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Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: What are the factors that promote education in delivering high-value, cost-conscious care?

Background: Healthcare costs are increasing, with most recent numbers showing U.S. expenditures on healthcare of more than $3 trillion, almost 18% of the gross domestic product. High-value care focuses on understanding the benefits, risks, and costs of care and promoting interventions that add value.

Study design: Systematic review.

Setting: Physicians, resident physicians, and medical students in North America, Asia, and Oceania.

Synopsis: Seventy-nine articles were included in the analysis, with 14 being RCTs. Most of the studies were conducted in North America (78.5%) and used a pre-post interventional design (58.2%). Practicing physicians (36.7%) made up the majority of participants in the study, with residents (15.2%) and medical students (6.3%) in smaller numbers. Analysis of the studies identified three factors for successful learning:

• effective transmission of knowledge about prices of services and general health economics, scientific evidence, and patient preferences;
• facilitation of reflective practice through feedback and/or stimulating reflection; and
• creation of a supportive environment.

Bottom line: The most-effective interventions in educating physicians, resident physicians, and medical students on high-value, cost-conscious care are effective transmission of knowledge, reflective practice, and supportive environment.

Citation: Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015;314(22):2384-2400.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

Clinical question: Is there a clinical difference in rates of return of spontaneous circulation (ROSC) and survival to discharge in patients with in-hospital cardiac arrest (IHCA) depending on time of day and day of the week?

Background: Current U.S. data from the American Hospital Association’s “Get with the Guidelines-Resuscitation” (AHA GWTG-R) show hospital survival is lower at night and on the weekends. However, little data exist in the U.K. describing patients already hospitalized and the outcomes of in-hospital cardiac arrest with respect to time of day and day of the week.

Study design: Observational cohort study.

Setting: One hundred forty-six hospitals in the United Kingdom.

Synopsis: Study investigators included 27,700 patients ≥16 years of age receiving chest compressions and/or defibrillation from the U.K. National Cardiac Arrest Audit (NCAA) from April 2011 to September 2013. When compared to weekday daytime, the risk-adjusted rates of ROSC were worse for weekend daytime (odds ratio [OR] ROSC >20 min. 0.88; 95% CI, 0.81–0.95) and nighttime (OR ROSC >20 min. 0.72; 95% CI, 0.68–0.76). Hospital survival had similar trends, with OR for the weekend daytime of 0.72 (95% CI, 0.64–0.80) and OR for nighttime 0.58 (95% CI, 0.54–0.63; P value for all was <0.001).

IHCAs were equally likely to occur during the day and night, and the patients were broadly similar, thus suggesting differences in outcomes were secondary to care differences. However, unmeasured patient characteristics may have affected the outcomes. Given that the study was observational, it is difficult to attribute causality, but results are similar to the large, multicenter study published by the AHA GWTG-R registry.

Bottom line: IHCAs that occur during the night or on weekends have increased odds of worse outcomes.

Citation: Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study [published online ahead of print December 11, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004223.

Short Take

USPSTF Recommends Statins for More Americans

The U.S. Preventive Services Task Force recommends a low- to moderate-dose statin for adults ages 40–75 with no history of cardiovascular disease and a calculated 10-year cardiovascular disease event risk of ≥10%.

Citation: U.S. Preventive Services Task Force. Draft recommendation statement: statin use for the primary prevention of cardiovascular disease in adults: preventive medication. Available at:

http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement175/statin-use-in-adults-preventive-medication1. Published December 2015. Accessed April 1, 2016.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

The Centers for Medicare and Medicaid Services has been letting patients grade their hospital experiences, and those "patient experience scores" may give some insight into a hospital's health outcomes, a new study suggests.

Some people have been concerned that patient experience isn't the most important factor to measure, said coauthor Dr. Ashish K. Jha, of the Harvard T. H. Chan School of Public Health in Boston.

"Medicare has been putting a lot of data out for a long time, but the broad consensus has been it's very hard for consumers to use this info," Jha told Reuters Health by phone. "CMS responded by giving out star ratings that consumers can understand easily."

The five-star rating system is based on patients' answers to 27 questions about a recent hospital stay. Questions cover communication with nurses and doctors, the responsiveness of hospital staff, the hospital's cleanliness and quietness, pain management, communication about medicines, discharge

information, and would they recommend the hospital.

The survey is administered to a random sample of adult patients between 48 hours and six weeks after hospital discharge. Consumers can compare their local hospitals online.

For the new study, the researchers compared the CMS patient-experience ratings at more than 3,000 hospitals in October 2015 to data from those hospitals on death or readmission within 30 days of discharge.

Patients in the study had been hospitalized for myocardial infarction, pneumonia or heart failure.

Of the 3,000 hospitals, 125 had five stars, more than 2,000 had three or four stars, 623 had two stars, and 76 had only one star.

Four and five-star hospitals tended to be small rural nonteaching hospitals in the Midwest.

Five-star hospitals had the lowest average patient death rate, 9.8 percent over the 30 days following discharge, while four three and two-star hospitals all had just over 10 percent mortality rates and one-star hospitals had an average 11.2 percent mortality rate, as reported in a research letter online April 10 in JAMA Internal Medicine.

Five-star hospitals also readmitted less than 20 percent of patients over the next month, while other hospitals all readmitted at least that many.

The data only included Medicare patients, who are older andmay not have the same results as younger patients, and there was not much difference between two, three and four-star hospitals, the authors note.

"If you use the star rating you're more likely to end up at a high quality hospital," Jha said. "But I wouldn't use only the star rating to choose a hospital."

"I don't think these data are enough to by themselves to suggest that (patients) should use the star rating as a single guide to choose an institution," agreed Dr. Joshua J. Fenton of the University of California, Davis, who was not part of the new study.

No large hospitals had five stars, and more than half of the five-star facilities didn't have an intensive care unit, Fenton told Reuters Health by phone.

"I can say from practicing in a rural hospital for a few years and we did not have an ICU, when we hospitalized someone with pneumonia or congestive heart failure, we would certainly not have kept them there if we thought it was likely there would be a complication," he said.

Smaller rural hospitals "select" less acute patients, he said. The authors of the new study tried to account for that, but it may still have affected the results.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
3. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
3. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.

Hospitalists’ struggles with the promise and pitfalls of the electronic health record (EHR) can also impinge on their personal satisfaction with their jobs.

The EHR has been identified as a major contributor to physician burnout. Research conducted in 2013 by the RAND Corporation and the American Medical Association (AMA) identified EHRs as the leading cause of physician dissatisfaction, emotional fatigue, depersonalization, and lost enthusiasm for the job.1 The MEMO study found that increased numbers of EHR functions in primary-care settings were associated with physician-reported stress, burnout, and desire to leave the practice.2 Daniel Roberts, MD, FHM, and colleagues found that more than half of hospitalists (52.3%) were affected by burnout, although rates were not higher than in outpatient settings.3

“It’s not fair to blame all physician burnout on the EHR, but the EHR has enabled others to place new demands on physicians and their practices,” says Christine Sinsky, MD, a former hospitalist and current vice president of professional satisfaction for AMA. “The current state of EHR technology appears to worsen professional satisfaction in multiple ways, resulting in reduced face time with patients and more time spent on data-entry functions.”

Dr. Sinsky says her association is trying to address the problem, both with advocacy to delay or revise government requirements for EHR adoption and through its STEPS Forward initiative to help physicians and their staffs redesign medical practices to minimize stress in a changing healthcare environment.

The AMA/RAND research did not break out hospital medicine specifically, although it identified high rates of job dissatisfaction for internists.

Jonathan Pell, MD, hospitalist and assistant professor of medicine at the University of Colorado in Denver, says more research is needed to connect the dots between the EHR and hospitalists’ job satisfaction.

“It makes me wonder, does the EHR affect hospitalists differently than it does outpatient doctors?” he says. “More hospitals and health systems are starting to survey physicians regarding their job satisfaction.”

Dr. Pell also points to computerized physician order entry as a related contributor to job stress.

What Can the Hospitalist Do?

“I’m a believer in the EHR,” says R.J. Bunnell, MD, hospitalist at the 321-bed McKay-Dee Hospital in Ogden, Utah, and physician champion for EHR implementation at Salt Lake City–based Intermountain Healthcare. “We have the potential to reduce medical errors and decrease the burden on physicians, eventually providing unique decision support tools.”

Dr. Bunnell says many of the issues with EHR stem from the complex designs of the systems and cumbersome data collection.

“The practice of medicine is getting more complex year by year, with more regulatory oversight and well-intentioned—but poorly designed—mandates,” he says. “Physicians spend less one-on-one time with their patients and feel they no longer have power over their jobs.”

Dr. Bunnell helped plan implementation of the Intermountain EHR, including its rollout at McKay-Dee last fall.

“We had a positive response to going electronic here,” he says. “Part of it was just the inefficiency of how we did things before, where physicians were already spending 60% of their day on documenting. We started working with our vendor in 2013 to set things up. The team was very proactive, and we spent more than a year on staff training. There’s always a steep learning curve, but it has gone better here than other places.”

Poor rollout and lack of physician involvement in system design can be major contributors to EHR burnout, he adds.

“But for hospitalists, going forward, this is the kind of thing where our specialty could really shine—creating specialized roles for ourselves as agents of change,” Dr. Bunnell says. “If we as physicians don’t recognize the drivers behind these mandates, we’ll just continue to react to them. My hope is that … we will embrace the change, get involved, and find ways to use these tools to fulfill their promise.” TH

Larry Beresford is a freelance writer in California.

References

1. Friedberg MW, Chen PG, Van Busum KR, et al. Research report: factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica, CA: Rand Corporation, 2013.
2. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO Study. J Am Med Inform Assoc. 2014;21(e1): e100-106.
3. Roberts DL, Shanafelt TD, Dyrbye LN, West CP. A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med. 2014;9(3):176-181.

Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.

Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.

Have you been a practicing hospitalist for five years, a member of SHM for three years, and an attendee at an SHM annual meeting? If so, you may be eligible to set yourself apart as a leader in the hospital medicine movement who is committed to quality, improved outcomes, and exceptional patient care.

Physicians, nurse practitioners, physician assistants, and practice administrators are invited to apply to the Fellow (FHM) or Senior Fellow (SFHM) in Hospital Medicine designation from SHM.

Learn more at www.hospitalmedicine.org/fellow. Applications will be open for the SHM Fellows Class of 2017 from May 23, 2016, to November 18, 2016.

To ensure hospitalists have the latest information about diagnosis, treatment, and transition of hospitalized patients with venous thromboembolism (VTE), SHM has developed:

• An online tool kit, including a literature review; implementation guide; and other references, materials, and tools such as discharge instructions and checklists
• A webinar series with free CME

These resources are now available. Get the scoop at www.hospitalmedicine.org/VTEtreatment.

To ensure hospitalists have the latest information about diagnosis, treatment, and transition of hospitalized patients with venous thromboembolism (VTE), SHM has developed:

• An online tool kit, including a literature review; implementation guide; and other references, materials, and tools such as discharge instructions and checklists
• A webinar series with free CME

These resources are now available. Get the scoop at www.hospitalmedicine.org/VTEtreatment.

To ensure hospitalists have the latest information about diagnosis, treatment, and transition of hospitalized patients with venous thromboembolism (VTE), SHM has developed:

• An online tool kit, including a literature review; implementation guide; and other references, materials, and tools such as discharge instructions and checklists
• A webinar series with free CME

These resources are now available. Get the scoop at www.hospitalmedicine.org/VTEtreatment.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

(Reuters Health) - Patients assigned a "nonurgent" status on arrival in the emergency room might still be sick enough to be hospitalized, a new study shows.

Patients deemed by triage nurses to be "nonurgent" often receive diagnostic services and procedures, and some are even admitted to critical care units, researchers found.

Triage was never intended to completely rule out severe illness, only to give patients an estimate of how long they may have to wait to see a doctor, the researchers note.

Dr. Renee Y. Hsia of the University of California, San Francisco and colleagues used a national survey of patient visits to the emergency department (E.D.) between 2009 and 2011, with triage scores assigned by a nurse when the patient arrived. The scores range from one to five, with one through three including immediate, emergency and urgent patients, and four and five being semi-urgent and nonurgent.

They used data on almost 60,000 observations of patients age 18 to 64 collected between 2009 and 2011, which represented 240 million E.D. visits. More than 90 percent had a score of one to

four and were deemed "urgent" visits, while about eight percent had a score of five and were "nonurgent."

Almost half of nonurgent visits involved diagnostic scans, imaging or blood tests, and a third involved procedures like splinting or giving intravenous fluids. For urgent visits, about three-quarters involved diagnostics and half involved procedures.

About four of every 100 non-urgent visits resulted in hospital admission, as reported in JAMA Internal Medicine.

Backache, acute upper respiratory infections, soft-tissue inflammation, and acute sore throat were among the 10 most common diagnoses for both urgent and non-urgent patients.

"Triage is normally done at the very beginning of the visit, usually by a triage nurse," Hsia told Reuters Health by email. "Triaging patients is an extremely difficult task, since patients are what we (as providers) call 'undifferentiated,' since there has not been time to do a full history and physical, and nurses have limited information upon which to base their determination."

"We should not expect triage categorization to be perfect, and one of the goals of this paper is to show that, indeed, triage is not," Hsia said.

Many states have policies that patients with Medicaid insurance who present to the E.D. for "non-urgent" visits will be charged a co-payment, which may keep people from seeking

needed care, even though the triage system is not perfect, she said.

"It is important that we do not blame the patient for going to the E.D. if there were no alternatives that were available in a timely manner," Hsia said.

"Our study cannot distinguish the reasons behind why we found such a high proportion of visits that received diagnostic services or procedures," she said.

Some of the procedures may not have needed to happen in an E.D. setting, but since the patients presented there, they were treated, Hsia added.

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

In the first two installments of my own list of attributes that are important underpinnings of successful hospitalist groups, I covered group culture and decision making, recruiting, the importance of a written policy and procedure manual and performance dashboard, and roles for advanced practice clinicians. I’ll continue numbering from last month and complete the list in this column.

7. Clear Reporting Relationships

Most hospitalists are employed by one entity, usually a hospital subcorporation or staffing company, yet in many respects they report to someone else, such as a hospital CMO. For many, this can feel like serving two masters.

As an example, a hospitalist is employed by St. Excellence Medical Group (SEMG), a subsidiary of St. Excellence Hospital. Yet the hospital CMO is the key person establishing hospitalist performance targets, mediating disagreements between hospitalists and cardiologists, etc. So the hospitalists and CMO might jointly make plans for changes in the hospitalist practice that have staffing or budgetary implications only to find that the SEMG president resists spending more on the hospitalist program. For some hospitalist groups, this problem of being stuck between two masters can be a real barrier to getting things done.

Because the employed physician group nearly always directs most of its attention to outpatient care, the hospitalists are sometimes an afterthought, sort of a like a neglected stepchild. And worse, I’ve worked with more than one organization in which the CMO and physician president of the employed physician group are engaged in a power struggle, with the hospitalist group (and other physician specialties) caught in the middle and suffering as a result.

I think the best way out of this dilemma is for the employed physician group to function as a management services organization, providing human resources (payroll, etc.) and revenue cycle functions to the hospitalist groups. But for nearly all other issues, such as policies and procedures, staffing, strategic planning, hiring and firing, etc., the lead hospitalist should report to the CMO.

8. Well-Organized Group Meetings

My experience is that nearly every hospitalist group has periodic meetings to discuss and make decisions on operational and clinical issues. But the effectiveness of the meetings varies a lot. In some cases, they’re little more than disorganized gripe sessions.

I think most groups should have monthly meetings scheduled for about an hour or a little longer. Attendance at most meetings should be the expectation; that means even those not working clinically that day should be expected to attend unless away on vacation or some other meaningful conflict. Simply not being on clinical service that day should not be a reason to miss the meeting. Attendance by phone periodically is usually fine, especially for those who would otherwise have a long drive to attend in person or have child care duties, etc.

An agenda should be circulated in advance of the meeting; minutes, afterward. The best minutes highlight any “to-do” items, including person responsible and target completion date. Tasks occurring over longer than a month should be tracked in the minutes of every meeting until resolved. All past meeting minutes should be readily accessible via a network computer drive for review by any member of the group at any time.

Although some of every meeting will typically need to be devoted to one-way communication from the group leader or others, ideally in every meeting meaningful time should be devoted to joint problem-solving by all in attendance to ensure all are engaged in the meetings and find them useful. Some one-way communication (e.g., regular reports of performance data) typically can be distributed via email and other means rather than devoting meeting time to review it.

9. Effective Compensation

The amount of compensation should be competitive with your market, but because compensation is typically seen as an entitlement, unusually high compensation amounts usually have little impact on performance. But the method of compensation can matter, that is, the portion of total dollars that are fixed, tied to production, or tied to performance.

I think it’s best if the compensation method is generally similar to the way Medicare and other payors reimburse physician services. As payors tie increasing portions of compensation to performance and bundled payments, it makes sense for these changes to be mirrored in hospitalist compensation formulas to the extent that is practical. As I’ve written in February 2014 and many other times, I think there will always be a role for a portion of compensation tied to individual productivity.

According to SHM’s 2014 State of Hospital Medicine report, 64% of hospitalist groups have some component of compensation tied to citizenship activities such as committee participation, grand rounds presentations, community talks, publications, etc. I described a citizenship bonus program in detail in my November 2011 column. And while I was once an advocate of it, I’m now ambivalent. My anecdotal experience with the group I’m part of and many others I’ve worked with makes me suspect that a bonus for good citizenship might just squash intrinsic motivation as described in Daniel Pink’s book Drive.

If you do tie some portion of compensation to citizenship, I strongly encourage not connecting it to basic expectations like meeting attendance or turning in billing data on time. These are standard parts of the job, and citizenship pay should be reserved for going beyond the basics.

10. Good Social Connections

The way things look to me, doctors across all specialties have historically enjoyed robust and rewarding social connections with one another. But with each passing year, the nature of the work, financial pressures, and even clinical vocabulary become more and more different; that is, our Venn diagrams overlap less and less.

I think doctors in different specialties are becoming less connected, and disagreements or new stresses can more easily divide us.

Although all hospitals and medical groups are working hard to implement operational and technical adjustments to keep up with changing clinical practice and reimbursement models, I see very few deliberately focused on maintaining or strengthening the social connections and feeling of occupational solidarity and shared mission across doctors and other providers (see my June 2010 column). Those that do so—to my way of thinking—will be uniquely positioned to weather the storm of rapid change much more effectively. TH

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."

NEW YORK (Reuters Health) - Among medically treated patients with acute coronary syndrome (ACS), prior clopidogrel therapy appears to be associated with more cardiovascular events, researchers have found.

As Dr. Chee Tang Chin told Reuters Health by email, "We found that among patients who were admitted for an acute coronary syndrome and did not undergo coronary revascularization, those patients who were already taking clopidogrel were at a higher risk for a subsequent

cardiovascular event, as compared to patients not taking clopidogrel on admission."

The study, a prespecified subanalysis of the TRILOGY ACS trial, was published online March 30 in Heart.

Of almost 9,000 patients, 73% first received clopidogrel in-hospital within 72 hours of presentation and daily until randomization to clopidogrel versus prasugrel (plus aspirin). The remaining 27% were taking clopidogrel prior to admission and continued daily clopidogrel therapy until the date of randomization.

Over 30 months, those with prior clopidogrel use had a significantly higher frequency of cardiovascular death, MI and stroke (20.8% vs. 18.3%, p=0.002). There was no significant  difference in the frequency of bleeding events.

Dr. Chin pointed out that in the prior users, "This excess risk was largely accounted for by the higher burden of high-risk co-morbidities among this group, such as diabetes and prior

cardiovascular disease. However, consistent with the overall TRILOGY-ACS results, the use of a more potent antiplatelet agent such as prasugrel did not modify this risk."

"These results," Dr. Chin concluded, "are important as they imply that among ACS patients treated only medically, strategies beyond platelet inhibition need to be considered for further optimizing outcomes."