of a physician in that field given the circumstances. So if the defendant is a hospitalist, the attorneys are looking for an expert witness who is also a hospitalist. Seems like a reasonable system, right? Individuals are judged by their peers. But the system is far from perfect.

Critics point out the system is inherently flawed when we rely on “experts” to help us determine the standard of care. Aside from working in a given field of medicine, there are no specific qualifications to be an expert witness. Unfortunately, not all experts are experts, and not all experts are completely honest. And there can be a lot of money at stake. Plaintiffs attorneys and defense attorneys, along with expert witnesses for both sides, stand to profit from lawsuits. All of this drives up the cost of medical malpractice premiums.

I will not tell you not to become an expert witness. Until we see real, sustainable tort reform, we have to live with the system. If I am sued, my defense attorney would seek an expert witness’s opinion. If a patient is hurt because of alleged negligence, the patient’s attorney would seek the opinion of an expert witness. So we need honest physicians to provide honest opinions as expert witnesses. This goes for defendants and plaintiffs.

Many expert witnesses find gratification in knowing they helped a patient or a physician. As I mentioned previously, an expert-witness gig can be financially lucrative, but it is not without its drawbacks. Expert witnesses are subject to the code of ethics set forth by the medical society and state board of registration in medicine. Any sworn testimony you provide is discoverable. It is easier than you might think for others (e.g., opposition attorneys) to believe you have contradicted yourself when you give your opinion on the same subject in more than one case. As an expert witness, know that you will be cross-examined by an attorney, either in deposition or at trial. Testifying under oath can be a grueling experience.

Most expert witnesses are reputable physicians in their fields. You should feel honored for being asked to participate as an expert witness, but think carefully before you accept the offer. Understand what is being asked of you before you take on this responsibility. TH

AMANE KANEKO

Think Twice Before Accepting an Expert Witness Offer

A medical malpractice attorney recently contacted me, asking if I would be interested in reviewing a case. They are looking for a hospitalist “expert witness.” I’ve never done this before and don’t know if I’m qualified. Can you tell me about the benefits and risks of being a medical expert witness?

R. Jones, MD

Miami

Dr. Hospitalist responds: Most physicians complete medical school and postgraduate training without firsthand knowledge of our legal system. Unfortunately, a number of physicians become defendants in medical lawsuits during their professional careers. I hear with increasing frequency about hospitalists being sued for alleged medical malpractice. I am not surprised. This is not an indictment against hospital HM, but more a matter of probability. There are at least tenfold more hospitalists today than 10 years ago.

To be clear, I am not an attorney, nor do I have any formal legal training. I suggest you speak with an attorney if you have questions about the law.

Laws vary from state to state, but for the most part, plaintiff attorneys and defense attorneys retain expert witnesses to help them determine the merits of a lawsuit. Did the defendant have a duty to treat the patient? Was there a breach of the standard of care? What were the damages, and were they due to the defendant’s actions or lack of action?

Understand that our judicial system holds that a physician in the same field as the defendant is the most qualified to determine whether the defendant met the standard of care. Standard of care is what is reasonably expected of a physician in that field given the circumstances. So if the defendant is a hospitalist, the attorneys are looking for an expert witness who is also a hospitalist. Seems like a reasonable system, right? Individuals are judged by their peers. But the system is far from perfect.

Critics point out the system is inherently flawed when we rely on “experts” to help us determine the standard of care. Aside from working in a given field of medicine, there are no specific qualifications to be an expert witness. Unfortunately, not all experts are experts, and not all experts are completely honest. And there can be a lot of money at stake. Plaintiffs attorneys and defense attorneys, along with expert witnesses for both sides, stand to profit from lawsuits. All of this drives up the cost of medical malpractice premiums.

I will not tell you not to become an expert witness. Until we see real, sustainable tort reform, we have to live with the system. If I am sued, my defense attorney would seek an expert witness’s opinion. If a patient is hurt because of alleged negligence, the patient’s attorney would seek the opinion of an expert witness. So we need honest physicians to provide honest opinions as expert witnesses. This goes for defendants and plaintiffs.

Many expert witnesses find gratification in knowing they helped a patient or a physician. As I mentioned previously, an expert-witness gig can be financially lucrative, but it is not without its drawbacks. Expert witnesses are subject to the code of ethics set forth by the medical society and state board of registration in medicine. Any sworn testimony you provide is discoverable. It is easier than you might think for others (e.g., opposition attorneys) to believe you have contradicted yourself when you give your opinion on the same subject in more than one case. As an expert witness, know that you will be cross-examined by an attorney, either in deposition or at trial. Testifying under oath can be a grueling experience.

Most expert witnesses are reputable physicians in their fields. You should feel honored for being asked to participate as an expert witness, but think carefully before you accept the offer. Understand what is being asked of you before you take on this responsibility. TH

At sold-out HM09 in Chicago in May, I had the pleasure of moderating a panel discussion titled “Who Says 15 Patients a Day is the Right Number?” As you might guess, each panelist (including me) said, in effect, “No one says 15 patients a day is the right number.”

Despite being a very important issue to SHM, the society doesn’t have an official position on the “right” or optimal daily patient volume or workload for a hospitalist. SHM generates and disseminates a lot of information to help each practice make decisions about workload, including SHM’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” articles available at www.hospitalmedicine.org, and articles in The Hospitalist. But all practices, and individual hospitalists, will have to decide what level of patient volume enables safe care, a sustainable and satisfying workload, and reasonable economic performance.

Workload Metrics

A problem that makes any workload discussion difficult is that many terms are sometimes used to mean different things. For example, “daily census” is used when comparing workloads between practices, but “daily encounters” is nearly always a more informative metric. Remember, daily encounters for a practice will always be higher (though on rare occasion, the same) than daily census.

The only definition of encounters that can be reliably compared between practices is billable encounters. Confusion arises when one person is reporting billable encounters, and another person is counting as one encounter each time a hospitalist interacted with a patient (e.g., went into the patient’s room or made a chart entry) and reports a higher encounter volume despite having the same workload and patient volume. Of course, billable encounters fail to perfectly describe our workloads, but until someone comes up with a better metric that is universally understood and applicable across all settings, billable encounters is the best metric we have.

Both billable encounters and census can be tricky. We might be convinced that because she averages 17 billable encounters per day, Dr. Krause has a higher workload than Dr. Palmer, who averages 15. But it turns out that Dr. Palmer works 210 shifts annually, generating 3,150 annual encounters; Dr. Krause’s 181 annual shifts generate 3,077 encounters. So while Dr. Krause does indeed work harder on the average day, she has lower annual productivity. My experience is that by failing to compare workloads over long periods, such as a year, many attempts to compare workloads yield misleading conclusions.

Comparing encounter volume from one practice to the next fails to capture other ways workloads differ. Dr. Krause may be the principal caregiver for a number of ICU patients; Dr. Plant might turn such patients over to intensivists. For this reason, work relative value units (wRVUs), which attempt to capture the complexity of each encounter, usually are a more meaningful—though still imperfect—metric.

Apples vs. Apples

Any truly valid method of comparing workloads should sum the annual workload for the entire practice and divide by the total provider full-time equivalents (FTEs). Yet problems arise because night shifts usually are less productive than day shifts. Consider a practice that has a distinct night shift worked by a doctor who does no day-shift work the day before or after. There is a tendency to leave this night shift out of the analysis of average workload per FTE, which makes the practice appear more productive than it really is.

For example, the practice I am part of has dedicated nocturnists who don’t work day shifts. So when thinking about how hard we’re working, we tend to sum each “day” doctor’s wRVUs for the year and divide by the number of day doctors. Calculated this way, our day doctors appear to be more productive than SHM data might indicate, but when including our nocturnists’ production and FTEs in the analysis, the overall workload per FTE in the practice is similar to the data.

Productivity Per FTE

While I think productivity per FTE per year is the best metric to use when comparing a practice to external survey data or comparing one practice to another, it is confounded by two sticky problems: inconsistent definitions of what constitutes an FTE, and the lack of an agreed-upon method of accounting for the contribution of nonphysician providers.

The most common definitions of what constitutes an FTE are based on the number of hours or shifts worked. One practice might define an FTE as 2,000 hours of work annually; another might use 180 annual shifts. Unless each shift has a clearly defined duration, it will be very difficult to reach conclusions. Although each practice might make sound decisions about how they define an FTE, they’re ultimately making arbitrary choices that aren’t consistent from one practice to the next. Controlling for this issue is very difficult.

Even trickier is how to compare the contributions of physician assistants (PAs) and nurse practitioners (NPs) from one practice to the next. In the above example, Dr. Plant’s practice has eight physician FTEs and four NPPs, and Dr. Krause’s group has eight MDs and no NPPs. How much more productive should we expect Dr. Plant’s practice to be? (NPPs make many valuable contributions, in addition to increasing productivity, but these are outside the scope of this article.)

Though survey data offer some clues, there is no established standard for increased productivity expected of PAs and NPs. One approach I use is to compare an NPP’s total compensation (salary and benefits) with that of the average physician FTE. If the cost of each NPP is 60% of an MD, then one could say that each NPP represents 0.6 “physician FTE equivalents” and could be expected to increase the productivity of the practice proportionately. So Dr. Plant’s group might be expected to have the productivity of 10.2 physician FTEs (4 NPPs X 0.6 = 2.2 “physician FTE equivalents,” added to the eight physician FTEs). (Note: While I think converting NPP FTEs into “physician equivalents” is useful in analyzing the effect of workloads on budgets, there are clearly many other very important issues when trying to quantify the contribution of NPPs to a practice.)

Judgment Rules

There are dozens of additional issues, such as the effect on productivity resulting from inefficient hospital systems (e.g., a clunky electronic health record, typed admit notes aren’t available for a few days compared with records available within two to four hours of dictation), activities such as attending Rapid Response Team activations, and differences in the social complexity of the patient population. None of these would show up in wRVU reports, so they are missing from the analysis I’ve described above.

I think it is impossible to control for all of the differences between practices that influence the definition of appropriate workload. This is the main reason SHM probably will never have a firm position on exactly what is the right or optimal number.

Although 15 patients a day is a reasonable starting point (I prefer to see fewer patients daily, but work more days/shifts annually), things get complicated in a hurry, and there will always be significant variation. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He also is 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.

At sold-out HM09 in Chicago in May, I had the pleasure of moderating a panel discussion titled “Who Says 15 Patients a Day is the Right Number?” As you might guess, each panelist (including me) said, in effect, “No one says 15 patients a day is the right number.”

Despite being a very important issue to SHM, the society doesn’t have an official position on the “right” or optimal daily patient volume or workload for a hospitalist. SHM generates and disseminates a lot of information to help each practice make decisions about workload, including SHM’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” articles available at www.hospitalmedicine.org, and articles in The Hospitalist. But all practices, and individual hospitalists, will have to decide what level of patient volume enables safe care, a sustainable and satisfying workload, and reasonable economic performance.

Workload Metrics

A problem that makes any workload discussion difficult is that many terms are sometimes used to mean different things. For example, “daily census” is used when comparing workloads between practices, but “daily encounters” is nearly always a more informative metric. Remember, daily encounters for a practice will always be higher (though on rare occasion, the same) than daily census.

The only definition of encounters that can be reliably compared between practices is billable encounters. Confusion arises when one person is reporting billable encounters, and another person is counting as one encounter each time a hospitalist interacted with a patient (e.g., went into the patient’s room or made a chart entry) and reports a higher encounter volume despite having the same workload and patient volume. Of course, billable encounters fail to perfectly describe our workloads, but until someone comes up with a better metric that is universally understood and applicable across all settings, billable encounters is the best metric we have.

Both billable encounters and census can be tricky. We might be convinced that because she averages 17 billable encounters per day, Dr. Krause has a higher workload than Dr. Palmer, who averages 15. But it turns out that Dr. Palmer works 210 shifts annually, generating 3,150 annual encounters; Dr. Krause’s 181 annual shifts generate 3,077 encounters. So while Dr. Krause does indeed work harder on the average day, she has lower annual productivity. My experience is that by failing to compare workloads over long periods, such as a year, many attempts to compare workloads yield misleading conclusions.

Comparing encounter volume from one practice to the next fails to capture other ways workloads differ. Dr. Krause may be the principal caregiver for a number of ICU patients; Dr. Plant might turn such patients over to intensivists. For this reason, work relative value units (wRVUs), which attempt to capture the complexity of each encounter, usually are a more meaningful—though still imperfect—metric.

Apples vs. Apples

Any truly valid method of comparing workloads should sum the annual workload for the entire practice and divide by the total provider full-time equivalents (FTEs). Yet problems arise because night shifts usually are less productive than day shifts. Consider a practice that has a distinct night shift worked by a doctor who does no day-shift work the day before or after. There is a tendency to leave this night shift out of the analysis of average workload per FTE, which makes the practice appear more productive than it really is.

For example, the practice I am part of has dedicated nocturnists who don’t work day shifts. So when thinking about how hard we’re working, we tend to sum each “day” doctor’s wRVUs for the year and divide by the number of day doctors. Calculated this way, our day doctors appear to be more productive than SHM data might indicate, but when including our nocturnists’ production and FTEs in the analysis, the overall workload per FTE in the practice is similar to the data.

Productivity Per FTE

While I think productivity per FTE per year is the best metric to use when comparing a practice to external survey data or comparing one practice to another, it is confounded by two sticky problems: inconsistent definitions of what constitutes an FTE, and the lack of an agreed-upon method of accounting for the contribution of nonphysician providers.

The most common definitions of what constitutes an FTE are based on the number of hours or shifts worked. One practice might define an FTE as 2,000 hours of work annually; another might use 180 annual shifts. Unless each shift has a clearly defined duration, it will be very difficult to reach conclusions. Although each practice might make sound decisions about how they define an FTE, they’re ultimately making arbitrary choices that aren’t consistent from one practice to the next. Controlling for this issue is very difficult.

Even trickier is how to compare the contributions of physician assistants (PAs) and nurse practitioners (NPs) from one practice to the next. In the above example, Dr. Plant’s practice has eight physician FTEs and four NPPs, and Dr. Krause’s group has eight MDs and no NPPs. How much more productive should we expect Dr. Plant’s practice to be? (NPPs make many valuable contributions, in addition to increasing productivity, but these are outside the scope of this article.)

Though survey data offer some clues, there is no established standard for increased productivity expected of PAs and NPs. One approach I use is to compare an NPP’s total compensation (salary and benefits) with that of the average physician FTE. If the cost of each NPP is 60% of an MD, then one could say that each NPP represents 0.6 “physician FTE equivalents” and could be expected to increase the productivity of the practice proportionately. So Dr. Plant’s group might be expected to have the productivity of 10.2 physician FTEs (4 NPPs X 0.6 = 2.2 “physician FTE equivalents,” added to the eight physician FTEs). (Note: While I think converting NPP FTEs into “physician equivalents” is useful in analyzing the effect of workloads on budgets, there are clearly many other very important issues when trying to quantify the contribution of NPPs to a practice.)

Judgment Rules

There are dozens of additional issues, such as the effect on productivity resulting from inefficient hospital systems (e.g., a clunky electronic health record, typed admit notes aren’t available for a few days compared with records available within two to four hours of dictation), activities such as attending Rapid Response Team activations, and differences in the social complexity of the patient population. None of these would show up in wRVU reports, so they are missing from the analysis I’ve described above.

I think it is impossible to control for all of the differences between practices that influence the definition of appropriate workload. This is the main reason SHM probably will never have a firm position on exactly what is the right or optimal number.

Although 15 patients a day is a reasonable starting point (I prefer to see fewer patients daily, but work more days/shifts annually), things get complicated in a hurry, and there will always be significant variation. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He also is 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.

At sold-out HM09 in Chicago in May, I had the pleasure of moderating a panel discussion titled “Who Says 15 Patients a Day is the Right Number?” As you might guess, each panelist (including me) said, in effect, “No one says 15 patients a day is the right number.”

Despite being a very important issue to SHM, the society doesn’t have an official position on the “right” or optimal daily patient volume or workload for a hospitalist. SHM generates and disseminates a lot of information to help each practice make decisions about workload, including SHM’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” articles available at www.hospitalmedicine.org, and articles in The Hospitalist. But all practices, and individual hospitalists, will have to decide what level of patient volume enables safe care, a sustainable and satisfying workload, and reasonable economic performance.

Workload Metrics

A problem that makes any workload discussion difficult is that many terms are sometimes used to mean different things. For example, “daily census” is used when comparing workloads between practices, but “daily encounters” is nearly always a more informative metric. Remember, daily encounters for a practice will always be higher (though on rare occasion, the same) than daily census.

The only definition of encounters that can be reliably compared between practices is billable encounters. Confusion arises when one person is reporting billable encounters, and another person is counting as one encounter each time a hospitalist interacted with a patient (e.g., went into the patient’s room or made a chart entry) and reports a higher encounter volume despite having the same workload and patient volume. Of course, billable encounters fail to perfectly describe our workloads, but until someone comes up with a better metric that is universally understood and applicable across all settings, billable encounters is the best metric we have.

Both billable encounters and census can be tricky. We might be convinced that because she averages 17 billable encounters per day, Dr. Krause has a higher workload than Dr. Palmer, who averages 15. But it turns out that Dr. Palmer works 210 shifts annually, generating 3,150 annual encounters; Dr. Krause’s 181 annual shifts generate 3,077 encounters. So while Dr. Krause does indeed work harder on the average day, she has lower annual productivity. My experience is that by failing to compare workloads over long periods, such as a year, many attempts to compare workloads yield misleading conclusions.

Comparing encounter volume from one practice to the next fails to capture other ways workloads differ. Dr. Krause may be the principal caregiver for a number of ICU patients; Dr. Plant might turn such patients over to intensivists. For this reason, work relative value units (wRVUs), which attempt to capture the complexity of each encounter, usually are a more meaningful—though still imperfect—metric.

Apples vs. Apples

Any truly valid method of comparing workloads should sum the annual workload for the entire practice and divide by the total provider full-time equivalents (FTEs). Yet problems arise because night shifts usually are less productive than day shifts. Consider a practice that has a distinct night shift worked by a doctor who does no day-shift work the day before or after. There is a tendency to leave this night shift out of the analysis of average workload per FTE, which makes the practice appear more productive than it really is.

For example, the practice I am part of has dedicated nocturnists who don’t work day shifts. So when thinking about how hard we’re working, we tend to sum each “day” doctor’s wRVUs for the year and divide by the number of day doctors. Calculated this way, our day doctors appear to be more productive than SHM data might indicate, but when including our nocturnists’ production and FTEs in the analysis, the overall workload per FTE in the practice is similar to the data.

Productivity Per FTE

While I think productivity per FTE per year is the best metric to use when comparing a practice to external survey data or comparing one practice to another, it is confounded by two sticky problems: inconsistent definitions of what constitutes an FTE, and the lack of an agreed-upon method of accounting for the contribution of nonphysician providers.

The most common definitions of what constitutes an FTE are based on the number of hours or shifts worked. One practice might define an FTE as 2,000 hours of work annually; another might use 180 annual shifts. Unless each shift has a clearly defined duration, it will be very difficult to reach conclusions. Although each practice might make sound decisions about how they define an FTE, they’re ultimately making arbitrary choices that aren’t consistent from one practice to the next. Controlling for this issue is very difficult.

Even trickier is how to compare the contributions of physician assistants (PAs) and nurse practitioners (NPs) from one practice to the next. In the above example, Dr. Plant’s practice has eight physician FTEs and four NPPs, and Dr. Krause’s group has eight MDs and no NPPs. How much more productive should we expect Dr. Plant’s practice to be? (NPPs make many valuable contributions, in addition to increasing productivity, but these are outside the scope of this article.)

Though survey data offer some clues, there is no established standard for increased productivity expected of PAs and NPs. One approach I use is to compare an NPP’s total compensation (salary and benefits) with that of the average physician FTE. If the cost of each NPP is 60% of an MD, then one could say that each NPP represents 0.6 “physician FTE equivalents” and could be expected to increase the productivity of the practice proportionately. So Dr. Plant’s group might be expected to have the productivity of 10.2 physician FTEs (4 NPPs X 0.6 = 2.2 “physician FTE equivalents,” added to the eight physician FTEs). (Note: While I think converting NPP FTEs into “physician equivalents” is useful in analyzing the effect of workloads on budgets, there are clearly many other very important issues when trying to quantify the contribution of NPPs to a practice.)

Judgment Rules

There are dozens of additional issues, such as the effect on productivity resulting from inefficient hospital systems (e.g., a clunky electronic health record, typed admit notes aren’t available for a few days compared with records available within two to four hours of dictation), activities such as attending Rapid Response Team activations, and differences in the social complexity of the patient population. None of these would show up in wRVU reports, so they are missing from the analysis I’ve described above.

I think it is impossible to control for all of the differences between practices that influence the definition of appropriate workload. This is the main reason SHM probably will never have a firm position on exactly what is the right or optimal number.

Although 15 patients a day is a reasonable starting point (I prefer to see fewer patients daily, but work more days/shifts annually), things get complicated in a hurry, and there will always be significant variation. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He also is 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.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

Lying in bed, I’m jarred by what can only be an anvil dropping heavily upon my chest. Wakefulness reveals a more canine, cranium-like object. Staring deep into cataract-smudged eyes, I ponder the question that has occupied my mind for nearly two weeks: What would Hogan want?

My Dog Has Cancer

More accurately, he has a tumor—or, I guess, what appears to be a tumor on his chest X-ray. It was discovered, incidentally, on a liver ultrasound that was being done for abnormal liver function test results. That study revealed nothing wrong with his liver, but led to a follow-up radiograph showing a 4.9-cm, right-lower-lobe lung mass. Also uncovered in this process was a tangle of complex emotions, turmoil, and uncertainty surrounding my first personal foray into end-of-life decision-making.

Hogan, my now-presumed-cancer-ridden, 10-year-old Weimaraner, came into my life permanently when he was all of 8 weeks old. I first met him during a visit to the breeder when his litter was only three days old. Over the successive weeks, I visited him often, anxious for the day I’d be able to take my new companion home.

I picked up Hogan on Fourth of July weekend during my chief year of residency—sort of a gift for completing my grueling training. He was the first dog I raised, trained, and cared for by myself. And while we had our share of eaten walls, destroyed comforters, and chewed bits of Jeep Cherokee, this was no “Marley & Me” relationship. We were more like roommates, best friends. We hiked, camped, and went everywhere together—either an idyllic boy-and-his-dog relationship or a sad, pitifully lonely, soul-in-need-of-a-girlfriend existence, depending on your point of view, I suppose.

In the end, the two viewpoints melded as Hogan eventually brought my wife and I together, a story that shall not be printed in these pages.

Through the years, Hogan bore witness to many personal and family milestones. My chief residency, my first grand rounds (his constant audience during my preparation brought him unparalleled expertise in canine zoonoses), my first house, our marriage, a horribly flailing attempt to recapture the magic of my first dog through a second Weim named Grady (definitely “Marley & Me” mixed with a healthy dose of “Dumb & Dumber”), and the birth of our first child.

It was during this time that Hogan began a long journey toward today. He became a little long in the tooth, droopy in the belly, and slow on the trail. His limitless energy and boundless passion for chasing tennis balls gave way to such leisurely pursuits as park pooping and command disobedience. His fluid, sinew-laced limbs became arthritic shells of their former selves, betraying the youthful grace that still echoed inside of him. I distinctly recall the first time Grady beat him to a tennis ball, a moment that clearly represented a passing of the baton—a crestfallen 6-year-old canine eclipsed by the 2-year-old whippersnapper. The youngster sprinted back, bursting with a mouthful of tennis ball and pride. The elder took a decidedly more tortuous and tortured route back—a carriage of nonchalance that failed in its attempt to convey the message that “chasing tennis balls is stupid.”

On the advice of our veterinarian, we stopped throwing Frisbees at Hogan at age 8, out of concern that an awkward jump might result in a paralytic shift in his progressively stenosing spine. While Hogan is otherwise healthy, his hips and forepaws are riddled with osteoarthritis, his eyes carry the cottony haze of cataracts, and his abdomen and skin are home to lumpy lipomas. So, on the advent of his 10th birthday, we are asked to decide how many resources, how much physical distress, how much intervention we afford to an older, sleep-most-of-the-day arthritic dog.

This scenario is complicated by the idiosyncrasies and mores of veterinary medicine. Unlike human medicine, which is replete with tomes of data steeped in decades of experience, our veterinarian counterparts often are left with gaping treatment holes and inadequately studied interventions. This is not a knock against the profession. In fact, I have had nothing short of fantastic experiences with the veterinary professionals with whom I’ve interacted. Rather, there just aren’t prospective, randomized, controlled trials to inform whether intervention will enhance Hogan’s quantity and quality of life.

Then there are the economic realities of the situation. As one who has rarely been ill and always been insured, I was staggered by the cost of medicine for the uninsured. Two-hundred-dollar antibiotics, $500 ultrasounds, $1,500 CT scans, and up to $10,000 operative and surgical ICU stays would have invoked, “you’re joking, right?” exclamations from me prior to this experience. Now they are just another variable that complicates this already emotionally complex discussion—the variable that makes you feel hollow inside for considering it, foolhardy for not.

Questions Abound

What price would I pay to have another few years with my best friend? What if it’s only a year, six months? Would the money be better spent funding my child’s 529 account? What if this is a benign process and intervention is for naught? What if this tumor is metastatic and intervention is futile? Should we spend the extra money on an upfront staging CT scan that has much lower sensitivity than those we routinely utilize?

If we intervene, should we attempt a costly, CT-guided biopsy to rule in malignant disease, or go straight to lobectomy? What if the surgery negatively alters his quality of life? What if he dies on the table? What do I know about the surgical outcomes of the two centers I’m considering? Should we attempt an open or laparoscopic approach to this tumor?

Can we achieve a cure? If we do, what does that mean for a dog in the twilight years of his life? Should we just let the disease progress to its natural endpoint?

What Would Hogan Want?

These are the questions that haunt me. As I stare into Hogan’s eyes, a portal to my companion’s soul, I am tormented by the cauldron of emotions, the indecision bred by incomplete information and the guilt that comes from knowing that Hogan unconditionally trusts that I will do what is right for him.

Will I? My eyes continue to ask Hogan what he would want until finally the answer becomes obvious.

Hogan wants his breakfast. TH

Dr. Glasheen is associate professor of medicine and director of the hospital medicine group and hospitalist training program at the University of Colorado at Denver.

SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.

All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.

One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.

SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.

With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.

One Tent, Many Spikes in the Ground

The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.

As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.

So, is this worrisome? Quite the contrary. I believe it is healthy.

Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.

We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.

Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.

As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.

One Voice, One Goal

But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.

Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.

In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.

As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.

SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH

Dr. Flanders is president of SHM.

SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.

All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.

One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.

SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.

With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.

One Tent, Many Spikes in the Ground

The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.

As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.

So, is this worrisome? Quite the contrary. I believe it is healthy.

Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.

We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.

Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.

As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.

One Voice, One Goal

But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.

Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.

In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.

As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.

SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH

Dr. Flanders is president of SHM.

SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.

All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.

One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.

SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.

With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.

One Tent, Many Spikes in the Ground

The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.

As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.

So, is this worrisome? Quite the contrary. I believe it is healthy.

Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.

We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.

Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.

As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.

One Voice, One Goal

But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.

Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.

In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.

As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.

SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH

Dr. Flanders is president of SHM.