Jason Stein, MD, knows he could walk into almost any nursing unit in any hospital in the country, ask a simple question, and get blank stares in return.

“I would ask, ‘Which patients here in the nursing unit don’t have an order for VTE prophylaxis?’ ” says Dr. Stein, associate director for quality improvement and assistant professor of medicine at Emory University School of Medicine in Atlanta. “And they would tell me, ‘What kind of place do you think this is? How can we possibly know that?’ ”

It’s not idle chat. Venous thromboembolism (VTE) is a condition known throughout HM for three things: It runs rampant in hospitals; it can be deadly; and it’s easily preventable.

This month, SHM—along with dozens of other healthcare organizations, including the Agency for Healthcare Research Quality (AHRQ)—is highlighting the dangers of VTE and deep vein thrombosis (DVT), and promoting best practices to prevent them.

“SHM’s leadership of awareness efforts and championing VTE [prevention] has played an important role in keeping this on everybody’s mind,” Dr. Stein says.

VTE: A Hospital-Based Epidemic

Although it is easy to target at-risk populations and prevent it, VTE is widespread and dangerous.

“By published estimates, each year VTE kills more people than HIV, car accidents, and breast cancer combined,” says Gregory A. Maynard, MD, Ms, chief of the division of hospital medicine and clinical professor of medicine at the University of California at San Diego.

The risk of VTE in hospital patients should give hospitalists and their colleagues pause. Here’s why:

• According to the American Heart Association, more than 200,000 cases of VTE are reported each year, and VTE occurs for the first time in approximately 100 out of every 100,000 persons each year;
• Research published last year in The Lancet estimates 52% of hospitalized patients are at risk for VTE;
• 1 in 3 VTE patients experiences a pulmonary embolism;
• 30% of new VTE patients die within three days;
• 20% of new VTE patients die suddenly from pulmonary embolus; and
• DVT is responsible for approximately 8,000 hospital discharges every year. Pulmonary embolism accounts for nearly 100,000.

Risk Factors and Prevention

In a hospital setting, VTE risk factors are especially straightforward to monitor and prevent, but Dr. Maynard sees room for improvement.

“We don’t need to do better things; we need to do things better,” he told colleagues at a recent grand rounds. “Pharmacologic prophylaxis is the preferred way to prevent VTE in the hospital, which can reduce DVT and pulmonary embolism by 50% to 65%.”

Most hospital patients have at least one of these VTE risk factors, which are sorted into three categories:

• Stasis: conditions such as advanced age, immobility, paralysis, or stroke;
• Hypercoaguability: smoking, pregnancy, cancer, or sepsis; and
• Endothelial damage: surgery, prior VTE, central lines, or trauma.

Because the potential VTE risk is so high in hospital patients, the assessment must go hand in hand with prophylaxis, says Dr. Maynard and other hospitalists working with VTE.

Recent research has shown that prescribing medications to prevent VTE before it begins is safe, effective, and cost-effective.

The Hospitalist’s Role

Ray Grover/Alamy

The responsibility for VTE risk assessment and prevention often falls to hospitalists. In its online VTE Resource Room, SHM provides information for hospitalists working to assess and prevent VTE in their patients. It also provides a complete toolkit for hospitalists interested in addressing VTE prevention systematically throughout their hospitals. The toolkit is part of a comprehensive VTE Prevention Collaborative, which provides real-world mentoring and materials to hospitalists as they develop VTE monitoring and prevention programs.

“In 2005, when SHM set up the Quality Improvement resource room, we began with VTE prophylaxis,” Dr. Stein says. “VTE is the No. 1 cause of preventable death in hospitals, and preventing it is a fundamentally simple thing for hospitalists to do. We’re trying to get physicians to order a shot in the abdomen once a day. … If we can’t do that, we’re in trouble. On the flipside, if we can figure that out, we can derive mechanisms that we can apply to more complex problems in care.”

Together with SHM, Drs. Stein and Maynard have pioneered a two-pronged approach known as “measure-vention.” The underlying principal of measure-vention is that monitoring for VTE risk in real time can empower hospital staff to remedy issues in real time. In most hospitals, VTE risk can only be measured retrospectively through quality improvement data, which can take months to collect.

SHM and Dr. Stein have implemented an information technology approach at five of Emory’s hospitals. Each facility assesses patients who don’t have VTE prophylaxis every hour. The data is distributed to nursing stations, where nurses and other providers can apply VTE interventions within minutes. The program has driven Emory’s VTE prophylaxis rates to more than 90%, and Dr. Stein is working to make the program exportable to other hospitals, with the help of funding and assistance from SHM.

“As the leader of the VTE prevention program at Emory hospitals, I hear lots of stories about preventable VTE—not just about patients, but from friends of friends and family members,” he says. “It’s extraordinary.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Jason Stein, MD, knows he could walk into almost any nursing unit in any hospital in the country, ask a simple question, and get blank stares in return.

“I would ask, ‘Which patients here in the nursing unit don’t have an order for VTE prophylaxis?’ ” says Dr. Stein, associate director for quality improvement and assistant professor of medicine at Emory University School of Medicine in Atlanta. “And they would tell me, ‘What kind of place do you think this is? How can we possibly know that?’ ”

It’s not idle chat. Venous thromboembolism (VTE) is a condition known throughout HM for three things: It runs rampant in hospitals; it can be deadly; and it’s easily preventable.

This month, SHM—along with dozens of other healthcare organizations, including the Agency for Healthcare Research Quality (AHRQ)—is highlighting the dangers of VTE and deep vein thrombosis (DVT), and promoting best practices to prevent them.

“SHM’s leadership of awareness efforts and championing VTE [prevention] has played an important role in keeping this on everybody’s mind,” Dr. Stein says.

VTE: A Hospital-Based Epidemic

Although it is easy to target at-risk populations and prevent it, VTE is widespread and dangerous.

“By published estimates, each year VTE kills more people than HIV, car accidents, and breast cancer combined,” says Gregory A. Maynard, MD, Ms, chief of the division of hospital medicine and clinical professor of medicine at the University of California at San Diego.

The risk of VTE in hospital patients should give hospitalists and their colleagues pause. Here’s why:

• According to the American Heart Association, more than 200,000 cases of VTE are reported each year, and VTE occurs for the first time in approximately 100 out of every 100,000 persons each year;
• Research published last year in The Lancet estimates 52% of hospitalized patients are at risk for VTE;
• 1 in 3 VTE patients experiences a pulmonary embolism;
• 30% of new VTE patients die within three days;
• 20% of new VTE patients die suddenly from pulmonary embolus; and
• DVT is responsible for approximately 8,000 hospital discharges every year. Pulmonary embolism accounts for nearly 100,000.

Risk Factors and Prevention

In a hospital setting, VTE risk factors are especially straightforward to monitor and prevent, but Dr. Maynard sees room for improvement.

“We don’t need to do better things; we need to do things better,” he told colleagues at a recent grand rounds. “Pharmacologic prophylaxis is the preferred way to prevent VTE in the hospital, which can reduce DVT and pulmonary embolism by 50% to 65%.”

Most hospital patients have at least one of these VTE risk factors, which are sorted into three categories:

• Stasis: conditions such as advanced age, immobility, paralysis, or stroke;
• Hypercoaguability: smoking, pregnancy, cancer, or sepsis; and
• Endothelial damage: surgery, prior VTE, central lines, or trauma.

Because the potential VTE risk is so high in hospital patients, the assessment must go hand in hand with prophylaxis, says Dr. Maynard and other hospitalists working with VTE.

Recent research has shown that prescribing medications to prevent VTE before it begins is safe, effective, and cost-effective.

The Hospitalist’s Role

Ray Grover/Alamy

The responsibility for VTE risk assessment and prevention often falls to hospitalists. In its online VTE Resource Room, SHM provides information for hospitalists working to assess and prevent VTE in their patients. It also provides a complete toolkit for hospitalists interested in addressing VTE prevention systematically throughout their hospitals. The toolkit is part of a comprehensive VTE Prevention Collaborative, which provides real-world mentoring and materials to hospitalists as they develop VTE monitoring and prevention programs.

“In 2005, when SHM set up the Quality Improvement resource room, we began with VTE prophylaxis,” Dr. Stein says. “VTE is the No. 1 cause of preventable death in hospitals, and preventing it is a fundamentally simple thing for hospitalists to do. We’re trying to get physicians to order a shot in the abdomen once a day. … If we can’t do that, we’re in trouble. On the flipside, if we can figure that out, we can derive mechanisms that we can apply to more complex problems in care.”

Together with SHM, Drs. Stein and Maynard have pioneered a two-pronged approach known as “measure-vention.” The underlying principal of measure-vention is that monitoring for VTE risk in real time can empower hospital staff to remedy issues in real time. In most hospitals, VTE risk can only be measured retrospectively through quality improvement data, which can take months to collect.

SHM and Dr. Stein have implemented an information technology approach at five of Emory’s hospitals. Each facility assesses patients who don’t have VTE prophylaxis every hour. The data is distributed to nursing stations, where nurses and other providers can apply VTE interventions within minutes. The program has driven Emory’s VTE prophylaxis rates to more than 90%, and Dr. Stein is working to make the program exportable to other hospitals, with the help of funding and assistance from SHM.

“As the leader of the VTE prevention program at Emory hospitals, I hear lots of stories about preventable VTE—not just about patients, but from friends of friends and family members,” he says. “It’s extraordinary.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Jason Stein, MD, knows he could walk into almost any nursing unit in any hospital in the country, ask a simple question, and get blank stares in return.

“I would ask, ‘Which patients here in the nursing unit don’t have an order for VTE prophylaxis?’ ” says Dr. Stein, associate director for quality improvement and assistant professor of medicine at Emory University School of Medicine in Atlanta. “And they would tell me, ‘What kind of place do you think this is? How can we possibly know that?’ ”

It’s not idle chat. Venous thromboembolism (VTE) is a condition known throughout HM for three things: It runs rampant in hospitals; it can be deadly; and it’s easily preventable.

This month, SHM—along with dozens of other healthcare organizations, including the Agency for Healthcare Research Quality (AHRQ)—is highlighting the dangers of VTE and deep vein thrombosis (DVT), and promoting best practices to prevent them.

“SHM’s leadership of awareness efforts and championing VTE [prevention] has played an important role in keeping this on everybody’s mind,” Dr. Stein says.

VTE: A Hospital-Based Epidemic

Although it is easy to target at-risk populations and prevent it, VTE is widespread and dangerous.

“By published estimates, each year VTE kills more people than HIV, car accidents, and breast cancer combined,” says Gregory A. Maynard, MD, Ms, chief of the division of hospital medicine and clinical professor of medicine at the University of California at San Diego.

The risk of VTE in hospital patients should give hospitalists and their colleagues pause. Here’s why:

• According to the American Heart Association, more than 200,000 cases of VTE are reported each year, and VTE occurs for the first time in approximately 100 out of every 100,000 persons each year;
• Research published last year in The Lancet estimates 52% of hospitalized patients are at risk for VTE;
• 1 in 3 VTE patients experiences a pulmonary embolism;
• 30% of new VTE patients die within three days;
• 20% of new VTE patients die suddenly from pulmonary embolus; and
• DVT is responsible for approximately 8,000 hospital discharges every year. Pulmonary embolism accounts for nearly 100,000.

Risk Factors and Prevention

In a hospital setting, VTE risk factors are especially straightforward to monitor and prevent, but Dr. Maynard sees room for improvement.

“We don’t need to do better things; we need to do things better,” he told colleagues at a recent grand rounds. “Pharmacologic prophylaxis is the preferred way to prevent VTE in the hospital, which can reduce DVT and pulmonary embolism by 50% to 65%.”

Most hospital patients have at least one of these VTE risk factors, which are sorted into three categories:

• Stasis: conditions such as advanced age, immobility, paralysis, or stroke;
• Hypercoaguability: smoking, pregnancy, cancer, or sepsis; and
• Endothelial damage: surgery, prior VTE, central lines, or trauma.

Because the potential VTE risk is so high in hospital patients, the assessment must go hand in hand with prophylaxis, says Dr. Maynard and other hospitalists working with VTE.

Recent research has shown that prescribing medications to prevent VTE before it begins is safe, effective, and cost-effective.

The Hospitalist’s Role

Ray Grover/Alamy

The responsibility for VTE risk assessment and prevention often falls to hospitalists. In its online VTE Resource Room, SHM provides information for hospitalists working to assess and prevent VTE in their patients. It also provides a complete toolkit for hospitalists interested in addressing VTE prevention systematically throughout their hospitals. The toolkit is part of a comprehensive VTE Prevention Collaborative, which provides real-world mentoring and materials to hospitalists as they develop VTE monitoring and prevention programs.

“In 2005, when SHM set up the Quality Improvement resource room, we began with VTE prophylaxis,” Dr. Stein says. “VTE is the No. 1 cause of preventable death in hospitals, and preventing it is a fundamentally simple thing for hospitalists to do. We’re trying to get physicians to order a shot in the abdomen once a day. … If we can’t do that, we’re in trouble. On the flipside, if we can figure that out, we can derive mechanisms that we can apply to more complex problems in care.”

Together with SHM, Drs. Stein and Maynard have pioneered a two-pronged approach known as “measure-vention.” The underlying principal of measure-vention is that monitoring for VTE risk in real time can empower hospital staff to remedy issues in real time. In most hospitals, VTE risk can only be measured retrospectively through quality improvement data, which can take months to collect.

SHM and Dr. Stein have implemented an information technology approach at five of Emory’s hospitals. Each facility assesses patients who don’t have VTE prophylaxis every hour. The data is distributed to nursing stations, where nurses and other providers can apply VTE interventions within minutes. The program has driven Emory’s VTE prophylaxis rates to more than 90%, and Dr. Stein is working to make the program exportable to other hospitals, with the help of funding and assistance from SHM.

“As the leader of the VTE prevention program at Emory hospitals, I hear lots of stories about preventable VTE—not just about patients, but from friends of friends and family members,” he says. “It’s extraordinary.” TH

Brendon Shank is a freelance writer based in Philadelphia.

Wouldn’t you know it? The same day the February issue of The Hospitalist was being shipped to the post office, former Sen. Tom Daschle—President Obama’s “chosen one” to spearhead healthcare reform— surprised us all. Embroiled in a tax and ethics scandal, Daschle up and withdrew his nomination for secretary of the Department of Health and Human Services (HHS). Considering our February cover story outlines Obama and Daschle’s plan for comprehensive healthcare reform—and the magazine cover has a nice picture of Obama with Daschle in the background—the timing couldn’t have been … better.

In publishing circles, it’s one of those slow-motion moments. You know, the kind of moment sitcoms rewind and show from three different angles. Do they really think we need to see Cosmo Kramer trip and fall three times? I got it.

It’s not as if we declared Thomas Dewey the next president of the United States. If nothing else, consider the February issue a collector’s item. Once I’m done writing this column, I’m going to FedEx a box of February issues to Daschle’s office. I hope he hangs one on the wall—a reminder of how close he came to history.

The fact of the matter is, I’m guessing Daschle’s departure will do little to slow Obama’s push for healthcare reform. Case in point: The day after Daschle withdrew his nomination, the House of Representatives approved legislation to provide federally funded healthcare to 4 million more Americans by expanding the State Children’s Health Insurance Program, or SCHIP (see “2009: A Pivotal Year for Policy,” p. 14). The president’s first healthcare reform legislation passed Congress by a pair of two-thirds votes and will inject $35 billion into the program over the next five years. More importantly, the fact that the legislation was signed into law on Day 15 of the new administration signals Obama’s commitment to comprehensive healthcare reform.

Most in the HM community fully support the president on the idea that it’s time to change the way healthcare is delivered, revamp the way providers are paid for their services, and eliminate the term “uninsured.” Unfortunately, the president’s tidal wave of support for healthcare reform is being chipped away by a wayward economy and missteps in the confirmation process. A similar message was conveyed during a policy report to SHM’s board of directors in late January in Washington, D.C. Key HM issues, such as bundling and coordination of care, appear to be on the traditional route within the legislative process. Translation: a slower one rife with political obstacles.

At press time, Obama had not put forth a new HHS nominee. Some names thrown into the ring: Jeanne Lambrew, PhD, a deputy health adviser to Obama and Daschle’s former right hand; Rep. Rosa DeLauro (D-Conn.); and Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. And a possibility from the other side of the aisle: Mitt Romney, former Massachusetts governor and presidential candidate. (OK, the Romney mention is a shout-out to the blogosphere. Massachusetts physicians would lay siege to the White House if Romney were nominated.)

Pundits are calling for an individual with many of Daschle’s key attributes: expertise in the healthcare system, knowledge of the inner workings of Washington, and confluence—not to mention influence—with the president in healthcare issues. From the looks of things—and knowing that Daschle’s place in the Obama cabinet was considered a slam dunk—the president will have the unenviable task of replacing the person he thought was most capable of being the “lead architect” to implement “our healthcare plan,” as he said in the Dec. 11 news conference introducing Daschle as his HHS nominee.

Although the task is great and the process delayed, it’s unlikely the healthcare debate is going to slide to the back burner. Although healthcare reform ideology spans the full spectrum—politically, philosophically, and economically—the healthcare debate is alive and kicking in this new administration.

We’ll just have to make sure the next HHS leader is confirmed before The Hospitalist shines the spotlight on them. TH

Jason Carris is editor of The Hospitalist.

Wouldn’t you know it? The same day the February issue of The Hospitalist was being shipped to the post office, former Sen. Tom Daschle—President Obama’s “chosen one” to spearhead healthcare reform— surprised us all. Embroiled in a tax and ethics scandal, Daschle up and withdrew his nomination for secretary of the Department of Health and Human Services (HHS). Considering our February cover story outlines Obama and Daschle’s plan for comprehensive healthcare reform—and the magazine cover has a nice picture of Obama with Daschle in the background—the timing couldn’t have been … better.

In publishing circles, it’s one of those slow-motion moments. You know, the kind of moment sitcoms rewind and show from three different angles. Do they really think we need to see Cosmo Kramer trip and fall three times? I got it.

It’s not as if we declared Thomas Dewey the next president of the United States. If nothing else, consider the February issue a collector’s item. Once I’m done writing this column, I’m going to FedEx a box of February issues to Daschle’s office. I hope he hangs one on the wall—a reminder of how close he came to history.

The fact of the matter is, I’m guessing Daschle’s departure will do little to slow Obama’s push for healthcare reform. Case in point: The day after Daschle withdrew his nomination, the House of Representatives approved legislation to provide federally funded healthcare to 4 million more Americans by expanding the State Children’s Health Insurance Program, or SCHIP (see “2009: A Pivotal Year for Policy,” p. 14). The president’s first healthcare reform legislation passed Congress by a pair of two-thirds votes and will inject $35 billion into the program over the next five years. More importantly, the fact that the legislation was signed into law on Day 15 of the new administration signals Obama’s commitment to comprehensive healthcare reform.

Most in the HM community fully support the president on the idea that it’s time to change the way healthcare is delivered, revamp the way providers are paid for their services, and eliminate the term “uninsured.” Unfortunately, the president’s tidal wave of support for healthcare reform is being chipped away by a wayward economy and missteps in the confirmation process. A similar message was conveyed during a policy report to SHM’s board of directors in late January in Washington, D.C. Key HM issues, such as bundling and coordination of care, appear to be on the traditional route within the legislative process. Translation: a slower one rife with political obstacles.

At press time, Obama had not put forth a new HHS nominee. Some names thrown into the ring: Jeanne Lambrew, PhD, a deputy health adviser to Obama and Daschle’s former right hand; Rep. Rosa DeLauro (D-Conn.); and Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. And a possibility from the other side of the aisle: Mitt Romney, former Massachusetts governor and presidential candidate. (OK, the Romney mention is a shout-out to the blogosphere. Massachusetts physicians would lay siege to the White House if Romney were nominated.)

Pundits are calling for an individual with many of Daschle’s key attributes: expertise in the healthcare system, knowledge of the inner workings of Washington, and confluence—not to mention influence—with the president in healthcare issues. From the looks of things—and knowing that Daschle’s place in the Obama cabinet was considered a slam dunk—the president will have the unenviable task of replacing the person he thought was most capable of being the “lead architect” to implement “our healthcare plan,” as he said in the Dec. 11 news conference introducing Daschle as his HHS nominee.

Although the task is great and the process delayed, it’s unlikely the healthcare debate is going to slide to the back burner. Although healthcare reform ideology spans the full spectrum—politically, philosophically, and economically—the healthcare debate is alive and kicking in this new administration.

We’ll just have to make sure the next HHS leader is confirmed before The Hospitalist shines the spotlight on them. TH

Jason Carris is editor of The Hospitalist.

Wouldn’t you know it? The same day the February issue of The Hospitalist was being shipped to the post office, former Sen. Tom Daschle—President Obama’s “chosen one” to spearhead healthcare reform— surprised us all. Embroiled in a tax and ethics scandal, Daschle up and withdrew his nomination for secretary of the Department of Health and Human Services (HHS). Considering our February cover story outlines Obama and Daschle’s plan for comprehensive healthcare reform—and the magazine cover has a nice picture of Obama with Daschle in the background—the timing couldn’t have been … better.

In publishing circles, it’s one of those slow-motion moments. You know, the kind of moment sitcoms rewind and show from three different angles. Do they really think we need to see Cosmo Kramer trip and fall three times? I got it.

It’s not as if we declared Thomas Dewey the next president of the United States. If nothing else, consider the February issue a collector’s item. Once I’m done writing this column, I’m going to FedEx a box of February issues to Daschle’s office. I hope he hangs one on the wall—a reminder of how close he came to history.

The fact of the matter is, I’m guessing Daschle’s departure will do little to slow Obama’s push for healthcare reform. Case in point: The day after Daschle withdrew his nomination, the House of Representatives approved legislation to provide federally funded healthcare to 4 million more Americans by expanding the State Children’s Health Insurance Program, or SCHIP (see “2009: A Pivotal Year for Policy,” p. 14). The president’s first healthcare reform legislation passed Congress by a pair of two-thirds votes and will inject $35 billion into the program over the next five years. More importantly, the fact that the legislation was signed into law on Day 15 of the new administration signals Obama’s commitment to comprehensive healthcare reform.

Most in the HM community fully support the president on the idea that it’s time to change the way healthcare is delivered, revamp the way providers are paid for their services, and eliminate the term “uninsured.” Unfortunately, the president’s tidal wave of support for healthcare reform is being chipped away by a wayward economy and missteps in the confirmation process. A similar message was conveyed during a policy report to SHM’s board of directors in late January in Washington, D.C. Key HM issues, such as bundling and coordination of care, appear to be on the traditional route within the legislative process. Translation: a slower one rife with political obstacles.

At press time, Obama had not put forth a new HHS nominee. Some names thrown into the ring: Jeanne Lambrew, PhD, a deputy health adviser to Obama and Daschle’s former right hand; Rep. Rosa DeLauro (D-Conn.); and Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee. And a possibility from the other side of the aisle: Mitt Romney, former Massachusetts governor and presidential candidate. (OK, the Romney mention is a shout-out to the blogosphere. Massachusetts physicians would lay siege to the White House if Romney were nominated.)

Pundits are calling for an individual with many of Daschle’s key attributes: expertise in the healthcare system, knowledge of the inner workings of Washington, and confluence—not to mention influence—with the president in healthcare issues. From the looks of things—and knowing that Daschle’s place in the Obama cabinet was considered a slam dunk—the president will have the unenviable task of replacing the person he thought was most capable of being the “lead architect” to implement “our healthcare plan,” as he said in the Dec. 11 news conference introducing Daschle as his HHS nominee.

Although the task is great and the process delayed, it’s unlikely the healthcare debate is going to slide to the back burner. Although healthcare reform ideology spans the full spectrum—politically, philosophically, and economically—the healthcare debate is alive and kicking in this new administration.

We’ll just have to make sure the next HHS leader is confirmed before The Hospitalist shines the spotlight on them. TH

Jason Carris is editor of The Hospitalist.

Jeff Dichter, MD, admits he’s not the typical 21st-century hospitalist. He isn’t in his 30s anymore and he isn’t practicing HM full time anymore. He is, however, one of the original 300 SHM members. And after 10 years as a hospitalist, building an HM program of his own, and serving five years on SHM’s Board of Directors, Dr. Dichter is among more than 500 hospitalists in the inaugural Fellow in Hospital Medicine (FHM) class (Download the complete list as a PDF). The designation is for physicians who have devoted their career to HM and whose personal and professional activities embody both the mission and goals of SHM and the medical profession.

“The society and the profession have grown beyond my wildest expectations,” says Dr. Dichter, former SHM president and medical director of cardiovascular intensive care at Regions Hospital in Saint Paul, Minn. “I am thrilled, and continue to be thrilled, at the growth. For me, personally, I am greatly honored.”

Jenn Myers, MD, agrees the honor is especially gratifying. Dr. Myers chose a hospitalist career in 2002 after finishing her residency at Johns Hopkins in Baltimore. Now an assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, she says the FHM designation is both “important and exciting.”

“I think I have a focused practice in HM that is different from most of my general IM colleagues,” she says. “It’s good to have that practice recognized on a national level. … It’s also good to be part of anything inaugural.”

The first class will be inducted at HM09 next month in Chicago. Selection criteria included a minimum of five years as a practicing hospitalist, no history of professional disciplinary action, and letters of recommendation from SHM peers.

Jeff Dichter, MD, admits he’s not the typical 21st-century hospitalist. He isn’t in his 30s anymore and he isn’t practicing HM full time anymore. He is, however, one of the original 300 SHM members. And after 10 years as a hospitalist, building an HM program of his own, and serving five years on SHM’s Board of Directors, Dr. Dichter is among more than 500 hospitalists in the inaugural Fellow in Hospital Medicine (FHM) class (Download the complete list as a PDF). The designation is for physicians who have devoted their career to HM and whose personal and professional activities embody both the mission and goals of SHM and the medical profession.

“The society and the profession have grown beyond my wildest expectations,” says Dr. Dichter, former SHM president and medical director of cardiovascular intensive care at Regions Hospital in Saint Paul, Minn. “I am thrilled, and continue to be thrilled, at the growth. For me, personally, I am greatly honored.”

Jenn Myers, MD, agrees the honor is especially gratifying. Dr. Myers chose a hospitalist career in 2002 after finishing her residency at Johns Hopkins in Baltimore. Now an assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, she says the FHM designation is both “important and exciting.”

“I think I have a focused practice in HM that is different from most of my general IM colleagues,” she says. “It’s good to have that practice recognized on a national level. … It’s also good to be part of anything inaugural.”

The first class will be inducted at HM09 next month in Chicago. Selection criteria included a minimum of five years as a practicing hospitalist, no history of professional disciplinary action, and letters of recommendation from SHM peers.

Jeff Dichter, MD, admits he’s not the typical 21st-century hospitalist. He isn’t in his 30s anymore and he isn’t practicing HM full time anymore. He is, however, one of the original 300 SHM members. And after 10 years as a hospitalist, building an HM program of his own, and serving five years on SHM’s Board of Directors, Dr. Dichter is among more than 500 hospitalists in the inaugural Fellow in Hospital Medicine (FHM) class (Download the complete list as a PDF). The designation is for physicians who have devoted their career to HM and whose personal and professional activities embody both the mission and goals of SHM and the medical profession.

“The society and the profession have grown beyond my wildest expectations,” says Dr. Dichter, former SHM president and medical director of cardiovascular intensive care at Regions Hospital in Saint Paul, Minn. “I am thrilled, and continue to be thrilled, at the growth. For me, personally, I am greatly honored.”

Jenn Myers, MD, agrees the honor is especially gratifying. Dr. Myers chose a hospitalist career in 2002 after finishing her residency at Johns Hopkins in Baltimore. Now an assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, she says the FHM designation is both “important and exciting.”

“I think I have a focused practice in HM that is different from most of my general IM colleagues,” she says. “It’s good to have that practice recognized on a national level. … It’s also good to be part of anything inaugural.”

The first class will be inducted at HM09 next month in Chicago. Selection criteria included a minimum of five years as a practicing hospitalist, no history of professional disciplinary action, and letters of recommendation from SHM peers.

“The issue for hospitalists really isn’t different from anybody else,” says Erin A. Egan, MD, JD, a hospitalist at the University of Colorado at Denver and chair of SHM’s Ethics Committee. “If you can claim something quantifiable, you better be able to back it up. If you claim something qualitative, essentially you’re offering an opinion, and opinions don’t have to be based in fact.”

Virtua Health in Voorhees, N.J., and Cooper Health System, based in Camden, N.J., have been engaged in a legal battle since February. Virtua’s advertising claims the hospital has the most “Top Docs” in the region. After Cooper launched a legal challenge to the validity of the claim, a state judge ruled that Virtua could continue to say it had the most “Top Docs,” a claim based on a compilation of rankings from four regional magazines. The judge did, however, rule that Virtua had to withdraw wording from advertising that claimed the findings were made by an "independent" source, as Virtua had hired a group to compile the rankings. The judge also told Virtua to remove Web links to sites that explained how the figures were tallied. A federal case is pending.

Dr. Egan notes that few HM advertising tiffs result in similar legal claims unless they involve fraud. She adds that such battles often are costly and fruitless. For this reason, she urges advertisers to ensure their promotions are legally defensible. She offers these tips for any HM group when creating a marketing campaign:

• Use subjective language for subjective claims;
• Make sure you can back up all factual claims; and
• Think about the response you will give if you are challenged.

“The issue for hospitalists really isn’t different from anybody else,” says Erin A. Egan, MD, JD, a hospitalist at the University of Colorado at Denver and chair of SHM’s Ethics Committee. “If you can claim something quantifiable, you better be able to back it up. If you claim something qualitative, essentially you’re offering an opinion, and opinions don’t have to be based in fact.”

Virtua Health in Voorhees, N.J., and Cooper Health System, based in Camden, N.J., have been engaged in a legal battle since February. Virtua’s advertising claims the hospital has the most “Top Docs” in the region. After Cooper launched a legal challenge to the validity of the claim, a state judge ruled that Virtua could continue to say it had the most “Top Docs,” a claim based on a compilation of rankings from four regional magazines. The judge did, however, rule that Virtua had to withdraw wording from advertising that claimed the findings were made by an "independent" source, as Virtua had hired a group to compile the rankings. The judge also told Virtua to remove Web links to sites that explained how the figures were tallied. A federal case is pending.

Dr. Egan notes that few HM advertising tiffs result in similar legal claims unless they involve fraud. She adds that such battles often are costly and fruitless. For this reason, she urges advertisers to ensure their promotions are legally defensible. She offers these tips for any HM group when creating a marketing campaign:

• Use subjective language for subjective claims;
• Make sure you can back up all factual claims; and
• Think about the response you will give if you are challenged.

“The issue for hospitalists really isn’t different from anybody else,” says Erin A. Egan, MD, JD, a hospitalist at the University of Colorado at Denver and chair of SHM’s Ethics Committee. “If you can claim something quantifiable, you better be able to back it up. If you claim something qualitative, essentially you’re offering an opinion, and opinions don’t have to be based in fact.”

Virtua Health in Voorhees, N.J., and Cooper Health System, based in Camden, N.J., have been engaged in a legal battle since February. Virtua’s advertising claims the hospital has the most “Top Docs” in the region. After Cooper launched a legal challenge to the validity of the claim, a state judge ruled that Virtua could continue to say it had the most “Top Docs,” a claim based on a compilation of rankings from four regional magazines. The judge did, however, rule that Virtua had to withdraw wording from advertising that claimed the findings were made by an "independent" source, as Virtua had hired a group to compile the rankings. The judge also told Virtua to remove Web links to sites that explained how the figures were tallied. A federal case is pending.

Dr. Egan notes that few HM advertising tiffs result in similar legal claims unless they involve fraud. She adds that such battles often are costly and fruitless. For this reason, she urges advertisers to ensure their promotions are legally defensible. She offers these tips for any HM group when creating a marketing campaign:

• Use subjective language for subjective claims;
• Make sure you can back up all factual claims; and
• Think about the response you will give if you are challenged.

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

You know that feeling of frustration you get when something that should work—computers, airline schedules—just doesn't? Here's something new to add to that list: prostate cancer screenings.

Bob Wachter, MD, professor and chief of the division of hospital medicine at the University of California at San Francisco and author of Wachter’s World, sums up the findings of two recent New England Journal of Medicine studies in a recent post.

“One, a European study, found that PSA screening led to little benefit. The American study found that, after seven years of followup, the unscreened group had a 13% lower mortality rate than the screened group, with not a whiff of benefit.”

Dr. Wachter describes how his own father chose not to act on a PSA that came back in the 8 ng/mL range in the late 1990s. His father recently turned 79 and is healthy. “A heartfelt thanks to my dad’s urologists, who gave him what proved to be sage advice when all of the pressures—social, psychological, and financial—might have steered them toward more aggressive recommendations,” Dr. Wachter writes.

A Smarter Investment?

The Happy Hospitalist ponders what would happen if the $8,760 a year his patient and her husband spent on cigarettes was invested in the stock market. “Let’s say that the price of a pack of cigarettes only rises 5% a year (a conservative estimate). How much money could you save up by not spending $8,760 on cigarettes and instead investing it with a post-inflation return on average of 7%?”

The answer? After 10 years, the total would be $153,716; after 50 years, it would be $5.8 million.

“My, how foolish we are as a nation,” The Happy Hospitalist writes. “Looking for ways to pay for the healthcare of its citizenry, when the answers are staring us in the face.”

Brave New Hospitalist

HM welcomes a rookie to the ranks this week. Spiffer, an internist from California who doesn’t mince words on her blog, explains her new gig as a hospitalist to patients. “This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

“I love my patients and will miss them,” she says. “But here I go, into a brave new world.”

Welcome, Spiffer. 

Less than 8% of U.S. hospitals have electronic medical record (EMR) systems in at least one clinical unit, and only 1.5% have a comprehensive system in all of their units, according to a March 25 report on the New England Journal of Medicine's Web site. The news isn't all bad: One hospitalist and information technology (IT) expert views this study as an opportunity for HM to push for EMR programs in their institutions.

Dirk Stanley, MD, MPH, a hospitalist and chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass., says the environment for EMR initiatives is especially ripe given the government’s recent commitment of nearly $20 billion in stimulus funding for health IT implementation over the next six years.

The stimulus financing won't be available until fiscal 2011, but Dr. Stanley says the timeline gives hospitalists time to negotiate an EMR system that could work across their institutions. He adds that keeping lines of communication open between specialists is just as important as maintaining a productive dialogue between physicians and the staff that implement the software programs.

"Every doctor wants their information their way," Dr. Stanley says. "And this is a really difficult reflex for a lot of doctors. When you enter these political negotiations, you have to try to get doctors to understand that perfection on a small scale sometimes results in big problems on the large scale. If everybody is willing to compromise just a little bit, you can find a happy medium. As a hospitalist, it puts you in a nice political middle ground."

Less than 8% of U.S. hospitals have electronic medical record (EMR) systems in at least one clinical unit, and only 1.5% have a comprehensive system in all of their units, according to a March 25 report on the New England Journal of Medicine's Web site. The news isn't all bad: One hospitalist and information technology (IT) expert views this study as an opportunity for HM to push for EMR programs in their institutions.

Dirk Stanley, MD, MPH, a hospitalist and chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass., says the environment for EMR initiatives is especially ripe given the government’s recent commitment of nearly $20 billion in stimulus funding for health IT implementation over the next six years.

The stimulus financing won't be available until fiscal 2011, but Dr. Stanley says the timeline gives hospitalists time to negotiate an EMR system that could work across their institutions. He adds that keeping lines of communication open between specialists is just as important as maintaining a productive dialogue between physicians and the staff that implement the software programs.

"Every doctor wants their information their way," Dr. Stanley says. "And this is a really difficult reflex for a lot of doctors. When you enter these political negotiations, you have to try to get doctors to understand that perfection on a small scale sometimes results in big problems on the large scale. If everybody is willing to compromise just a little bit, you can find a happy medium. As a hospitalist, it puts you in a nice political middle ground."

Less than 8% of U.S. hospitals have electronic medical record (EMR) systems in at least one clinical unit, and only 1.5% have a comprehensive system in all of their units, according to a March 25 report on the New England Journal of Medicine's Web site. The news isn't all bad: One hospitalist and information technology (IT) expert views this study as an opportunity for HM to push for EMR programs in their institutions.

Dirk Stanley, MD, MPH, a hospitalist and chief medical informatics officer at Cooley Dickinson Hospital in Northampton, Mass., says the environment for EMR initiatives is especially ripe given the government’s recent commitment of nearly $20 billion in stimulus funding for health IT implementation over the next six years.

The stimulus financing won't be available until fiscal 2011, but Dr. Stanley says the timeline gives hospitalists time to negotiate an EMR system that could work across their institutions. He adds that keeping lines of communication open between specialists is just as important as maintaining a productive dialogue between physicians and the staff that implement the software programs.

"Every doctor wants their information their way," Dr. Stanley says. "And this is a really difficult reflex for a lot of doctors. When you enter these political negotiations, you have to try to get doctors to understand that perfection on a small scale sometimes results in big problems on the large scale. If everybody is willing to compromise just a little bit, you can find a happy medium. As a hospitalist, it puts you in a nice political middle ground."

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

“The important task rarely must be done today, or even this week. … But the urgent task calls for instant action. … The momentary appeal of these tasks seems irresistible and important, and they devour our energy. But in the light of time’s perspective, their deceptive prominence fades; with a sense of loss we recall the vital tasks we pushed aside. We realize we’ve become slaves to the tyranny of the urgent.” 1

—Charles Hummel

A few months ago, on one of my presidential travels, I met a young hospitalist who was overwhelmed. Thirty-year-old Emily had finished her residency in a good program just six months before. She had been a good resident, even winning an award as Resident of the Year. She was married with a young child at home and had recently moved to a new city, which was about 500 miles from her and her husband’s families. Her husband was staying at home to care for their child. They had chosen to move to this city because of its ideal climate and abundance of outdoor activities. The city had several HM opportunities, and Emily had chosen the one with the largest, most mature program. Everything seemed perfect at the start of her new job, but within a few months, she was overwhelmed, which led her to thoughts of quitting or moving to a program across the city to improve her lot.

One could naturally think that this was just a hospitalist in transition, from residency to attending. She was dealing with a lot of professional and personal issues, and maybe she had just not found her groove yet. And this was certainly true. Professionally, she was dealing with about a 20-patient-a-day workload. She had volunteered for two hospital committees and was serving as a physician champion for a UTI bundle the hospital was rolling out. The program was not short-staffed, but it did foster a culture of finishing your work before going home, and Emily was consistently staying one or two hours beyond her eight- to 12-hour shifts.

When I asked her about the specifics of her HM program, she had few complaints. The program had several night hospitalists, so she was grateful for the lack of night call. They also had fellows from an academic medical center helping with weekend admissions, so weekend call was once every six weeks. The monthly hours required by the program were reasonable. She got along with the group and hospital leadership; her salary was competitive and, in fact, guaranteed the first two years. At that time, she would graduate to a modified-productivity system based on a combination of work RVUs and quality metrics.

Yet Emily clearly was overwhelmed and contemplating a resignation.

As I talked with her, I started working through the differential diagnosis like any physician would. Knowing that the source of many hospitalist issues is the program itself, I worked through the various pillars of hospitalist satisfaction as demonstrated in SHM’s white paper on career satisfaction: reward/recognition, workload schedule, community/environment, and autonomy control.2 There seemed to be minor issues in some of the areas but nothing significant.

I then jumped to job fit and attempted to get a rough estimate of job control. Once again, minor issues. Emily did not appear to have a major disconnect between her desire for control and the control she currently had in her work.

So, being the persistent diagnostician, I asked her what she thought she needed. She immediately said, “Six more hours in a day!” And then, as I talked with her some more, the problem became apparent. She was a victim of what Charles Hummel described in 1967 as the “Tyranny of the Urgent.”1

Hummel was not the first to describe being overwhelmed by the small things of the day, nor will he be the last. Steven Covey, David Allen, and many others have made entire careers describing effective time-management techniques to control the small things. The core problem is that each of us starts the day with a plan, but we are sidetracked by many small tasks. At a given moment, the tasks appear to need an inconsequential amount of our time; however, they add up to significant amounts of time over the course of a day. Thus, we are detracted from accomplishing the core plan for the day—or the week or the month.

Hummel, a Christian writer, is not for everyone, but his discussion about the delirious enticement of completing a task that is thrown in front you was extremely insightful. I particularly like his reference to the demands and interruptions of the telephone. And Hummel was writing about this before e-mail, cell phones, televisions in public places, and instant messaging were prevalent.

On one hand, HM is perfectly synergistic with the tyranny of the urgent. Patients don’t get sick on a schedule. Codes and RRT calls occur suddenly. Families arrive at the hospital and can’t be ignored. Admissions and consults sprout up and orders need to be written. The list goes on.

As hospitalists, we must seek to prioritize what is important. We must actively choose to do this one thing rather than the million other tasks thrown at us. I am not saying to ignore patient care, but take a careful look at what you can control.

As I talked with Emily, I discovered she constantly checked her e-mail throughout the day, even on days she wasn’t working. She never sat down and took a lunch, even for 20 minutes. She hadn’t taken a family vacation, even for a short weekend, mainly because of what she described as work demands. She also told me that she enjoyed reading novels but had not read a single book since starting her new job.

As I spoke with Emily, I pointed out some of the things she was telling me. Soon, she started to slow down and think a little. I coached her to limit herself in the next two years to one quality improvement activity or committee. I also suggested she simply use the next two professional years to learn how to become an attending. I told her to read and continue to become comfortable with decision-making as a hospitalist—all else professionally should take a back seat.

Personally, I coached her to eliminate some of the daily distractions, specifically the overuse of her e-mail. I suggested she ask the nurses to avoid interrupting her when she is writing a note; take a regular lunch with a colleague; leave work on time.

In the end, each of us needs to decide what is important and discover how we should spend our time. Of course, we need to fix the practice issues so HM can thrive, but each of us needs to do a personal assessment, discover (or maybe rediscover) what is important, budget our time, and follow through. If we do, we will all be better off.

Thank you for allowing me to serve as your president. TH

Dr. Cawley is SHM president.

References

1. Hummel, Charles E. Tyranny of the Urgent. Downers Grove, Ill.: Intervarsity Press; 1967.

2. A challenge for a new specialty: a white paper on hospitalist career satisfaction. SHM Web site. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=14631. Accessed March 2, 2009.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of hospital medicine and the hospitalist training program, and as associate program director of the Internal Medicine Residency Program.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of hospital medicine and the hospitalist training program, and as associate program director of the Internal Medicine Residency Program.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

Let’s begin with a couple of clinical questions:

Scenario One: You are discharging a 70-year-old man admitted five days earlier with community-acquired pneumonia (CAP). He has diabetes, class II heart failure, hyperlipidemia, and hypertension. He can perform daily activities, is off oxygen, and is doing well on oral antibiotics. His heart failure and blood pressure are under control, but his finger-stick blood sugars are consistently high (140-190 mg/dL) throughout his stay. You discharge him on his outpatient medication regimen. His next scheduled follow-up appointment is in four weeks.

When would you have him see his primary-care provider?

a. In two days;

b. In one week;

c. In two weeks; or

d. In four weeks.

Getty Images

Scenario Two: You admit a 70-year-old diabetic woman with atypical chest pain. She has described her pain, which is localized under her left breast, as “burning.” It occurred at rest and did not change with activity or eating. It improved about two hours after receiving an antacid. Her EKG and three troponins are normal. Her LDL cholesterol is 125 mg/dL. She is a former smoker and her blood pressure is controlled through use of lisinopril.

What do you do?

a. Order an exercise stress test;

b. Order a dobutamine stress echo;

c. Refer the patient to cardiology; or

d. Discharge the patient to home and have her follow up if she has further symptoms.

Answers:

Scenario One: We don’t know.

Scenario Two: We don’t know.

Healthcare Rationing?

Within hours of President Obama’s signing of the new economic stimulus package, I received an e-mail from my dad, who had read online that the new legislation would result in healthcare rationing. Having followed this issue relatively closely, I was puzzled by how the stimulus plan’s direct impact on healthcare—$87 billion for Medicaid, $25 billion for extension of COBRA medical insurance, $10 billion for the National Institutes of Health (NIH), nearly $20 billion for information technology infrastructure, and $1 billion for comparative effectiveness research (CER)—could be interpreted as the rationing of healthcare.

A quick peek at the Internet revealed the answer. A handful of bloggers clearly were interpreting the combination of Obama’s pledge to reduce healthcare costs and the billion-dollar appropriation for CER to mean the government would use the results of this research to limit care based on cost-effectiveness. In other words, a bureaucrat would decide if an elderly patient would receive a hip replacement based on whether it made fiscal sense.

So is healthcare rationing Obama’s solution to healthcare reform?

More Equals Less

There is great variability in the care provided throughout the U.S. There are well-known disparities—within age, race, and sex, for example—but there are also less apparent disparities. Medicare beneficiaries matched for severity of illness receive vastly different care based solely upon where they live. In 2003, per capita healthcare spending was $5,278, $5,661, and $11,350 for patients living in Portland, Oregon; Seattle; and Miami, respectively. That equates to about $125,000 additional lifetime healthcare costs for a 65-year-old treated in Miami compared with the same 65-year-old in Portland.1

And what does the Miamian get for the added cost? The results are surprisingly counterintuitive. It turns out that chronically ill elderly patients treated in more-resource-intense parts of the country do not have improved survival, quality of life, or access to care compared with those in less-resource-intense parts of the country. In fact, across most of these variables, the outcomes appear worse the more we do.2

Discover What Works

The focus in medicine has been to improve outcomes and control costs through the application of evidence-based medicine. The idea is that we can improve outcomes if everyone would just follow the clinical guidelines for an individual disease state. This has become the primary focus of pay for performance and the Joint Commission’s mandates on quality indicators, such as early antibiotics in pneumonia care.

This is sound thinking, until you realize that the vast majority of the decisions we have no definitive answer. For example, BMJ Clinical Evidence estimates that of the 2,500 treatments used for a variety of clinical problems, only 36% of them were deemed “beneficial” or “likely to be beneficial,” while 46% were of unknown benefit.3 In the absence of evidence, we are forced to use our clinical judgment, a surprisingly scary proposition when affordable, high-quality care is the goal.

This clinical judgment is what policymakers refer to as discretionary decision-making. The problem is that there is great variability in what experienced, prudent physicians judge to be appropriate. Recently, 1,275 physicians were asked about their decision-making around clinical scenarios with variable levels of evidential support. When asked when they would recommend a routine follow-up visit for a patient with well-controlled hypertension, 47% of physicians in high-resource-use areas (e.g., Miami), compared with 9% of physicians in low-resource-use areas (e.g., Portland), would recommend followup within three months compared with after three months. Management of an elderly clinic patient with new-onset chest pain was met with similar levels of variability in cardiac testing, referral to cardiology, and admission to the hospital between the higher- and lower-resource areas.

Those results contrasted with the consistent use across all spending groups for relatively proven modalities, such as mammographic screening in patients 50 to 70 years old.4 When the definitive answer isn’t available, we are left to use our clinical judgment, which often results in overuse of resources without benefit, and possibly harm.

We need to augment our focus on adherence to current guidelines with the discovery necessary to develop future guidelines. This requires that we move toward better information about what works and what doesn’t.

Enter the Obama administration’s commitment of significant resources to NIH research and comparative effectiveness research. The former allows for continued discovery of new technologies, while the latter informs clinicians about which technologies work the best for a particular clinical disease state.

Coordinating Fragmented Care

As hospitalists, our daily to-do lists are riddled with the consequences of fragmented care. We spend hours trying to track down primary-care physicians, finding test results from outside facilities, and coordinating complex care with multiple providers across multiple continuums. This results in inefficient and costly hospitalist systems, repetition of expensive tests, and overall worse patient outcomes. Thus, the stimulus bill’s push will be to build information technology (IT) infrastructure, such as electronic medical records, with the goal of making safer, more efficient systems that improve outcomes while cutting costs.

While the devil will be in the details—and with medical IT, the details can be daunting—I think this is a wise investment in our future.

We must get healthcare costs under control and improve the quality of care. There are myriad thoughts and proposals on how to accomplish this. The new administration is betting that discovery and technology will provide the answer to what to do with an acute-chest-pain patient and, in turn, the brewing healthcare crisis in America. That doesn’t sound like healthcare rationing to me, Dad. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of hospital medicine and the hospitalist training program, and as associate program director of the Internal Medicine Residency Program.

References

1. Wennberg DE, Fisher ES, Skinner JS, Bronner KK. Extending the PFP agenda, part 2: How Medicare can reduce waste and improve the care of the chronically ill. Health Affairs. 2007;26:1575-1585.

2. Fischer ES, Wennberg, JE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298.

3. How much do we know? British Medical Journal Web site. Available at: http://clinical evidence.bmj.com/ceweb/about/knowledge.jsp. Accessed Feb. 24, 2009.

4. Sirovich B, Gallahger PM, Wennberg DE, Fisher ES. Discretionary decision-making by primary care physicians and the cost of U.S. healthcare. Health Affairs. 2008;27:813-823.

In the what-have-you-done-for-me-lately category, many hospitalists are expected to really ramp up their efforts to improve their hospital’s throughput. So many hospital executives, who not long ago were dazzled by impressive reductions in lengths of stay and cost per case attributable to hospitalists, seem to have turned their attention to discharging patients early in the day. To some hospitalists who still expect gratitude for things done in the past, it seems terribly unfair that administrators now expect us to attend to this new metric. And, by the way, don’t let discharging patients early in the day interfere with improvements in quality metrics, patient satisfaction, and documentation.

Because of these increasing demands on hospitalists, we might feel sorry for ourselves. I do sometimes. But I also know that if we became hospital executives—and some of us have—we would expect the same of hospitalists in our institutions.

I’m struck by how often hospitalists, particularly those not in leadership positions, fail to understand why it matters so much to the execs that discharge orders are written early in the day. For them, I’ll try to provide a brief explanation.

Why It Matters

An increasing number of hospitals are operating with all of their staffed beds fully occupied. Many end up with patients boarding in the ED or ICU because no “regular” beds are available. And hospitals really suffer financially when they have to cancel elective admissions, such as surgeries, because no beds are available for the patient postop.

Hospitals could build more beds to increase their capacity, but that requires a long time and something along the lines of $1 million per bed. Where could they get the financing in today’s market? The other option is to shorten the length of time a patient occupies a bed so that more patients can be served using the existing inventory.

In nearly every hospital, the biggest bed crunch occurs in the afternoon. This is the time patients are ready to leave the post-anesthesia care unit or ED and move to their “floor” bed. If patients being discharged that day haven’t left yet, gridlock occurs. Costs of the gridlock are spread throughout the hospital, notably in the ED, which suffers because of the resulting increased lengths of stay and reduced throughput. This isn’t just an economic issue for the hospital; patients are adversely affected, too.

Even if your hospital has spare beds, early discharge still matters. If the discharge day isn’t managed well and patients routinely leave late in the afternoon, the hospital will have to spend more on evening-shift nursing staff.

It makes sense to look at every step that must occur prior to a patient vacating their room on the day of discharge. The time that the doctor actually writes the discharge order is one of the most critical, rate-limiting steps in the discharge process, so helpful executives suggest we organize our rounds to see the potential discharges first, then get around to seeing the patients who are really sick. I think most hospitalists, including me, find it really difficult to do this. If you’re in this category, you might consider starting your rounds earlier in the day.

Consider Rounding Earlier

Starting rounds earlier is usually an unpopular idea. Many groups refuse to consider it. If you are in a group that works day (rounding) shifts with specified start and stop times, coming in before the start of your shift to begin rounding is just donating uncompensated time to the practice. That is one of many reasons I think it is best for most practices to avoid specified start and stop times for their day shifts. Instead, I think it is reasonable for each doctor to decide when to start and stop work each day depending on the workload. So on days you have a higher-than-usual number of expected discharges or sick patients, you would probably choose to start earlier. And when patient volumes are low, you might choose to start later. The same is true of when you choose to leave for the day. Choosing to start earlier in the day should mean that you can wrap things up earlier on most days.

For a lot of hospitalists, routinely starting rounds earlier would be OK as long as they can finish earlier. But there are some for whom this is really tough or impossible, such as those who need to take their kids to school before work each morning. Rounding early won’t do any good if the hospital doesn’t ensure test results and other information is available early.

A practice could choose to undertake an initiative as simple as the following steps to support improvements in writing most discharge orders early in the day:

• Encourage starting rounds earlier (e.g., 7 a.m.) on most days;
• Whenever possible, prepare discharge summaries the day before;
• As often as possible, write in the order section “probable discharge tomorrow” one day before planned discharges;
• Keep routine morning conferences, such as signout, as short as possible; move it to later in the day, or eliminate it entirely, if feasible; and
• If you have routine, sit-down rounds with case managers each morning, think about whether they get in the way of early-in-the-day discharges. If so, consider moving them to the afternoons, and focus on discussing the next day’s potential discharges rather than discharges for the current day.

Consider establishing targets for each of these metrics and audit performance compared with a historical baseline. For example, the goal might be that the “probable discharge tomorrow” order appears the day before discharge in 50% of hospitalist patients, and the discharge summary is prepared the day before in 30%. These things help ensure other hospital staff members realize discharge is possible or likely and can significantly reduce discharges that are a surprise to nurses and others.

There is nothing magic about the bulleted protocol above. I’m offering it as only one potential idea to improve throughput, and you might want to pursue an entirely different strategy.

The Flip Side

Two closely related issues come up when working on getting discharge orders written early in the day. The first is that some late-afternoon discharges are in reality very early discharges that might have otherwise waited until the next day. It is important to stress that not all discharge orders are written early, and that hospitalists should not hold on to patients who could be discharged late in the day and instead release them the next morning to make their statistics look better.

The other related point is that a declining length of stay and discharging early in the day begin to compete with each other at some point. From a bed management perspective, the theoretical optimal length of stay means discharging patients the moment they are ready and not waiting until the next morning. This means discharging around the clock without regard to the time of day, and that would look terrible when analyzed from the perspective of the portion of discharge orders written early in the day—not to mention it would be very unpleasant for patients asked to leave at night. So I’m not suggesting that we should be discharging patients around the clock, but I just want to point out the tension between length of stay and writing discharge orders early in the day. 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 hospital practice management consulting firm. He is part of the 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 SHM position.

In the what-have-you-done-for-me-lately category, many hospitalists are expected to really ramp up their efforts to improve their hospital’s throughput. So many hospital executives, who not long ago were dazzled by impressive reductions in lengths of stay and cost per case attributable to hospitalists, seem to have turned their attention to discharging patients early in the day. To some hospitalists who still expect gratitude for things done in the past, it seems terribly unfair that administrators now expect us to attend to this new metric. And, by the way, don’t let discharging patients early in the day interfere with improvements in quality metrics, patient satisfaction, and documentation.

Because of these increasing demands on hospitalists, we might feel sorry for ourselves. I do sometimes. But I also know that if we became hospital executives—and some of us have—we would expect the same of hospitalists in our institutions.

I’m struck by how often hospitalists, particularly those not in leadership positions, fail to understand why it matters so much to the execs that discharge orders are written early in the day. For them, I’ll try to provide a brief explanation.

Why It Matters

An increasing number of hospitals are operating with all of their staffed beds fully occupied. Many end up with patients boarding in the ED or ICU because no “regular” beds are available. And hospitals really suffer financially when they have to cancel elective admissions, such as surgeries, because no beds are available for the patient postop.

Hospitals could build more beds to increase their capacity, but that requires a long time and something along the lines of $1 million per bed. Where could they get the financing in today’s market? The other option is to shorten the length of time a patient occupies a bed so that more patients can be served using the existing inventory.

In nearly every hospital, the biggest bed crunch occurs in the afternoon. This is the time patients are ready to leave the post-anesthesia care unit or ED and move to their “floor” bed. If patients being discharged that day haven’t left yet, gridlock occurs. Costs of the gridlock are spread throughout the hospital, notably in the ED, which suffers because of the resulting increased lengths of stay and reduced throughput. This isn’t just an economic issue for the hospital; patients are adversely affected, too.

Even if your hospital has spare beds, early discharge still matters. If the discharge day isn’t managed well and patients routinely leave late in the afternoon, the hospital will have to spend more on evening-shift nursing staff.

It makes sense to look at every step that must occur prior to a patient vacating their room on the day of discharge. The time that the doctor actually writes the discharge order is one of the most critical, rate-limiting steps in the discharge process, so helpful executives suggest we organize our rounds to see the potential discharges first, then get around to seeing the patients who are really sick. I think most hospitalists, including me, find it really difficult to do this. If you’re in this category, you might consider starting your rounds earlier in the day.

Consider Rounding Earlier

Starting rounds earlier is usually an unpopular idea. Many groups refuse to consider it. If you are in a group that works day (rounding) shifts with specified start and stop times, coming in before the start of your shift to begin rounding is just donating uncompensated time to the practice. That is one of many reasons I think it is best for most practices to avoid specified start and stop times for their day shifts. Instead, I think it is reasonable for each doctor to decide when to start and stop work each day depending on the workload. So on days you have a higher-than-usual number of expected discharges or sick patients, you would probably choose to start earlier. And when patient volumes are low, you might choose to start later. The same is true of when you choose to leave for the day. Choosing to start earlier in the day should mean that you can wrap things up earlier on most days.

For a lot of hospitalists, routinely starting rounds earlier would be OK as long as they can finish earlier. But there are some for whom this is really tough or impossible, such as those who need to take their kids to school before work each morning. Rounding early won’t do any good if the hospital doesn’t ensure test results and other information is available early.

A practice could choose to undertake an initiative as simple as the following steps to support improvements in writing most discharge orders early in the day:

• Encourage starting rounds earlier (e.g., 7 a.m.) on most days;
• Whenever possible, prepare discharge summaries the day before;
• As often as possible, write in the order section “probable discharge tomorrow” one day before planned discharges;
• Keep routine morning conferences, such as signout, as short as possible; move it to later in the day, or eliminate it entirely, if feasible; and
• If you have routine, sit-down rounds with case managers each morning, think about whether they get in the way of early-in-the-day discharges. If so, consider moving them to the afternoons, and focus on discussing the next day’s potential discharges rather than discharges for the current day.

Consider establishing targets for each of these metrics and audit performance compared with a historical baseline. For example, the goal might be that the “probable discharge tomorrow” order appears the day before discharge in 50% of hospitalist patients, and the discharge summary is prepared the day before in 30%. These things help ensure other hospital staff members realize discharge is possible or likely and can significantly reduce discharges that are a surprise to nurses and others.

There is nothing magic about the bulleted protocol above. I’m offering it as only one potential idea to improve throughput, and you might want to pursue an entirely different strategy.

The Flip Side

Two closely related issues come up when working on getting discharge orders written early in the day. The first is that some late-afternoon discharges are in reality very early discharges that might have otherwise waited until the next day. It is important to stress that not all discharge orders are written early, and that hospitalists should not hold on to patients who could be discharged late in the day and instead release them the next morning to make their statistics look better.

The other related point is that a declining length of stay and discharging early in the day begin to compete with each other at some point. From a bed management perspective, the theoretical optimal length of stay means discharging patients the moment they are ready and not waiting until the next morning. This means discharging around the clock without regard to the time of day, and that would look terrible when analyzed from the perspective of the portion of discharge orders written early in the day—not to mention it would be very unpleasant for patients asked to leave at night. So I’m not suggesting that we should be discharging patients around the clock, but I just want to point out the tension between length of stay and writing discharge orders early in the day. 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 hospital practice management consulting firm. He is part of the 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 SHM position.

In the what-have-you-done-for-me-lately category, many hospitalists are expected to really ramp up their efforts to improve their hospital’s throughput. So many hospital executives, who not long ago were dazzled by impressive reductions in lengths of stay and cost per case attributable to hospitalists, seem to have turned their attention to discharging patients early in the day. To some hospitalists who still expect gratitude for things done in the past, it seems terribly unfair that administrators now expect us to attend to this new metric. And, by the way, don’t let discharging patients early in the day interfere with improvements in quality metrics, patient satisfaction, and documentation.

Because of these increasing demands on hospitalists, we might feel sorry for ourselves. I do sometimes. But I also know that if we became hospital executives—and some of us have—we would expect the same of hospitalists in our institutions.

I’m struck by how often hospitalists, particularly those not in leadership positions, fail to understand why it matters so much to the execs that discharge orders are written early in the day. For them, I’ll try to provide a brief explanation.

Why It Matters

An increasing number of hospitals are operating with all of their staffed beds fully occupied. Many end up with patients boarding in the ED or ICU because no “regular” beds are available. And hospitals really suffer financially when they have to cancel elective admissions, such as surgeries, because no beds are available for the patient postop.

Hospitals could build more beds to increase their capacity, but that requires a long time and something along the lines of $1 million per bed. Where could they get the financing in today’s market? The other option is to shorten the length of time a patient occupies a bed so that more patients can be served using the existing inventory.

In nearly every hospital, the biggest bed crunch occurs in the afternoon. This is the time patients are ready to leave the post-anesthesia care unit or ED and move to their “floor” bed. If patients being discharged that day haven’t left yet, gridlock occurs. Costs of the gridlock are spread throughout the hospital, notably in the ED, which suffers because of the resulting increased lengths of stay and reduced throughput. This isn’t just an economic issue for the hospital; patients are adversely affected, too.

Even if your hospital has spare beds, early discharge still matters. If the discharge day isn’t managed well and patients routinely leave late in the afternoon, the hospital will have to spend more on evening-shift nursing staff.

It makes sense to look at every step that must occur prior to a patient vacating their room on the day of discharge. The time that the doctor actually writes the discharge order is one of the most critical, rate-limiting steps in the discharge process, so helpful executives suggest we organize our rounds to see the potential discharges first, then get around to seeing the patients who are really sick. I think most hospitalists, including me, find it really difficult to do this. If you’re in this category, you might consider starting your rounds earlier in the day.

Consider Rounding Earlier

Starting rounds earlier is usually an unpopular idea. Many groups refuse to consider it. If you are in a group that works day (rounding) shifts with specified start and stop times, coming in before the start of your shift to begin rounding is just donating uncompensated time to the practice. That is one of many reasons I think it is best for most practices to avoid specified start and stop times for their day shifts. Instead, I think it is reasonable for each doctor to decide when to start and stop work each day depending on the workload. So on days you have a higher-than-usual number of expected discharges or sick patients, you would probably choose to start earlier. And when patient volumes are low, you might choose to start later. The same is true of when you choose to leave for the day. Choosing to start earlier in the day should mean that you can wrap things up earlier on most days.

For a lot of hospitalists, routinely starting rounds earlier would be OK as long as they can finish earlier. But there are some for whom this is really tough or impossible, such as those who need to take their kids to school before work each morning. Rounding early won’t do any good if the hospital doesn’t ensure test results and other information is available early.

A practice could choose to undertake an initiative as simple as the following steps to support improvements in writing most discharge orders early in the day:

• Encourage starting rounds earlier (e.g., 7 a.m.) on most days;
• Whenever possible, prepare discharge summaries the day before;
• As often as possible, write in the order section “probable discharge tomorrow” one day before planned discharges;
• Keep routine morning conferences, such as signout, as short as possible; move it to later in the day, or eliminate it entirely, if feasible; and
• If you have routine, sit-down rounds with case managers each morning, think about whether they get in the way of early-in-the-day discharges. If so, consider moving them to the afternoons, and focus on discussing the next day’s potential discharges rather than discharges for the current day.

Consider establishing targets for each of these metrics and audit performance compared with a historical baseline. For example, the goal might be that the “probable discharge tomorrow” order appears the day before discharge in 50% of hospitalist patients, and the discharge summary is prepared the day before in 30%. These things help ensure other hospital staff members realize discharge is possible or likely and can significantly reduce discharges that are a surprise to nurses and others.

There is nothing magic about the bulleted protocol above. I’m offering it as only one potential idea to improve throughput, and you might want to pursue an entirely different strategy.

The Flip Side

Two closely related issues come up when working on getting discharge orders written early in the day. The first is that some late-afternoon discharges are in reality very early discharges that might have otherwise waited until the next day. It is important to stress that not all discharge orders are written early, and that hospitalists should not hold on to patients who could be discharged late in the day and instead release them the next morning to make their statistics look better.

The other related point is that a declining length of stay and discharging early in the day begin to compete with each other at some point. From a bed management perspective, the theoretical optimal length of stay means discharging patients the moment they are ready and not waiting until the next morning. This means discharging around the clock without regard to the time of day, and that would look terrible when analyzed from the perspective of the portion of discharge orders written early in the day—not to mention it would be very unpleasant for patients asked to leave at night. So I’m not suggesting that we should be discharging patients around the clock, but I just want to point out the tension between length of stay and writing discharge orders early in the day. 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 hospital practice management consulting firm. He is part of the 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 SHM position.