At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at [email protected]. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to [email protected].

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail [email protected]. TH

At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at [email protected]. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to [email protected].

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail [email protected]. TH

At the 2006 SHM Annual Meeting Geriatrics Special Interest Forum, participants asked, “Can we create an area on the SHM Web site focused on our unique interests and needs?” Last month, SHM answered with a resounding “Yes!” as we launched the Geriatrics Special Interest Group on www.hospitalmedicine.org.

The SHM Geriatrics Special Interest Group provides a portal for SHM members to access relevant, timely information about and resources for geriatric medicine. The Community Forums provide a mechanism for participants to communicate with each other about issues in geriatric medicine and other areas of interest. In particular, the Geriatrics Special Interest Group allows users to post information about training and career development opportunities, professional meetings and forums, and funding opportunities. Users can access a wealth of geriatric-medicine resources, including breaking medical news, clinical and quality improvement tools, key publications, and archived SHM Annual Meeting presentations. The Geriatrics Special Interest Group will serve as a template for future member-requested special interest groups, including palliative care, pediatrics, and others.

The Geriatrics Special Interest Group was developed by SHM members, other experts from the community of geriatric medicine, and a team of SHM staffers. SHM member Melissa Mattison, MD, (Beth Israel Deaconess) serves as medical editor for the site and helped shape its vision, along with members Param Dedhia, MD, (Johns Hopkins, Bayview) and Jason Stein, MD (Emory University). The group also benefited from reviews and contributions made by John Degelau, MD, at HealthPartners Medical Group, Gavin W. Hougham, MD, PhD, at The John A. Hartford Foundation, Nancy Lundebjerg, MPA, and Jane Potter, MD, at the American Geriatrics Society, Odette van der Willik at the American Federation for Aging Research, and Paula M. Podrazik, MD, at the Case Management Society of America. The internal SHM development team was led by Shannon Roach and included Bruce Hanson, Travis Kamps, and Tina Budnitz.

To view the Geriatrics Special Interest Group, go to SHM’s Web site or type the address into your browser: www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=12369.

We hope SHM members will utilize the Geriatrics Special Interest Group to share ideas and resources, to network, and to improve inpatient geriatric medicine. Let us know if the site meets your needs by sending your comments and suggestions to Shannon Roach at [email protected]. Have an idea for another special interest group? E-mail us that suggestion, too.

SHM: BEHIND THE SCENES

Education and quality improvement: Reflections of a New Staff Member

By Kristin Beck

It’s nice to come to work every day and focus on education and quality improvement. Ensuring that hospitalists have the most up to date information as well as support and encouragement for implementing positive change are good reasons for leaving the house in the morning.

Only three weeks into my role as senior project manager, I have had the sincere pleasure of being involved with updating quality improvement resource rooms (common Web site areas that house tools for implementing quality improvement programs) by initiating a grant-supported program for examining observation units as they relate to treating the number one reason people are hospitalized. I have also accomplished writing and submitting a grant for the Quality Improvement Pre-Course, as well as, working with a committee that looks at patient quality care and projects to enhance it.

Our work here focuses on examining what has been done, how we can improve it, and how we can institute best practices. Not bad for three weeks’ work!

Conversations in our department focus on whether members get what they need and want. People meet regularly to discuss how we can refine and improve the services we offer. Strategies for securing funding and developing programs are reviewed, not for this calendar or fiscal year but for years to come. In one of my final interviews for this job, I was reminded that we don’t deliver here—we over-deliver. Looking through The Hospitalist, titles that stand out include the words unforgettable, safety, expert, leader, admire, and smart.

When people ask what I do in my new job, I tell them that hospital medicine looks at the total experience of being a doctor. It focuses not only on medical care but also on the complete experience of being a working professional: the arts of research, negotiation, best practices, team-focused care, conflict resolution, and systems change. I explain that we do life-saving work, for it is far more than the practice of just day-to-day medicine that improves all of our lives. I tell people that it is work that makes sense.

When you come to work every day and are surrounded by a dynamic, positive energy, the work you produce is likely to mirror the hospital medicine movement: You will reflect, revise, and grow stronger. Sincere, well-planned initiatives are infectious. Continually participating in an environment that asks the questions, “Where can we take this?” and “What can we do better?” is a pretty good reason to get out of bed in the morning.

Beck is the senior project manager at SHM.

VTE Prevention Collaborative off to a Great Start

The VTE Prevention Collaborative (VTE PC) is the latest SHM initiative to support hospitalist-led efforts to reduce the incidence of preventable, hospital-acquired VTE. Launched in January 2007, the program offers individualized assistance to hospitalists who want to take the lead on this critical quality and patient safety issue.

Hospital-Acquired Venous Thromboembolism

The problem of hospital-acquired VTE is huge. More than 2 million Americans suffer from VTE each year. Most hospitalized patients have at least one risk factor for VTE. In a large registry trial capturing more than 5,451 patients at 183 sites in a six-month period, 50% (2,726) developed their VTE during hospitalization.1 A 400-bed hospital with an average rate of VTE prophylaxis can expect that 200 patients will suffer from hospital-acquired VTE each year; around half of these cases are potentially preventable.1,2

The good news is that effective and safe measures to prevent hospital-acquired VTE exist. Pharmacologic prophylaxis reduces the incidence of asymptomatic and symptomatic DVT and pulmonary embolism (PE) by 50%-65%.3, 4-11 Prevention of DVT also prevents PE and fatalities from PE. The chief concern of prophylaxis is bleeding, but bleeding risk secondary to pharmacologic prophylaxis is a rare event, as is shown in abundant data from meta-analyses and placebo-controlled, randomized controlled trials.3,4

click for large version

Close the Gap

Reliably preventing VTE in the hospital is inherently complex. VTE risk and bleeding risks vary within patient populations, and these risks may change for an individual patient several times in the course of the hospital stay. Weight, age, renal function, medication changes, and recent or impending invasive interventions may all influence decisions about the best VTE prevention options. Transitions across care providers and locations translate into multiple opportunities for breakdown in the delivery of optimal VTE prophylaxis. Thoughtful, evidence-based protocols, multidisciplinary system changes, and comprehensive educational efforts are required to achieve optimal VTE prophylaxis in the complex hospital setting.

How the VTE PC Can Help

The VTE PC program builds on and complements the VTE prevention materials and educational resources that SHM has produced in recent years. “Our Quality Improvement Resource Rooms have the information and resources needed to tackle a number of key quality issues,” says SHM CEO Larry Wellikson. “The VTE PC project takes this one step further by providing individualized mentorship. SHM is committed to supporting these forward-thinking, unique strategies that will allow hospitalists to lead their hospitals into a better future.”

VTE PC participants can choose the type of support that best fits their needs: a full year of distance mentoring or a one-day evaluation and consultation visit to their site.

The mentoring program presents a perfect option for individuals interested in ongoing support for their planned or active VTE prevention projects. Through the project, SHM mentors with VTE and QI experts who work with participants during eight telephone calls scheduled throughout a yearlong mentoring period. During the calls, mentors offer individualized assistance on any topics, tasks, and barriers that are encountered in the course of designing, implementing, and evaluating a VTE prevention project. Instruction and assistance are tailored to participant needs and commonly focus on:

• Working with medical center administration;
• Using practical methods to assess institutional performance in VTE prophylaxis;
• Identifying and tracking patients with hospital-acquired VTE;
• Constructing a VTE risk-assessment model and integrating it into workflow, order sets, and protocols;
• Enhancing selection of appropriate prophylaxis by linking the VTE risk assessment to a corresponding menu of proven options; and
• Bolstering your chances of success by utilizing high-reliability design features and effective implementation techniques.

The on-site consultation program is a good option for individuals interested in securing expert evaluation and input on a VTE prevention program but who don’t need ongoing support. Through the on-site consultation program, SHM consultants with VTE and QI expertise visit applicants’ hospitals to evaluate active or planned VTE prevention programs. The visits are especially helpful to participants with existing VTE prevention programs that they wish to expand or improve upon.

The consultation visits feature a structured evaluation of the site’s strengths and resources, barriers to improvement, and the design and functioning of active or proposed VTE prevention interventions. Specific consultation-visit activities vary according to participant goals and needs but may include meeting with the local project team, QI leaders, hospital administrators, and hospital medicine group leaders, as well as reviewing project documents—order sets, policies, and procedures—data, and data collection/management tools. Following the visits, SHM consultants provide participants with a written report of findings and recommendations. Participants also receive one follow-up telephone consultation.

Collaborative Members

SHM membership has responded enthusiastically to the VTE PC project. Early enrollees have a wide range of experience with VTE prevention and QI in general. Some fill QI leadership roles in their hospitals or hospital medicine groups; for others, the VTE prevention project is their first experience leading a QI effort. Enrollees represent a range of hospital types (academic centers, community teaching hospitals, community hospitals) and sizes (staffed beds range from 135 to 650) and are located in every U.S. geographic region in multiple hospital systems.

Several participants represent hospitals where VTE prevention programs have been implemented, while most have active projects in which no intervention has yet been implemented; a handful are still in the planning/initial exploration phase of work. Nearly half of the enrolled sites have a history of failed QI efforts in VTE prevention.

Many enrollees are looking to their VTE prevention efforts as a means of positioning their hospital medicine group as a local QI force. “This is the first large project the hospitalist group has undertaken since getting up and running,” reports one attendee. “I would really like to make a positive impact on patient care and lay the groundwork with this project that would allow us to be successful with future undertakings.”

Applying to the Programs

Participation in both the mentoring and on-site consultation programs is open to hospitalists who lead proposed or active VTE prevention projects. Participation is free, but enrollment is limited, so interested individuals are encouraged to apply early. SHM members can apply to either program by completing the online application available on the VTE Prevention Collaborative Web site: www.hospitalmedicine.org/vte-pc.

Direct your questions about VTE Prevention Collaborative programs to [email protected].

Bibliography

1. Goldhaber SZ, Tapson VF; DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004 Jan;93(2):259-262.
2. Maynard G. Workbook for Improvement: optimize prevention of venous thromboembolism at your medical center [SHM Web site, VTE Quality Improvement Resource Room]. Available at: www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms&Template=/CM/ContentDisplay.cfm&ContentID=6092. Last accessed March 19, 2007.
3. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. Review. Comment in Chest. 2005 Jun;127(6):2297-2298.
4. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 [Agency for Healthcare Research and Quality Web site]. July 2001;332–346;AHRQ Publication No. 01-E058. Available at: www.ahrq.gov/clinic/ptsafety/. Last accessed March 19, 2007.
5. Belch JJ, Lowe GD, Ward AG, et al. Prevention of deep vein thrombosis in medical patients by low-dose heparin. Scott Med J. 1981 Apr;26(2):115–117.
6. Gardlund B. Randomised, controlled trial of low-dose heparin for prevention of fatal pulmonary embolism in patients with infectious diseases. The Heparin Prophylaxis Study Group. Lancet. 1996 May 18;347(9021):1357–1361. Comment in: ACP J Club. 1996 Nov-Dec;125(3):64 & Lancet. 1996 Jul 20; 348(9021):205-206.
7. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med. 1999 Sep 9;341(11):793–800.
8. Leizorovicz A, Cohen AT, Turpie AG, et al. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation. 2004 Aug 17;110(7):874-879.
9. Kleber FX, Witt C, Vogel G, et al. Randomized comparison of enoxaparin with unfractionated heparin for the prevention of venous thromboembolism in medical patients with heart failure or severe respiratory disease. Am Heart J. 2003 Apr;145(4):614–621.
10. Lechler E, Schramm W, Flosbach CW. The venous thrombotic risk in non-surgical patients: epidemiological data and efficacy/safety profile of a low-molecular-weight heparin (enoxaparin). The Prime Study Group. Haemostasis. 1996;26(Suppl):49–56.
11. Cohen AT, Davidson BL, Gallus AS, et al. Fondaparinux for the prevention of VTE in acutely ill medical patients (abstract 42). Blood. 2003;102:15a.

Awards Ceremony Preview

SHM created the Awards of Excellence program to honor members whose contributions to the hospital medicine movement deserve acknowledgment and respect. Award winners will receive complimentary registration and paid airfare to SHM’s Annual Meeting, which is being held this month in Dallas and will be presented during the President’s luncheon. Any physician member whose focus is the general medical care of hospitalized patients is eligible for nomination of the four awards. Award winners have been selected for the following categories: Clinical Excellence, Excellence in Teaching, Outstanding Service, and Research.

The SHM Award for Clinical Excellence will be presented to an individual for recognition of exemplary clinical service in hospital medicine. The Awards Committee has evaluated the candidates according to their outstanding contributions to patient care, their advancement of clinical knowledge, including their leadership and professionalism in medicine, as well as personal excellence in practice management.

The SHM Award for Excellence in Teaching is presented in recognition of outstanding teaching and mentorship in hospital medicine, most specifically within the academic and community practice settings. Consideration was given to those nominees who demonstrated outstanding teaching ability and who served as role models and mentored other hospitalists, residents, medical students, or other healthcare professionals.

The SHM Award for Outstanding Service in Hospital Medicine is presented in recognition of exceptional service to the discipline of hospital medicine. The winning candidate has displayed exemplary organizational and leadership activities within organized medicine and has shown contributing support in public policy.

The SHM Excellence in Research Award is presented in recognition of outstanding achievement by a researcher in the discipline of hospital medicine. The candidate selected presented peer-reviewed publications and continued education with additional research and training that provided for both intra- and extramural funding for research.

For additional information regarding SHM’s Awards Program, please e-mail [email protected]. TH

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

Supplement Editors:
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Contents

The recognition of urologic disease is a primary care issue, whether we've know it or not
Matt T. Rosenberg, MD, and Milton M. Lakin, MD

Screening for urologic malignancies in primary care: Pros, cons, and recommendations
Andrew J. Stephenson, MD; Louis Kuritzky, MD; and Steven C. Campbell, MD, PhD

Benign prostatic hyperplasia: When to 'watch and wait,' when and how to treat
Albert Levy, MD, and George P. Samraj, MD

Overactive bladder: Recognition requires vigilance for symptoms
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; Christopher T. Tallman, BS; and Shari A. Page, CFNP

Erectile dysfunction: A sentinel marker for cardiovascular disease in primary care
Martin M. Miner, MD, and Louis Kuritzky, MD

Evolving issues in male hypogonadism: Evaluation, management, and related cormorbidities
Martin M. Miner, MD, and Richard Sadovsky, MD

Identifying and treating premature ejaculation: Importance of the sexual history
Richard E. Payne, MD, and Richard Sadovsky, MD

Interstitial cystitis/painful bladder syndrome: Symptom recognition is key to early identification, treatment
Matt T. Rosenberg, MD; Diane K. Newman, RNC, MSN, CRNP; and Shari A. Page CFNP

Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key
Jeannette Potts, MD, and Richard E. Payne, MD

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

When you start work as a hospitalist, you’ll tend to immerse yourself in your new job. But you should also strive to maintain a work-life balance from the start, to guard against eventual burnout.

“It’s really work-family-self balance, because of the importance of self-care,” says Maureen Murray of Maureen Murray Associates in Pittsburgh, who provides professional training in stress management and work-life balance. “Self-care is more than just running or dieting—it’s the foundation of a balanced life.”

Areas of Self-Care

“If you don’t put yourself first, you won’t be very effective at caring for others,” says Murray. Her training program categorizes self-care into four areas:

Physical: What keeps me healthy? “Most people already know the answer to this,” says Murray. “Some form of regular activity, eating reasonably well, and getting some rest.” Mental: What energizes my mind? The answer is “something different,” according to Murray.

• Read a book or see a movie;
• Try a new cuisine; or
• Go out with friends who aren’t in the medical profession.

Emotional: What gives me contentment and joy? “This can be spending quality time with loved ones and friends because friends are often the first to fall through the cracks when we get busy,” says Murray. “The answer might also be a hobby that puts you ‘in the zone.’”

Spiritual: What feeds my spirit? This will be different for different people: attend church; take a walk in nature; meditate or pray; or read something inspirational.

The Eight-Step Program

Here are eight things you can do—starting now—to ensure a healthy balance in your career:

1. Select the best job for you. Keep your work-life-self balance in mind during the job search, particularly when it comes to comparing schedules, time off, benefits.
2. Consider location. If you have a family, or plan to have children soon, “choose a workplace that’s near your extended family,” advises Murray.
3. Find someone who’s doing it right. “After you start, look around and find role models who seem to be balancing their lives pretty well,” says Murray. “Look for the physician who’s not stressed, who’s juggling a family and work. Then ask them how they do it so well. Having a role model like this is really important.”
4. Talk about work. “There’s a temptation to isolate yourself and work really long hours,” warns Murray. “Grab a cup of coffee with a colleague or go for a walk with a friend.”
5. Be aware of stress. “You need to feel you’re in control of something—so control your reaction to stress,” says Murray. “Read about stress, but let go of the idea that coping with it is out of your hands.”
6. Plan ahead. Have a contingency plan for things that need to be done. “Ask yourself, ‘What’s my backup plan for childcare … and what’s my backup to the backup?’ ” says Murray. When you plan ahead, you can avoid stressful situations.
7. Laugh. “Laughter releases endorphins, which make you feel good,” Murray points out. “Seek the company of those you laugh with. And when you have options for what to watch on TV or on DVD, always choose the comedy.”
8. State your needs. “People need to communicate their needs about life balance,” Murray stresses. “This can be very difficult to do, whether it’s to your partner or your boss. State what you need in a positive way. ”

Be vigilant in maintaining a healthy work-life-self balance, with an emphasis on self, and your hospitalist career should be a happy one. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Recent developments at the American Board of Internal Medicine (ABIM) could affect your re-certification process as a working hospitalist. In 2004 SHM petitioned the ABIM to consider a program that would recognize the specific skills and knowledge of hospitalists. Last fall, ABIM voted to begin development of a Focused Recognition of Hospital Medicine through its Maintenance of Certification (MOC) system.

This focused recognition would give hospitalists a formal credential that recognizes hospital medicine as a distinct field within internal medicine. This is the first time in its history that ABIM has offered focused recognition for any subset of internal medicine, and—if approved—the first time that the umbrella organization, the American Board of Medical Specialties (ABMS), will offer a focused recognition for a subset of any specialty.

The Details

Robert Wachter, MD, professor of medicine at the University of California, San Francisco, is chair of ABIM’s Committee on Hospital Medicine Focused Recognition (HMFR). This committee is finalizing the details of how the focused recognition will work. Issues on their agenda include:

• Demonstration of a focused practice: The committee is considering setting a minimum volume of hospitalized patients for this that can reasonably apply to academic physicians, physician-administrators, and researchers—as well as clinical hospitalists.
• Requirements for demonstrating performance in practice: For MOC requirements, ABIM is increasingly examining the use of real practice data. In other words, measuring what physicians do rather than what they know.
• Tests for MOC: The exam for MOC with Focused Recognition of Hospital Medicine could be taken from the current MOC, with the same core content on internal medicine as well as new content relevant to hospital medicine, or it could be an entirely different test, focusing on hospital medicine.

The timeframe for an MOC with a Focused Recognition of Hospital Medicine is likely to be shorter than a standard MOC. “The minimum number of years that would elapse is still being discussed, but it would be no fewer than two and no more than four or five,” says Dr. Wachter. “Now, you don’t have to do an MOC until year 10. I’m hoping that people would start working toward their MOC as soon as they end their residency, but—people being people—they may not actually start work on this until year nine.”

What the Future Holds

In June the Committee on HMFR will present its recommendations for the process to the ABIM board, including how HMFR would relate to the rest of ABIM certification and MOC in internal medicine. Once approved, the plan will be presented to ABMS. “It will have to go through a process at ABMS, which takes a year or 18 months,” warns Holly Humphrey, MD, professor of medicine and dean for Medical Education at Pritzker School of Medicine, University of Chicago.

The goal is not to limit the practice of hospital medicine to those who have been through the focused recognition certification, but rather to lend credibility to the field. “What may change is that people hiring hospitalists may value this,” speculates Dr. Wachter. “The market will dictate” how necessary the re-certification becomes. TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

Heather A. Harris, MD, director of Eden Inpatient Services at Eden Medical Center in Castro Valley, Calif., has been a hospitalist for nearly four years and helped start her hospital medicine practice, which currently employs eight full-time day hospitalists and “a cadre of night folks.”

“I’ve been on both ends of looking for a job and hiring hospitalists,” she says. Below, she and other hospitalists share advice on how to choose your first position in hospital medicine.

Begin Early

The best job search begins before you graduate. “When you’re looking for a job, start as early as possible,” advises Sameer Badlani, MD, hospitalist and instructor at the University of Chicago. “Most people don’t realize how long it takes.”

To prepare for employment, take steps toward getting your medical license and put your paperwork in order. “If you know which state or states you want to be in, go ahead and start the state licensing as soon as possible,” says Dr. Badlani. “Each state has its own set of forms, and you can at least have the packet ready to send in.”

You can also prepare your certification materials so that they are ready to turn over to your future employer: “The FCVS [Federation Credentials Verification Service] is a repository for all your training certificates,” explains Dr. Badlani. “It costs $250 to get a copy of all your certificates, and an additional $30 every time you send it out to a [potential employer]. Some states will only accept certificates from FCVS, and I think that someday all states will require this.”

As a first step for the actual job search, Dr. Harris recommends trying to network through your university and your residency program. “Your program may keep a list of where residents have gone to work; you can at least talk to recent graduates that you know,” she says. “Call them up and see how they like what they’re doing.”

You can broaden your search by joining the industry association and exploring job postings. “I’d recommend that anyone become a member of SHM,” says Dr. Harris. “There are a variety of job postings available through their Web site. You can also simply “Google” ‘hospitalist jobs,’ and find all kinds of national services, headhunters, and companies.” To view job postings t through SHM’s online Career Center, visit www.hospitalmedicine.org and click “Career Center.”

Hospitalist Sanjiv Panwala, MD, a hospitalist at Providence Medical Center, Portland, Ore., has created www.mdgrad.com, a Web site that includes portals to hospital medicine job postings.

Narrow Your Search

When you take these first steps, you’ll discover just how many positions you have to choose from. How can you narrow your job search?

“Clearly, [you have] to distinguish the things that are important to you,” says Dr. Harris. “There’s quite a distinction between an academic and community-based position; you need to think this through before you begin your job search.”

Regardless of this first decision, there are universal factors to consider. “As in any job search, you start by thinking about the area of the country you want to be in, urban versus rural, and other factors,” explains Dr. Harris. “Then you think about the things that separate [hospital medicine] programs from one another.” You’ll find you have a lot of choices.

“There seem to be [hospital medicine] jobs everywhere,” says Dr. Panwala. “The money is in Texas or the Midwest, if that’s what’s important to you.”

Once you’ve decided on your general career path and where you’d like to live and work, consider what type of work you want to do. “One thing you should think about is whether you want to see patients in critical care arenas, or just those patients on the floors,” says Dr. Harris. “These are very different populations, and require different skill sets. You should also consider whether or not you want to work with residents. Residents work in some community settings, too.”

An Academic Job Search

If you decide you want to work in an academic setting, you don’t have to go far to start your search. “I’d think you could start by talking to the head of your department and ask if they can look around and put in a word for you,” says Dr. Harris.

Mark V. Williams, MD, FACP, director of Emory Healthcare’s Hospital Medicine Unit in Atlanta and editor of The Journal of Hospital Medicine, will become chief of the new Division of Hospital Medicine at Northwestern Memorial Hospital in Chicago later this year. He recommends scoping out how a potential employer’s hospital medicine group is perceived and treated within the institution.

“People coming out of residency should look at the amount of support provided by the department of medicine for the hospital medicine group,” he says. “Are the hospitalists active members of the department, with key faculty in leadership positions such as residency or associate residency program director, or are they being hired just to deliver clinical care? Ask if there is funded support for hospital medicine research faculty. If not, the job may be just like working in a community setting, only community settings historically pay better.”

Signs that an institution has a strong commitment to the field include the presence of a division of hospital medicine, and possibly even a hospital medicine fellowship.

Questions to Ask

Even if you’ve got your eye on a specific hospital medicine group, go though the interview process at several institutions so that you can see what the market offers. Important factors to consider include:

Who would I work for? Who owns the hospital medicine practice? “There are differences in who’s sponsoring the group,” says Dr. Harris. “It may be independent, employed by the hospital, or a national group that contracts with the hospital. The answer will give you insights into the job. You may not get the entire picture, but you’ll get a clue.” Consider whether the practice can offer opportunities for advancement—possibly even partnership—and the type of clinical or administrative work you prefer.

What type of schedule would I work? How is the schedule arranged? Consider the number of hours you’d spend on call, and the number of nights and weekends you’d be expected to cover.

“Residents don’t have a sustainable schedule, so anything that’s not ridiculous sounds good,” warns Dr. Harris. “But a seven-on, seven-off shift is very tiring and can lead to burnout over time. So consider whether a given schedule is realistic for the long-term.” Find out how many vacation days are included—or if there are none.

What is the workload? During the interviewing process, ask about the average number of encounters per day. Definitely ask those “nitty-gritty” questions about patient load, admissions, and so on, advises Dr. Harris.

Pay special attention to the number of encounters. “Seeing 18 to 20 patients a day is a lot; those are the turn-and-burn organizations that aren’t necessarily sustainable,” says Dr. Panwala. “The money offered for this may be appealing to younger hospitalists. But remember, if you’re getting paid more, nothing is free.”

Dr. Harris adds, “Ask if that includes admissions and—if there’s critical care work—ask how many of those encounters are in critical care, because those patients will take more time.”

Michael-Anthony Williams, MD, regional CMO of Sound Inpatient Physicians in Denver, advises job seekers to look at “what they have to do” for the salary offered. “Look at … the number of days worked, the length of those days, and the number of encounters per day. You have to ask questions about these things, because the information isn’t necessarily going to be laid out in front of you.”

What about compensation and benefits? Your first consideration of salary, benefits, and other compensation should be to ensure the figures are in line with what the market offers. You can find general information on what hospitalists make from SHM’s “Bi-Annual Survey on the State of the Hospital Medicine Movement,” available at www.hospitalmedicine.org. The Medical Group Management Association (MGMA) and the Association of American Medical Colleges (AAMC) provide salary scales, and salaries for positions at public institutions like university hospitals are public information.

Do your homework, and then simply ask each interviewer what the salary range is for hospitalists. “It doesn’t put me off to have these discussions [on compensation and benefits] early on,” says Dr. Harris.

You may be tempted to choose a job based on salary—but be careful: “Don’t always look at the amount of money as the deciding factor,” says Dr. Badlani. “If a job offers $5,000 or $10,000 more, what are they expecting for that extra salary? And consider how much of that additional money will go to taxes.”

As you gather information on these areas, you’ll need to keep it straight. Dr. Harris advises you to create a simple system that allows you to compare hospital medicine practices you’re considering. “Come up with a chart and list out everything,” she says. “It’s going to vary considerably” from practice to practice, and you’ll need a method to compare one job possibility with another.

How the Process Works

Here is how the interviewing process is likely to flow: “Generally, people send me their resumes, then I’ll have a phone interview with the best candidates,” says Dr. Harris. “If that works out, the next step is that they’ll come in for a tour of the hospital and meet some of the other folks in the group.”

Candidates are invited to call or e-mail physicians in the group with questions; the group will decide which candidate to hire.

That face-to-face meeting with members of the group is essential. “Spend time with other hospitalists,” advises Dr. Badlani. “See what their daily work looks like, including what kind of patients you’ll be seeing.”

You should ask those hospitalists some of the same questions you’ve asked your main interviewer, including questions about schedule, workload, and compensation. “Talk to as many people in the practice as possible,” says Dr. Michael-Anthony Williams. “They’ll give you an honest answer.”

If you like what you see and the group likes you, you’ll get a job offer followed by a contract to sign. “When we extend an offer, they have time to determine what they want,” says Dr. Harris, explaining that she realizes a candidate may be faced with several job options. “When they say yes, we’ll extend a contract and begin the credentialing process.”

The process is not over at this point; you may be months away from your first day on the job. “You need to become credentialed for each hospital you’ll work at, and for the group,” explains Dr. Harris. “At our hospital, that can take three to four months—other places take around two months. Just so you know that you shouldn’t be looking for a job in June and thinking you’ll work in July.”

You’ll have a part to play in the credentialing process. There will be paperwork to fill out, and you’ll need to provide your diploma and medical license and letters of support. “The credentialing committee at our hospital won’t proceed until [all of this] is 100% complete,” says Dr. Harris.

Find a Good Fit

The most important factor to consider in taking a job is simply, are you a good fit for the group? Finding a good match for the group’s values and mission is crucial to the success of the organization and the new hire.

When you meet with hospitalists in the group, “Ask what the mission or values are of the group,” says Dr. Michael-Anthony Williams. “Do they know what their mission is—and is it coherent? Coherence will lend stability over time.”

Dr. Panwala stresses finding a “like-minded” group. “You’ll work with them day in and day out. If you don’t mesh well, you’re going to be miserable,” he says. “You turn your patient over to another hospitalist at 8 p.m., and when you come in the next morning, you take over someone else’s patients. It’s very much a marriage.”

What Interviewers Look For

Because its essential to find a good personality fit for a group, allow decision-makers to get a sense of who you are during the interview phase.

“It’s important to be honest about your values and about who you are,” says Dr. Harris. She believes that most hospital medicine directors look for candidates who are “actively interested in being a hospitalist—preferably for a long time,” for physicians who are team players, and for traits that include flexibility and responsibility.

“I look for someone who’s outgoing,” adds Dr. Mark Williams. “ I want a nice person—someone who’s willing to bend over backward to help others. I appreciate people who’ve won humanitarian awards in residency.”

There are also more basic traits you should display. “General etiquette is important,” stresses Dr. Harris. “Be prompt in your responses when using phone and e-mail. If you’re interested in the position, be engaged in the process. After you come in to the hospital, send a brief letter or a quick e-mail thanking the person and expressing your interest—or your lack of interest. This doesn’t have to be very formal.”

When interviewing candidates for academic hospitalist positions, Dr. Mark Williams says, “I look for residents who have won awards, who have laudatory letters of recommendation from their program director. I love letters that say this resident was in the top of their class, or the best we’ve seen in five years. I look for those who have done research, and those who published case report abstracts, which shows they’re industrious.”

Dr. Mark Williams also asks questions of candidates early in the process and listens carefully to their responses. “I especially look for good communication skills, which are so critical for hospitalists,” he says. “If someone has poor communication skills, they’ll have a tough time on the job.”

To determine their skills, “I’ll ask about their goals, and ask what they see as their weakness,” he says. “It’s very positive to see someone articulate their weaknesses.”

Before You Sign

When you’re presented with a contract, it’s time to take a close look at what’s being offered. “Before you sign anything, you need to come to an agreement with the other party in the contract that this is exactly what we agreed to. Otherwise, it’s no deal,” says Fred A. McCurdy, MD, PhD, MBA, FAAP, FACPE, professor and regional chairman of pediatrics, Texas Tech University Health Sciences Center at Amarillo. “Everything needs to be really specific in the offer letter or the contract—their duties, expectations—all clarified up front.”

Examine the benefits, including retirement and insurance. Ideally, you want disability insurance—and malpractice insurance with tail coverage is essential. (Tail coverage, also called extended reporting coverage, covers you after you leave a group in case a patient files a lawsuit years after the fact.)

Make sure you understand what the contract says, and make sure your employer doesn’t hold too much power. “Check to see if you can be assigned to areas of work that would be a deal-breaker—if you can be sent to another city or state to work, for example,” says Dr. McCurdy.

As a new physician, you do have some leverage to negotiate for better compensation or schedule. Dr. McCurdy says of recent residents, “The two biggest benefits they bring to the table are their youth and the fact that they’re current and up to date on what’s going on in [internal medicine]. They have energy, and they’ll bring energy to the program; and they’ve spent three years in intense study and have the most up-to-date knowledge of anyone you can hire.”

Point out these advantages to the right interviewer, and you may be able to negotiate.

Dr. Badlani encourages new hires to negotiate their moving expenses, bonuses, and malpractice insurance.

But keep in mind that not all hospital medicine programs can or will negotiate. “It’s quite variable,” admits Dr. McCurdy.

Dr. Harris’ program is a prime example. “In my experience, we don’t have a tremendous amount of negotiating,” she says. “Basically, we say, ‘Here’s the deal.’ ”

Dr. McCurdy advises having someone else read the contract for you. “When you’re enthusiastic about a new job, you don’t see everything,” he explains. “And you need to have a lawyer read it to make sure it’s a correctly constructed legal document.”

Dr. Harris simply advises that you “read through the contract with a fine-tooth comb. Does it have a non-compete clause that prohibits you from practicing in the region after you leave? You can find a job [locally] without this clause.”

Dr. McCurdy has allowed new hires to strike these clauses from their contracts, but it’s a trade-off. “Non-compete clauses are hard to enforce,” he acknowledges. “Our boilerplate contract has one, because we want to send the message that we don’t want to spend two years training you and then have you leave and go to work for the competition. So if [a candidate] wants to strike that clause from the contract, I’ll say that’s fine, but on the basis of that I’ll make it a binding three-year contract.”

What if, after researching, interviewing, reviewing the contract, and taking every step possible to ensure you get the best job, you find you’ve made a mistake? “Remember, your contract is only for one year,” Dr. Badlani points out. “You can always change next year if you don’t like your [first choice].” TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

A standard internal medicine residency program will only take you only so far in teaching you to be a hospitalist. The rest is up to you. “There have been some changes in resident training,” says Vineet Arora, MD, MA, assistant professor of medicine and associate program director, Internal Medicine Residency Program at the University of Chicago. “Future hospitalists should consider how current resident training may or may not help prepare them for a hospital medicine career.”

Given this advice, residents who plan to enter hospital medicine must be especially proactive in shaping their education, experience, and skills. The steps outlined here can serve as a general guide.

Six Ways to Shape Your Residency Toward Hospital Medicine

1) Find a mentor: Your first step is to find a professor or working hospitalist who can help you plan and carry out your education. “Training to become a hospitalist is more than just being a super-resident,” explains Dr. Arora. “It carries special competencies.”

A hospitalist mentor can help you understand what your program does and does not offer, and how to accumulate the best knowledge and skills for a career in hospital medicine.

2) Practice applicable procedures: It’s important to note that your program’s procedures requirements may not be adequate for some hospitalist positions. This can hold true even for residency programs that follow the American Board of Internal Medicine (ABIM) procedural requirements.

“There’s been a change in procedural requirements in the last year,” says Dr. Arora. “Although the Board says you must be able to know, understand, and explain certain procedures it does not require that you perform these procedures competently. So, residents no longer need to demonstrate these procedures. If your program has adopted these requirements, you’ll be at a disadvantage in your job search.”

Check with your residency program director on your program’s requirements and how they match procedure requirements of your future employer. “I don’t think it should be a requirement for hospitalists, but it’s good to have,” says Bradley T. Rosen, MD, MBA, Division of General Internal Medicine at Cedars-Sinai Medical Center, Los Angeles, of the required procedures. “It depends on where you’re going to practice hospital medicine. In smaller, less urban hospitals and in less densely populated areas, the more versatile the hospitalist will have to be. The less support you have in terms of subspecialties, the more important it is to do procedures. Many hospitalists [in these environments] manage patients in the ICU—those patients need a lot of procedures.”

Every hospital will have its own credentialing criteria, but most match the ABIM requirements. “You’d have to know when you’re applying what you have and what you need,” says Dr. Rosen. “If you’re adept at doing procedures, that gives the advantage to you in a job search.”

Regardless of what type of hospital medicine position you want, document every procedure you do in residency. “Consider keeping a log book of your procedures to make sure they meet requirements for hospital credentialing committees,” advises Dr. Arora. “If you want to be a successful, competitive hospitalist [candidate], you have to keep a log book to prove your procedure experience.”

The good news is that if you need more experience with procedures for a certain position, you can get it on the job. “If you meet the hospital’s criteria you can be hired with basic privileges, then be given temporary privileges to perform certain procedures with proctoring, before those privileges become permanent,” says Dr. Rosen. “The ABIM requirements will get you in the door at most hospitals for those procedures.”

3) Add education in key areas: An internal medicine residency may not offer adequate training in some vital aspects of hospital medicine. “Supplement your education with key areas that may not be covered, such as perioperative medicine and hospital-acquired hazards,” advises Dr. Arora.

She recommends you sign up for an elective rotation in perioperative medicine and consultation. “A lot of hospitalists might be responsible for perioperative care or consultation, or surgical co-management,” she says. “This isn’t currently a core competency of many residency programs, so elective rotation is important to consider.”

Another area on which you should concentrate is the prevention against hospital-acquired conditions. These include deep vein thrombosis (DVT), nosocomial infections, delirium, pressure ulcers, and falls.

4) Study communication methods: Look beyond the clinical knowledge and skills you need, and learn how hospital medicine works. This includes methods of communication for discharge and general communication with patients’ primary care providers (PCPs).

“The system in which residents train may not be good about communication with primary care physicians,” says Dr. Arora. “It’s important to think about timely discharge summaries and how they can affect your practice. You may not find this on the academic side, so it’s worth rotating in a community-based hospital to see what a workday is like. Maybe your hospital [communicates with PCPs] by e-mail, and another uses faxes. You need to understand how communication takes place.”

Jeanne M. Farnan, MD, hospitalist scholar at The University of Chicago Hospitals, Section, General Internal Medicine, believes today’s residents are experienced in transitions of care due to the recently reduced duty hours. “Communications for these transitions will become more of a priority, [and] much more pertinent for medical school deans and directors,” she speculates. “These communications need to be a more structured curriculum so that residents learn to communicate more effectively with other physicians, working as part of a multi-disciplinary team.”

Meanwhile, residents can find role models for good communications. “See what the attending physicians are doing,” advises Dr. Farnan. “These skills can be learned on the job, because clearly residents have been learning this way. Look to see how physicians do it well, the strategies they use. Talk to all the stakeholders; ask PCPs what details they like to see when receiving communications about their hospitalized patients.”

5) Perform a QI project: Hospitalists play a vital role in their hospitals’ quality improvement (QI) efforts. Regardless of which career path you’re pursuing within hospital medicine, you should focus on QI in your residency.

“You’ll need basic skills in quality improvement and patient safety,” says Dr. Arora. “It’s best if you can become part of a QI committee or be mentored on a QI project.”

Read about QI tools and resources on SHM’s Web site (www.hospitalmedicine.org) under “Quality & Safety.”

6) Self-study: Supplement your residency education by reading on your own. “Targeted reading will be helpful, especially if you’re not doing a fellowship,” says Dr. Arora. Read The Hospitalist and the Journal of Hospital Medicine, pick up a textbook on hospital medicine, and study SHM’s The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (available online at www.hospitalmedicine.org under “Education.”)

“The Core Competencies are designed as a blueprint or framework to help faculty design their curricula for inpatient training,” explains co-editor Alpesh Amin, MD, MBA, FACP, professor and executive director of the hospitalist program at the University of California, Irvine, School of Medicine. “The competencies talk about the clinical issues, procedures, and systems-based practice” performed in hospital medicine. “It’s not meant to be comprehensive, but it’s pretty inclusive of what we thought hospitalists should know,” he says.

Each chapter in The Core Competencies includes knowledge, skills, and attitudes for the subject covered. “Chapters could be used as [residents] try to develop skills around these specific areas,” says Dr. Amin.

Your residency experience is vital to becoming a good physician, but it may not be enough to make you truly competitive in the field of hospital medicine. “Residency is a good foundation, but you need to be aware of how to make the best of it,” advises Dr. Arora. Follow these steps, and you’ll be better prepared to join your first choice of hospital medicine practice. TH

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Your longtime patient is admitted with a myocardial infarction. While you are talking with him, his wife, and his two adult children during your morning rounds, he suddenly gasps and becomes unresponsive. The monitor sounds, showing ventricular fibrillation. The nurse rushes in and hits the code blue alert button, and people begin filling the room.

While you are with a patient, the code blue alert goes off in the next room for a patient unknown to you. As the first physician on the scene, you begin directing resuscitation attempts. You notice the patient’s wife and her friend standing in the corner of the room, watching with horrified expressions.

The 15-year-old asthmatic patient you admitted to the ICU last night has rapidly increasing respiratory distress and requires intubation. His mother has been sitting at his bedside all night.

No one disagrees that the patient’s needs come first in these situations. There is little or no time to establish rapport, to explain what is going on, and why. Usually, family and friends are quickly ushered out of the room by nursing or spiritual-care personnel. They are escorted away from their loved one’s room while an army of people in scrubs and white coats races past them. They sit in the waiting room, trying to imagine what’s going on and fearing the worst. Often, the moment of arrest is the last image they have of their loved one until they view the body, peacefully arranged with clean white sheets but often with the disconnect of strange new tubes in place, distorting the familiar face.

With invasive procedures, family members also fear that something will go wrong, or that their loved one will suffer pain or discomfort during the procedure. While recovering, loved ones may be heavily sedated, grotesquely draped with tubes, and surrounded by frightening machines.

Why are family members banned from the patient’s bedside in these situations? Let’s examine the rationale and evidence for this practice.

Three Perspectives

There appear to be three perspectives on this issue: those of the providers, the family members, and the patient. Each looks at the situation differently. Research on these perspectives is conducted in one of two ways; researchers either express opinions and concerns in a hypothetical fashion without using experience, or a survey is conducted using actual outcomes. These surveys suffer from the weakness of self-selection, because those with negative feelings may not respond.

Providers

The provider’s common concerns include:

• Emotional trauma to the family member witnessing the process—or to the patient, who may fear that the experience will traumatize his or her loved one;
• Family members interfering with the process, demanding that CPR be stopped or continued inappropriately, or physically getting in the way of an already crowded room;
• Risk of litigation;
• Interference with resident training;
• Provider discomfort, causing suboptimal performance; and
• Patient confidentiality.1

Providers are also concerned about saying something that may be interpreted as inappropriate by the family. For example, staff members sometimes use humor to relieve the stress of a situation—humor that may be misconstrued or misinterpreted by family members. Cardiopulmonary resuscitation is not portrayed in a realistic fashion on many TV medical dramas, such as “ER” or “House,” and family members and patients may have unrealistic expectations or may believe that a poor outcome resulted from provider error.2

Hypothetical category studies used survey data gathered from emergency department (ED) and critical care physicians and nurses, allied health professionals, social workers, and spiritual care personnel. These studies are descriptive and quite heterogeneous, using different survey tools, sample sizes, and populations. In general, nurses were more often supportive of family presence than physicians, and attending physicians were more supportive than residents.1 Providers with no personal experience of family presence tended to oppose it.

Studies of the attitudes of providers familiar with family presence are also mostly retrospective, descriptive surveys.3 A few looked at provider opinions before and after experiencing family presence. Family presence was more often supported in these surveys, although McClenathan’s survey found that the majority of respondents did not favor it.4 Provider concerns, it turns out, were unrealized in actual family presence experiences. Some respondents, however, described the family’s presence as a source of stress.5,6

Interestingly, a survey of the American Association for the Surgery of Trauma (AAST) and the Emergency Nurses Association (ENA) found that 18% of AAST members felt family presence was beneficial, compared with 64% of ENA members. More AAST than ENA members felt that family presence was inappropriate during all phases of a code blue. The issue of who should decide whether or not a family should be present was also variable, with nurses leaning toward the family or the code team, while physicians were more likely to indicate the senior medical officer.7

Those in favor of family presence cite several benefits: the ability to educate the family about the patient’s condition in real time, the essential patient information families can provide, the assistance a family can offer in positioning and supporting the patient, and the fact that their presence can help providers to recognize the patient as part of a loving family unit. The patient’s rights to dignity, privacy, and pain control are less likely to be overlooked, even in urgent situations, with family members present.1 Attention to these important patient and family issues also serves to reduce the risk of litigation.

Families

In surveys and polls, the majority of the American public consistently reports the desire to be with a loved one during emergency procedures or at the time of death. Seventy percent of surveyed emergency and critical care nurses and physicians in Australia want to be present for a loved one. Many family members feel they have a right to be present. Moreover, outcomes data indicate that more than 90% of those who have had this experience say they would do it again.3,8 One randomized prospective study was terminated early; once the staff saw the benefits of family presence, they felt that continuing the study would be unethical.9

Positive family member comments included the following:

• “I couldn’t imagine not being a part of it”;
• “I saw that everything was done for him”;
• “I felt he knew that I was there”; and
• “Seeing and touching helped relieve the stress I felt weeks later.”5

Negative comments included:

• “ … Very unpleasant, haunting, and constant memory”;
• “ … Staff seemed too coldly professional”; and
• “I can still see him with all those needles.”

Several participants felt their loved ones were already dead and that the resuscitation was unnecessary, perhaps attempted only to run up the bill. Some wished they had been given their loved ones’ clothes that they saw tossed in the trash. Lack of preparation for what they were about to witness was also a complaint. Finally, families complained that hustling them out of the room or denying them entrance was insensitive.

Providers’ concerns about adverse psychological impact have not been realized in the literature, although one small study found that three of five families of CPR survivors may experience psychological stress up to 12 months later.9,10 Wagner’s study outlined six families’ struggles to decide when or whether to stay with their loved ones.11

Patients

In all this data, the patient’s voice is noticeably absent. Hypothetical category studies sometimes asked participants not only about their loved ones but also about how they felt if they themselves were the patients.12,13 While the majority of patients were not opposed to allowing the presence of a spouse or relative who wished to stay, they were less insistent than were family members. Age and race were associated with preferences: older (mean: 50 years) white patients preferred not to have family present. Therefore, an open family presence policy that doesn’t take into account the patient’s wishes may not be appropriate.

Of the available outcome data, Eichhorn’s 2001 report of nine adult and teenage patients, one of whom underwent CPR, found that all were comfortable with and reassured by having their families at their bedsides.14 Clearly, this is an area in need of further research.

Hospital Experience

Beginning in 1982, Foote Hospital in Jackson, Mich., was a pioneer of witnessed resuscitation in the ED.5 A follow-up article after nine years’ experience describes its success.15 Hospital policies for chaplain and ED staff outline a case-by-case assessment. If the option is believed to be appropriate and is approved by the treating ED physician, the chaplain or nurse prepares the family, escorts selected family members into the room, and remains with them for support and information. The family members may take a place at the patient’s bedside to touch and speak with their loved one.

Having family at the bedside “helps people having trouble with closure and those who have a good grasp on it, but not everybody,” says Debra Jamieson, RN, critical care supervisor at Foote Hospital. “You don’t have to go into a lot of depth; they can see everything you’re doing.”

Regarding provider stress, “you work through your own feelings about death and dying,” she says.

Mayo Clinic Rochester has a similar policy in its ED. “At St. Mary’s Hospital in Rochester, Minn., the emergency department has had a policy for allowing family members to be present during medical resuscitations. This is true for both adult and pediatric resuscitations,” says David Klocke, MD, assistant professor of emergency medicine and medicine. “I have never seen a family member lose control or interfere with the resuscitation, though on occasion I suspect this could occur.”

The critical care units are also moving toward developing a policy, according to Critical Care Committee Chairman Rolf Hubmayr, MD.

Professional Society Support

The ENA was probably the first society to introduce guidelines (in 1995) for family presence during resuscitation. The American Heart Association, Emergency Medical Services for Children, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Association of Critical Care Nurses all recommend family presence.1 Having a trained facilitator available for family support, offering multiprofessional support, providing staff education, and creating written policies are all recommended. At last check, however, only 5% of nurses work at facilities with written policies.

Conclusions

Bringing a family to the bedside should not happen haphazardly but should be handled with careful consideration and support for all involved. Institutional policy and protocol can provide legal support and define expectations. Providers should be educated, perhaps during advanced cardiac life support (ACLS), advanced trauma life support (ATLS), fundamental critical care support (FCCS), and pediatric advanced life support (PALS) courses. The patient’s wishes should be honored whenever possible. Family presence could even be added to the advance directive discussion. Certainly, more study in this area is needed. Given current data, however, it is reasonable to consider bringing families to the bedside in emergency situations. TH

The author gratefully acknowledges Debra Jamieson, RN, and Ned McGrady of Foote Hospital Pastoral Care for the extensive materials they supplied to assist with this article.

References

1. Guzzetta C. Family presence during CPR and invasive procedures. Presented at: 35th Critical Care Congress, Society of Critical Care Medicine; January 9, 2006; San Francisco, California.
2. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-1582.
3. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care. 2005 Nov;14(6):494-511.
4. McClenathan BM, Torrington KG, Uyehara CFT. Family member presence during cardiopulmonary resuscitation: a survey of US and international critical care professionals. Chest. 2002;122:2204-2211.
5. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987 Jun;16(6):673-675.
6. Hallgrimsdottir EM. Accident and emergency nurses’ perceptions and experiences of caring for families. J Clin Nurs. 2000 Jul;9(4):611-619.
7. Helmer SD, Smith RS, Dort JM, et al. Family presence during trauma resuscitation: a survey of AAST and ENA members. American Association for the Surgery of Trauma. Emergency Nurses Association. J Trauma. 2000 Jun;48(6):1015-1024. Comment in: J Trauma. 2000 Dec; 49(6):1157-1159 and J Trauma. 2001 Feb;50(2):386.
8. American Association of Critical-Care Nurses. Practice Alert. Family presence during CPR and invasive procedures. Available at: www.aacn.org/AACN/practiceAlert.nsf/Files/FP/$file/Family%20Presence%20During%20CPR%2011-2004.pdf. Last accessed March 29, 2007.
9. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
10. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000 Feb;100(2):32-42; quiz 43. Comment in: Am J Nurs. 2000 May;100(5):12, 14. Am J Nurs. May;101(5):11,45-55.
11. Wagner JM. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004 Sep;13(5):416-420. Comment in: Am J Crit Care. 2005 Jan;14(1):14.
12. Benjamin M, Holger J, Carr M. Personal preferences regarding family member presence during resuscitation. Acad Emerg Med. 2004 Jul;11(7):750-753.
13. Mazer MA, Cox LA, Capon JA. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006 Dec;34(12):2925-2928. Comment in: Crit Care Med. 2006 Dec; 34(12):3041-3042.
14. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. During invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001 May;101(5):48-55.
15. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.

Since April 2006, when the Massachusetts Health Care Reform Bill was signed into law at a ceremony in Boston’s historic Faneuil Hall, the state has been on a fast pace to meet its ambitious goal of providing every uninsured adult resident—by some estimates, more than 500,000—with affordable coverage.

The reform law is generating national attention for a few of its innovative provisions, such as the “individual mandate” requiring all adults to sign up for coverage by July 1, 2007, or face financial penalties and the “employer assessment,” which requires employers with more than 10 workers to pay money into a fund each year if they fail to provide coverage to their employees.

“It’s an important national model,” says U.S. Health and Human Services Secretary Mike Leavitt of the Massachusetts reform initiative, and already some of its components are being adapted in other states, including California.

But while the reform effort speeds along in the Bay State, questions remain: Will it work? And what will reform mean for the larger issue of cost management?

Coverage Concern

It is well documented that the growing ranks of the uninsured throughout the United States are placing financial pressures on the healthcare system. Those who get health insurance where they work probably don’t think much about—that is, until they lose it. But for people who don’t have a plan, there is risk and anxiety. They don’t get regular checkups. Most go to the hospital for emergencies only. A person who is uninsured and faces a devastating and expensive illness finds herself in poor financial health as well.

When people who don’t have access to preventive care get really sick, they generally end up in emergency departments. In Massachusetts, when patients can’t cover the cost of their care, that cost is passed along through an “uncompensated care pool” system that is paid for by taxpayers, insurers, and the hospitals themselves.

Any shortfalls in pool funding—a common occurrence in recent years—are borne entirely by hospitals; that is, they are forced to eat the cost, which, in turn, increases healthcare costs throughout the system.

Compassion requires us to improve access to primary care for all. Economics requires us to end the cost shifting that puts upward pressure on the price we all pay for healthcare.

A central tenet of the reform debate has been shared responsibility in our healthcare system. It has been argued by many, including hospitals, that the immense moral and financial challenge of ensuring that the citizenry has health insurance coverage should be shared by all; health insurance should not necessarily be the responsibility of the employer, nor should it be borne entirely by government or low-income individuals.

The health reform bill divides the pie more equitably than ever before. In addition to the individual mandate and employer assessment mentioned above, new requirements are placed on hospitals to ensure that they offer care in a more open and cost-effective way than in the past. And, until enrollment efforts are proven successful, the Commonwealth of Massachusetts is also committed to providing fairer payments to providers through Medicaid and through adequate funding of the uncompensated care pool.

Specifically, Massachusetts’ healthcare reform seeks to enroll 90,000 additional individuals into MassHealth (Medicaid). It created Commonwealth Care, a health insurance program that offers those earning less than 100% of the Federal Poverty Level ($9,805/year) a full range of healthcare services, including inpatient services in hospitals; preventive and primary care; medical care from a specialist in a doctor’s office, community health center, or hospital; emergency care; vision care; prescription drugs; inpatient and outpatient mental health and substance abuse services; and some dental coverage. These families pay no monthly premiums and limited co-pays.

Those earning between 100% and 300% of the poverty level—$9,805 to $29,412—pay monthly subsidies ranging from $18 to $106 per month for the same services. The state expects 200,000 uninsured families to qualify for Commonwealth Care plans.

An income of more than $29,412 qualifies a family to purchase a Commonwealth Choice plan, which contains no subsidies from the state. Another 200,000 fall under this category. The Choice plans were the subject of great deliberation in Massachusetts; patient advocates, providers, state officials, and the insurance companies creating the plans debated the scope of coverage (should prescription drugs be included?) and the monthly premium. (The state’s Commonwealth Health Insurance Connector Authority—the agency overseeing the reform law implementation—was expected to give its seal of approval to the Commonwealth Choice plans in March.)

The Cost Issue

Linked to the themes of affordability and access that are cited so often when this law is discussed is the challenge of effectively managing costs. Massachusetts’ hospitals have an opportunity to lead the way as the call to better manage healthcare costs grows louder.

Reform has addressed some of the pressures that are driving premium increases in Massachusetts. For example, cost shifting to the private market has been tackled: The state has had to amend its habit of paying less than cost for the services it covers under Medicaid. The reform law also established a Quality and Cost Council to work on other cost pressures.

After years of experience with razor-thin or non-existent margins, Massachusetts hospitals have learned how to run lean operations. Some of this streamlined activity is attributable to the increasing presence of hospitalists. The Massachusetts Hospital Association’s “Patients First” initiative, which (among other things) posts the staffing plans for each unit in every hospital in the state, shows more and more hospitals are using hospitalists. (You can view the staffing plans at www.patientsfirstma.org).

But there are some things hospitals do not completely control, like the cost of labor and new technology—the biggest and fastest-growing parts of hospital budgets. As part of the new reform-inspired focus on hospital costs, Massachusetts providers are turning their attention to administrative expenses—that is, cutting paperwork and frustration by standardizing claims forms and processes across payers. To improve this process further, insurers could do more to explain the benefits and obligations of their myriad products, instead of off-loading that work to harried hospital counselors.

Will Reform Work?

Early results are positive, but the hardest part of reform implementation is just beginning. Since health reform went into effect, approximately 60,000 new enrollees have qualified for the state’s newly expanded Medicaid program. The new Commonwealth Care plans for people and families at up to 300% of the federal poverty line have, to date, 45,000 enrollees. Think of it: More than 100,000 men, women, and children who did not have health coverage 10 months ago now carry an insurance card. They get preventive care. They have the security and comfort that comes with health coverage.

Hospitals, community and business groups, health agencies, health insurers, and community health centers across the state are working to inform the public about opportunities for health coverage. The Massachusetts Hospital Association has joined forces with other advocacy groups to produce hundreds of thousands of posters and brochures in 13 languages to help enrollment efforts. Hospitals are hosting information fairs and meetings and are reaching out to employer and civic organizations; business groups are doing the same. Making reform work is a shared responsibility at this point.

Health insurance is now everyone’s responsibility—individuals, government, employers, and healthcare providers. The state will help people who need it. But the rest of the population—both individuals and employers—must secure insurance plans to protect their own well-being and to make certain that their own health needs don’t burden the system and add costs—costs that could eventually make healthcare less accessible.

The concern now is whether affordable plans with adequate coverage will be available to people who don’t qualify for state help. The balance between good benefits and affordable pricing won’t be easy to achieve. It’s not impossible, however, and the current thinking throughout the state is that this bold health reform experiment cannot be allowed to fail. TH

Timothy Gens, Esq., is senior vice president of the Massachusetts Hospital Association.