Career

Physicians who receive professional coaching are less emotionally exhausted and less vulnerable to burnout, according to the results of a pilot study.

dragana991/iStock/Getty Images Plus

“This intervention adds to the growing literature of evidence-based approaches to promote physician well-being and should be considered a complementary strategy to be deployed in combination with other organizational approaches to improve system-level drivers of work-related stressors,” wrote Liselotte N. Dyrbye, MD, of the Mayo Clinic in Rochester, Minn., and coauthors in JAMA Internal Medicine.

Dr. Dyrbye and colleagues conducted a randomized pilot study of 88 Mayo Clinic physicians in the departments of medicine, family medicine, and pediatrics. Half (n = 44) received 3.5 hours of sessions facilitated by a professional coach. The other half (n = 44) served as controls. Participants’ well-being – in regard to burnout, quality of life, resilience, job satisfaction, engagement, and meaning at work – was surveyed at baseline and the study’s completion.

Physicians in the coaching group participated in a 1-hour initial telephone session, designed to establish a relationship between the physician and coach, as well as to assess needs, set goals, identify values, and create an action plan. During follow-up sessions, coaches would check in, help plan and set goals, and suggest strategies/changes to incorporate into daily life. Physicians were permitted to ask for support on any issue, but also were expected to see as many patients as their colleagues outside of the study.

After 6 months, physicians in the coaching group saw a significant decrease in emotional exhaustion by a mean of 5.2 points, compared with an increase of 1.5 points in the control group. At 5 months, absolute rates of high emotional exhaustion decreased by 19.5% in the coaching group and increased by 9.8% in the control group and absolute rates of overall burnout decreased by 17.1% in the coaching group and increased by 4.9% in the control group. Quality of life and resilience scores also improved, though there were no notable differences between groups in measures of job satisfaction, engagement, and meaning at work.

The authors noted their study’s limitations, which included a modest sample size and a volunteer group of participants.

In addition, the lower percentage of men in the study – 48 of 88 participants were women – may be a result of factors that deserve further investigation. Finally, burnout rates among volunteers were higher than those among other physicians, suggesting that “the study appealed to those in greatest need of the intervention.”

The study was funded by the Mayo Clinic department of medicine’s Program on Physician Well-Being and the Physician Foundation. Two of the authors – Dr. Dyrbye and Tait D. Shanafelt, MD, of Stanford (Calif.) University – reported being the coinventors of, and receiving royalties for, the Physician Well-Being Index, Medical Student Well-Being Index, Nurse Well-Being Index, and the Well-Being Index.

SOURCE: Dyrbye LN et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.2425.

Physicians who receive professional coaching are less emotionally exhausted and less vulnerable to burnout, according to the results of a pilot study.

dragana991/iStock/Getty Images Plus

“This intervention adds to the growing literature of evidence-based approaches to promote physician well-being and should be considered a complementary strategy to be deployed in combination with other organizational approaches to improve system-level drivers of work-related stressors,” wrote Liselotte N. Dyrbye, MD, of the Mayo Clinic in Rochester, Minn., and coauthors in JAMA Internal Medicine.

Dr. Dyrbye and colleagues conducted a randomized pilot study of 88 Mayo Clinic physicians in the departments of medicine, family medicine, and pediatrics. Half (n = 44) received 3.5 hours of sessions facilitated by a professional coach. The other half (n = 44) served as controls. Participants’ well-being – in regard to burnout, quality of life, resilience, job satisfaction, engagement, and meaning at work – was surveyed at baseline and the study’s completion.

Physicians in the coaching group participated in a 1-hour initial telephone session, designed to establish a relationship between the physician and coach, as well as to assess needs, set goals, identify values, and create an action plan. During follow-up sessions, coaches would check in, help plan and set goals, and suggest strategies/changes to incorporate into daily life. Physicians were permitted to ask for support on any issue, but also were expected to see as many patients as their colleagues outside of the study.

After 6 months, physicians in the coaching group saw a significant decrease in emotional exhaustion by a mean of 5.2 points, compared with an increase of 1.5 points in the control group. At 5 months, absolute rates of high emotional exhaustion decreased by 19.5% in the coaching group and increased by 9.8% in the control group and absolute rates of overall burnout decreased by 17.1% in the coaching group and increased by 4.9% in the control group. Quality of life and resilience scores also improved, though there were no notable differences between groups in measures of job satisfaction, engagement, and meaning at work.

The authors noted their study’s limitations, which included a modest sample size and a volunteer group of participants.

In addition, the lower percentage of men in the study – 48 of 88 participants were women – may be a result of factors that deserve further investigation. Finally, burnout rates among volunteers were higher than those among other physicians, suggesting that “the study appealed to those in greatest need of the intervention.”

The study was funded by the Mayo Clinic department of medicine’s Program on Physician Well-Being and the Physician Foundation. Two of the authors – Dr. Dyrbye and Tait D. Shanafelt, MD, of Stanford (Calif.) University – reported being the coinventors of, and receiving royalties for, the Physician Well-Being Index, Medical Student Well-Being Index, Nurse Well-Being Index, and the Well-Being Index.

SOURCE: Dyrbye LN et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.2425.

Physicians who receive professional coaching are less emotionally exhausted and less vulnerable to burnout, according to the results of a pilot study.

dragana991/iStock/Getty Images Plus

“This intervention adds to the growing literature of evidence-based approaches to promote physician well-being and should be considered a complementary strategy to be deployed in combination with other organizational approaches to improve system-level drivers of work-related stressors,” wrote Liselotte N. Dyrbye, MD, of the Mayo Clinic in Rochester, Minn., and coauthors in JAMA Internal Medicine.

Dr. Dyrbye and colleagues conducted a randomized pilot study of 88 Mayo Clinic physicians in the departments of medicine, family medicine, and pediatrics. Half (n = 44) received 3.5 hours of sessions facilitated by a professional coach. The other half (n = 44) served as controls. Participants’ well-being – in regard to burnout, quality of life, resilience, job satisfaction, engagement, and meaning at work – was surveyed at baseline and the study’s completion.

Physicians in the coaching group participated in a 1-hour initial telephone session, designed to establish a relationship between the physician and coach, as well as to assess needs, set goals, identify values, and create an action plan. During follow-up sessions, coaches would check in, help plan and set goals, and suggest strategies/changes to incorporate into daily life. Physicians were permitted to ask for support on any issue, but also were expected to see as many patients as their colleagues outside of the study.

After 6 months, physicians in the coaching group saw a significant decrease in emotional exhaustion by a mean of 5.2 points, compared with an increase of 1.5 points in the control group. At 5 months, absolute rates of high emotional exhaustion decreased by 19.5% in the coaching group and increased by 9.8% in the control group and absolute rates of overall burnout decreased by 17.1% in the coaching group and increased by 4.9% in the control group. Quality of life and resilience scores also improved, though there were no notable differences between groups in measures of job satisfaction, engagement, and meaning at work.

The authors noted their study’s limitations, which included a modest sample size and a volunteer group of participants.

In addition, the lower percentage of men in the study – 48 of 88 participants were women – may be a result of factors that deserve further investigation. Finally, burnout rates among volunteers were higher than those among other physicians, suggesting that “the study appealed to those in greatest need of the intervention.”

The study was funded by the Mayo Clinic department of medicine’s Program on Physician Well-Being and the Physician Foundation. Two of the authors – Dr. Dyrbye and Tait D. Shanafelt, MD, of Stanford (Calif.) University – reported being the coinventors of, and receiving royalties for, the Physician Well-Being Index, Medical Student Well-Being Index, Nurse Well-Being Index, and the Well-Being Index.

SOURCE: Dyrbye LN et al. JAMA Intern Med. 2019 Aug 5. doi: 10.1001/jamainternmed.2019.2425.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

For patients, including patients who are physicians, knowledge isn’t power, according to investigators.

megaflopp/Thinkstock

A literature review and retrospective analysis of more than 35,000 physicians treated as patients revealed minimal associations between level of medical knowledge and quality of health outcomes, reported Michael D. Frakes, PhD, of Duke University, Durham, N.C., and colleagues. The study findings stand in opposition to the “widely prevailing view” that information and medical knowledge among patients are integral to realizing high-quality, low-cost health care, the investigators noted.

“[This] research is particularly relevant to modern discussions and debates about the consumer-driven health care movement and the use of plans with high deductibles and high copayments to encourage greater patient and consumer involvement in health care decision making,” Dr. Frakes said in an interview. “Recent research has suggested that the financial incentives created by such structures discourage the use of both low-value care and high-value care. Some have argued that greater disclosure of information to patients may address this concern and steer patients towards high-value decisions. Our results cast doubt on the potential for information initiatives alone to meet this aim.”

The study is one of the first of its kind, the investigators noted in the National Bureau of Economic Research working paper. Other than a 2016 publication that found that physician mothers were less likely to have cesarean sections (Am Econ J: Econ Policy. 2016;8[1]:115-41), “there is no work which has been able to study the role of physicians as patients,” they wrote.

To fill this gap, the investigators turned to a unique data source: The Military Health System, which provides insurance to active and retired military personnel and their families. Military Health System spending exceeds $50 billion per year, constituting a major portion of American health care expenditures, and with more than 35,000 military physicians treated as patients, the dataset is highly relevant and powerful. The investigators objectively evaluated health outcomes by focusing on evidence-based, measurable clinical decisions deemed “high value” or “low value,” comparing how the frequency of these choices related with physician versus nonphysician patient status.

Coauthor Jonathan Gruber, PhD, of the Massachusetts Institute of Technology in Cambridge, Mass., explained this methodology in an interview. “The literature is clear that high-value care has positive health outcomes with relatively small increases in health care spending, and that low-value care has no impact on health outcomes with large increases in spending.”

“One concern with this analysis, of course, is that physicians may be of different health statuses and have different tastes for medical interventions than nonphysicians,” the investigators wrote. They addressed this problem in five ways, by focusing on widely accepted medical standards that apply to all patients; examining both high- and low-value care to eliminate one-sided bias; controlling for underlying health differences across groups; comparing physicians with other military officers to account for underlying tastes; and evaluating military officer dependents in comparison with physician dependents, the latter of whom may benefit from medical knowledge by virtue of personal relationship.

“Our results suggest that physicians do only slightly better than nonphysicians,” the investigators wrote, “but not by much and not always.” Low-value care was slightly less common among physicians, but this difference was described as “modest.” Analysis of high-value care was more mixed, with some results supporting equivalence between groups and others pointing to a slightly higher rate of high-value care among physician patients.

“These results provide a rough boundary on the extent to which additional information disclosure [beyond prevailing levels] can be expected to improve the delivery of health care in the U.S.,” the investigators wrote. “[M]ost of the explanation behind the over- and underutilization of low- and high-value services likely arises from factors other than informational deficiencies of patients.”

“Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully informed patients,” the investigators wrote, noting that this interpretation aligns with a recent working paper that found that physicians play a greater role in selecting the site of MRI scans than patient cost-sharing factors.

Looking to the future, Dr. Gruber said that he and his colleagues plan on exploring “what drives this lack of response among physicians [as patients].”

The study was funded by the National Institute on Aging. The investigators reported no conflicts of interest.

SOURCE: Frakes MD et al. Natl Bur Econ Res. 2019 Jul. doi: 10.3386/w26038.

This article was updated 8/6/19.

For patients, including patients who are physicians, knowledge isn’t power, according to investigators.

megaflopp/Thinkstock

A literature review and retrospective analysis of more than 35,000 physicians treated as patients revealed minimal associations between level of medical knowledge and quality of health outcomes, reported Michael D. Frakes, PhD, of Duke University, Durham, N.C., and colleagues. The study findings stand in opposition to the “widely prevailing view” that information and medical knowledge among patients are integral to realizing high-quality, low-cost health care, the investigators noted.

“[This] research is particularly relevant to modern discussions and debates about the consumer-driven health care movement and the use of plans with high deductibles and high copayments to encourage greater patient and consumer involvement in health care decision making,” Dr. Frakes said in an interview. “Recent research has suggested that the financial incentives created by such structures discourage the use of both low-value care and high-value care. Some have argued that greater disclosure of information to patients may address this concern and steer patients towards high-value decisions. Our results cast doubt on the potential for information initiatives alone to meet this aim.”

The study is one of the first of its kind, the investigators noted in the National Bureau of Economic Research working paper. Other than a 2016 publication that found that physician mothers were less likely to have cesarean sections (Am Econ J: Econ Policy. 2016;8[1]:115-41), “there is no work which has been able to study the role of physicians as patients,” they wrote.

To fill this gap, the investigators turned to a unique data source: The Military Health System, which provides insurance to active and retired military personnel and their families. Military Health System spending exceeds $50 billion per year, constituting a major portion of American health care expenditures, and with more than 35,000 military physicians treated as patients, the dataset is highly relevant and powerful. The investigators objectively evaluated health outcomes by focusing on evidence-based, measurable clinical decisions deemed “high value” or “low value,” comparing how the frequency of these choices related with physician versus nonphysician patient status.

Coauthor Jonathan Gruber, PhD, of the Massachusetts Institute of Technology in Cambridge, Mass., explained this methodology in an interview. “The literature is clear that high-value care has positive health outcomes with relatively small increases in health care spending, and that low-value care has no impact on health outcomes with large increases in spending.”

“One concern with this analysis, of course, is that physicians may be of different health statuses and have different tastes for medical interventions than nonphysicians,” the investigators wrote. They addressed this problem in five ways, by focusing on widely accepted medical standards that apply to all patients; examining both high- and low-value care to eliminate one-sided bias; controlling for underlying health differences across groups; comparing physicians with other military officers to account for underlying tastes; and evaluating military officer dependents in comparison with physician dependents, the latter of whom may benefit from medical knowledge by virtue of personal relationship.

“Our results suggest that physicians do only slightly better than nonphysicians,” the investigators wrote, “but not by much and not always.” Low-value care was slightly less common among physicians, but this difference was described as “modest.” Analysis of high-value care was more mixed, with some results supporting equivalence between groups and others pointing to a slightly higher rate of high-value care among physician patients.

“These results provide a rough boundary on the extent to which additional information disclosure [beyond prevailing levels] can be expected to improve the delivery of health care in the U.S.,” the investigators wrote. “[M]ost of the explanation behind the over- and underutilization of low- and high-value services likely arises from factors other than informational deficiencies of patients.”

“Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully informed patients,” the investigators wrote, noting that this interpretation aligns with a recent working paper that found that physicians play a greater role in selecting the site of MRI scans than patient cost-sharing factors.

Looking to the future, Dr. Gruber said that he and his colleagues plan on exploring “what drives this lack of response among physicians [as patients].”

The study was funded by the National Institute on Aging. The investigators reported no conflicts of interest.

SOURCE: Frakes MD et al. Natl Bur Econ Res. 2019 Jul. doi: 10.3386/w26038.

This article was updated 8/6/19.

For patients, including patients who are physicians, knowledge isn’t power, according to investigators.

megaflopp/Thinkstock

A literature review and retrospective analysis of more than 35,000 physicians treated as patients revealed minimal associations between level of medical knowledge and quality of health outcomes, reported Michael D. Frakes, PhD, of Duke University, Durham, N.C., and colleagues. The study findings stand in opposition to the “widely prevailing view” that information and medical knowledge among patients are integral to realizing high-quality, low-cost health care, the investigators noted.

“[This] research is particularly relevant to modern discussions and debates about the consumer-driven health care movement and the use of plans with high deductibles and high copayments to encourage greater patient and consumer involvement in health care decision making,” Dr. Frakes said in an interview. “Recent research has suggested that the financial incentives created by such structures discourage the use of both low-value care and high-value care. Some have argued that greater disclosure of information to patients may address this concern and steer patients towards high-value decisions. Our results cast doubt on the potential for information initiatives alone to meet this aim.”

The study is one of the first of its kind, the investigators noted in the National Bureau of Economic Research working paper. Other than a 2016 publication that found that physician mothers were less likely to have cesarean sections (Am Econ J: Econ Policy. 2016;8[1]:115-41), “there is no work which has been able to study the role of physicians as patients,” they wrote.

To fill this gap, the investigators turned to a unique data source: The Military Health System, which provides insurance to active and retired military personnel and their families. Military Health System spending exceeds $50 billion per year, constituting a major portion of American health care expenditures, and with more than 35,000 military physicians treated as patients, the dataset is highly relevant and powerful. The investigators objectively evaluated health outcomes by focusing on evidence-based, measurable clinical decisions deemed “high value” or “low value,” comparing how the frequency of these choices related with physician versus nonphysician patient status.

Coauthor Jonathan Gruber, PhD, of the Massachusetts Institute of Technology in Cambridge, Mass., explained this methodology in an interview. “The literature is clear that high-value care has positive health outcomes with relatively small increases in health care spending, and that low-value care has no impact on health outcomes with large increases in spending.”

“One concern with this analysis, of course, is that physicians may be of different health statuses and have different tastes for medical interventions than nonphysicians,” the investigators wrote. They addressed this problem in five ways, by focusing on widely accepted medical standards that apply to all patients; examining both high- and low-value care to eliminate one-sided bias; controlling for underlying health differences across groups; comparing physicians with other military officers to account for underlying tastes; and evaluating military officer dependents in comparison with physician dependents, the latter of whom may benefit from medical knowledge by virtue of personal relationship.

“Our results suggest that physicians do only slightly better than nonphysicians,” the investigators wrote, “but not by much and not always.” Low-value care was slightly less common among physicians, but this difference was described as “modest.” Analysis of high-value care was more mixed, with some results supporting equivalence between groups and others pointing to a slightly higher rate of high-value care among physician patients.

“These results provide a rough boundary on the extent to which additional information disclosure [beyond prevailing levels] can be expected to improve the delivery of health care in the U.S.,” the investigators wrote. “[M]ost of the explanation behind the over- and underutilization of low- and high-value services likely arises from factors other than informational deficiencies of patients.”

“Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully informed patients,” the investigators wrote, noting that this interpretation aligns with a recent working paper that found that physicians play a greater role in selecting the site of MRI scans than patient cost-sharing factors.

Looking to the future, Dr. Gruber said that he and his colleagues plan on exploring “what drives this lack of response among physicians [as patients].”

The study was funded by the National Institute on Aging. The investigators reported no conflicts of interest.

SOURCE: Frakes MD et al. Natl Bur Econ Res. 2019 Jul. doi: 10.3386/w26038.

This article was updated 8/6/19.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Everyone always told me that my time in residency would fly by, and the 3 years of internal medicine training really did seem to pass in just a few moments. Before I knew it, I had passed my internal medicine boards and practiced hospital medicine at an academic medical center.

One day last fall, I received notice from the American Board of Internal Medicine that it was time to recertify. I was surprised – had it already been 10 years? What did I have to do to maintain my certification?

As I investigated what it would take to maintain certification, I discovered that the recertification process provided more flexibility, compared with original board certification. I now had the option to recertify in internal medicine with a Focused Practice in Hospital Medicine (FPHM). Beginning in 2014, ABIM offered hospitalists, or internists whose clinical practice is mainly in the inpatient setting, the option to recertify in internal medicine, but with the designation that highlighted their clinical practice in the inpatient setting.

The first step in recertification for me was deciding to recertify with the focus in hospital medicine or maintain the traditional internal medicine certification. I talked with several colleagues who are also practicing hospitalists and weighed their reasons for opting for FPHM. Ultimately, my decision to pursue a recertification with a focus in hospital medicine relied on three factors: First, my clinical practice since completing residency was exclusively in the inpatient setting. Day in and day out, I care for patients who are acutely ill and require inpatient medical care. Second, I wanted my board certification to reflect what I consider to be my area of clinical expertise, which is inpatient adult medicine. Pursuing the FPHM would provide that recognition. Finally, I wanted to study and be tested on topics that I could utilize in my day-to-day practice. Because I exclusively practiced hospital medicine since graduation, areas of clinical internal medicine that I did not frequently encounter in my daily practice became less accessible in my knowledge base.

The next step then was to enter the FPHM Maintenance of Certification (MOC) program.

The ABIM requires two attestations to verify that I met the requirements to be a hospitalist. First was a self-attestation confirming at least 3 years of unsupervised inpatient care practice experience, and meeting patient encounter thresholds in the inpatient setting. The second attestation was from a “Senior Hospital Officer” confirming the information in the self-attestation was accurate.

Once entered into the program and having an unrestricted medical license to practice, I had to complete the remaining requirements of earning MOC points and then passing a knowledge-based assessment. I had to accumulate a total of 100 MOC points in the past 5 years, which I succeeded in doing through participating in quality improvement projects, recording CME credits, studying for the exam, and even taking the exam. I could track my point totals through the ABIM Physician Portal, which updated my point tally automatically for activities that counted toward MOC, such as attending SHM’s annual conference.

The final component was to pass the knowledge assessment, the dreaded exam. In 2018, I had the option to take the 10-year FPHM exam or do a general internal medicine Knowledge Check-In. Beginning in 2020, candidates will be able to sit for either the 10-year Focused Practice in Hospital Medicine exam or begin the Hospital Medicine Knowledge Check-In pathway. I had already decided to pursue FPHM and began to prepare to sit for an exam. I scheduled my exam through the ABIM portal at a local testing center.

The exam was scheduled for a full day, consisting of four sections broken up by a lunch break and section breaks. Specifically, the 220 single best answer, multiple-choice exam covered diagnosis, testing, treatment decisions, epidemiology, and basic science content through patient scenarios that reflected the scope of practice of a hospitalist. The ABIM provided an exam blueprint that detailed the specific clinical topics and the likelihood that a question pertaining to that topic would show up on the exam. Content was described as high, medium, or low importance and the number of questions related to the content was 75% for high importance, no more than 25% for medium importance, and no questions for low-importance content. In addition, content was distributed in a way that was reflective of my clinical practice as a hospitalist: 63.5% inpatient and traditional care; 6.5% palliative care; 15% consultative comanagement; and 15% quality, safety, and clinical reasoning.

Beginning 6 months prior to my scheduled exam, I purchased two critical resources to guide my studying efforts: the SHM Spark Self-Assessment Tool and the American College of Physicians Medical Knowledge Self-Assessment Program to review subject matter content and also do practice questions.

The latest version of SHM’s program, Spark Edition 2, provides updated questions and resources tailored to the hospital medicine exams. I appreciated the ability to answer questions online, as well as on my phone so I could do questions on the go. Moreover, I was able to track which content areas were stronger or weaker for me, and focus attention on areas that needed more work. Importantly, the questions I answered using the Spark self-assessment tool closely aligned with the subject matter I encountered in the exam, as well as the clinical cases I encounter every day in my practice.

While the day-long exam was challenging, I was gratified to receive notice from the ABIM that I had successfully recertified in internal medicine with a Focused Practice in Hospital Medicine!

Dr. Tad-y is a hospitalist at the University of Colorado at Denver, Aurora, and associate vice chair of quality in the department of medicine at the University of Colorado.

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]

Physician employment contracts increasingly include value- and quality-based metrics as bases for production bonuses, according to an analysis of recruitment searches from April 1, 2018, to March 31, 2019.

Metrics such as physician satisfaction rates, proper use of EHRs, following treatment protocols, and others that don’t directly measure volume are becoming more commonplace in employment contracts, though volume measures still are included, according to Phil Miller, vice president of communications at health care recruiting firm Merritt Hawkins and author of the company’s 2019 report on physician and advanced practitioner recruiting incentives, released July 8.

Of 70% of searches that offered a production bonus, 56% featured a bonus based at least in part on quality metrics, up from 43% in 2018. The finding represents the highest percent of contracts offering a quality-based bonus that the company has tracked, according to the report.

Merritt Hawkins’ review is based on a sample of the 3,131 permanent physician and advanced practitioner search assignments that Merritt Hawkins and its sister physician staffing companies at AMN Healthcare have ongoing or were engaged to conduct from April 1, 2018 to March 31, 2019.

Other common value-based metrics include reduction in hospital readmissions, cost containment, and proper coding.

While value-based incentives are on the rise, “facilities that employ physicians want to ensure they stay productive, and ‘productivity’ still is measured in part by what are essentially fee-for-service metrics, including relative value units [RVUs], net collections, and number of patients seen.”

RVUs were used in 70% of production formulas tracked in the 2019 review, up from 50% in the previous year and also a record high.

Mr. Miller noted that employers are seeking the “Goldilocks’ zone,” a balance point between traditional productivity measures and value-based metrics, very much a work in progress right now.

A possible corollary to the increase in production bonuses is a flattening of signing bonuses. During the current review period, 71% of contracts came with a signing bonus, up slightly from 70% in the previous year’s report and down from 76% 2 years ago.

Signing bonuses in the review period for the 2019 report averaged $32,692, down from $33,707 during the 2018 report’s review period.

Overall, family practice physicians remain the highest in demand for job searches, but specialty practice is gaining ground.

For the 2018-2019 review, family medicine was the most requested search by specialty, with 457 searches requested. While the ranking remains No. 1, as it has for the past 13 years, the number of searches has been on a steady decline. Last year, there were 497 searches, which was down from 607 2 years ago and 734 4 years ago.

Mr. Miller said there were a few reasons for the lower number of searches. “One is just the momentum shifts that are kind of inherent to recruiting. People put all of their resources into one area, typically, and in this case it was primary care and they realized, ‘Hey wait a minute, we need some specialists for these doctors to refer to, so now we have to put some of our chips in the specialty basket.’ ”

The Baby Boomers also is having an effect – as they age and are experiencing more health issues, more specialists are needed.

“[Older patients] visit the doctor twice or three times the rate of a younger person and they also generate a much higher percentage of inpatient procedures and tests and diagnoses,” he said.

On the opposite end of the spectrum, “younger people are less likely to have a primary care doctor who coordinates their care,” Mr. Miller said. “What they typically do is go to an urgent care center, a retail clinic, maybe even [use] telemedicine so they are not accessing the system in the same way or necessarily through the same provider.”

Demand for psychiatrists remained strong for the fourth year in a row, but the number of searches has declined for the last several years. For the current review period, there were 199 searches, down from 243 the previous year, 256 2 years ago, and 250 3 years ago.

There is “pretty much a crisis in behavioral health care now because there are so few psychiatrists and the demand has increased,” Mr. Miller noted.

[email protected]

Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Being in stressful situations is part of being a hospitalist. During a hospitalist’s work shift, one of the key determinants of stress is adequate staffing. With use of survey data from 569 hospital medicine groups (HMGs) across the nation, one of the topics examined in the 2018 State of Hospital Medicine Report is how HMGs cope with unfilled hospitalist physician positions.

The survey presented five options for covering unfilled hospitalist physician positions: use of locum tenens, use of moonlighters, use of voluntary extra shifts by the HMG’s existing hospitalists, use of required extra shifts, and leaving some shifts uncovered. Recipients were instructed to select all options that applied, so totals exceeded 100%. The data is organized according to HMGs that serve adults only, children only, and both adults and children.

For all three types of HMGs, the most common tactic to fill coverage gaps is through voluntary extra shifts by existing clinicians, reportedly used by 70.3% of HMGs that cover adults only, 66.7% by those that cover children only, and 76.9% by those that cover both adults and children. Data for adults-only HMGs was further broken down by geographic region, academic status, teaching status, group size, and employment model. Among adults-only HMGs, there is a direct correlation between group size and having members voluntarily work extra shifts, with 91.1% of groups with 30 or more full-time equivalent positions employing this tactic.

For HMGs that cover adults only and those that cover children only, the second most common tactic is to use moonlighters (57.4% and 53.3% respectively), while use of moonlighters is the third most commonly employed surveyed tactic for HMGs that cover both adults and children (53.8%).

HMGs that serve both adults and children were much more likely to utilize locum tenens to cover unfilled positions (69.2%) than were groups that serve adults only (44.0%) or children only (26.7%). The variability in the use of locum tenens is likely because of the willingness and/or ability of the respective groups to afford this option because it is generally the most expensive option of those surveyed.

Requiring that members of the group work extra shifts is the least popular staffing method among adults-only HMGs (10.0%) and HMGs serving both children and adults (7.7%). This strategy is unpopular, especially when there is little advance warning. Surprisingly, 40.0% of HMGs that see children only require members to work extra shifts to cover unfilled slots. This could be because pediatric HMGs are often smaller, and it would be more difficult to absorb the work if the shift is left uncovered. In fact, many pediatric HMGs staff with only one clinician at a time, so there may be no option besides requiring someone else in the group to come in and work.Of the options surveyed, perhaps the most uncomfortable for those hospitalist physicians on duty is to leave some shifts uncovered. The rapid growth and development of the specialty of hospital medicine has made it difficult for HMGs to continuously hire qualified hospitalists fast enough to meet demand. The survey found 46.2% of HMGs that serve both adults and children and 31.4% of groups that serve adults only have employed the staffing model of going short-staffed for at least some shifts. HMGs serving children-only are much less likely to go short-staffed (20.0%).

I work with a large HMG that has more than 70 members, and when it has been short-staffed, it tries to ensure a full complement of evening and night staff as the top priority because these shifts are typically more stressful. Since we have more hospitalist capacity during the day to absorb the loss of a physician, we pull staff from their daytime rounding schedules to execute this strategy. While going short-staffed is not ideal, this option has worked for many groups out of sheer necessity.

Dr. Stephan is a hospitalist at Allina Health’s Abbott Northwestern Hospital in Minneapolis and is a member of the SHM Practice Analysis Committee.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Christopher Moriates, MD, has been named executive director of the nonprofit health care organization Costs of Care (Boston). He replaces Neel Shah, MD, who was tabbed chairperson of the board.

Dr. Moriates serves a number of roles at the University of Texas at Austin. He is the assistant dean for health care value; associate chair for quality, safety and value; and associate professor of internal medicine.

In his role at Costs of Care, Dr. Moriates will direct an organization that uses feedback and stories from frontline physicians to help health systems provide high-quality care at lower costs.

Kai Mebust, MD, was recently named the new associate chief of medicine at Bassett Hospital (Cooperstown, N.Y.), where he has worked the past 15 years as a hospitalist and internist, serving as chief of hospitalists for the last decade. Dr. Mebust also completed his internship and residency at Bassett, and he is a fellow with the Society of Hospital Medicine.

Dr. Mebust will work closely with Dr. Charles Hyman, the center’s physician in chief, who is leaving the role at the end of the calendar year. Dr. Mebust will oversee inpatient services and be part of the transition process when Dr. Hyman departs.

Ronak Bhimani, MD, has been appointed chief medical officer at Lower Bucks Hospital (Bristol, Pa.). Dr. Bhimani moves over from Suburban Community Hospital (Norristown, Pa.), where he served as an academic hospitalist the past 2 years.

Previously, Dr. Bhimani was medical director of Kindred/Avalon Hospice and a core faculty member in the internal medicine program for residents at Suburban Community.

Danielle Prince, MD, was recently named associate medical director at St. Luke’s Siouxland PACE (Sioux City, Iowa), an affiliate of UnityPoint Health. Dr. Prince is a practicing hospitalist at UnityPoint Health St. Luke’s and served previously in as a family physician while working as chief medical informatics officer at Mercy Medical Center (Sioux City).

At Siouxland PACE, Dr. Prince will assist in managing the full-service care of elderly patients, including home health, specialty care, medications, transportation, and other therapies.

Alex Rankin, MD, has been named the new associate chief medical officer for the University of New Mexico Health Transfer Center and Patient Throughput in Albuquerque. A hospitalist with UNMH’s Family and Community Medicine department, Dr. Rankin was previously the medical director at the system’s 3 North facility since 2014.

Dr. Rankin came to UNMH after working for hospitals in Colorado and Nebraska and is a founding member of the UNMH patient flow committee, striving to improve patient care processes throughout the institution.

Tom Guirkin, MD, has been appointed vice president of medical affairs for Virginia Commonwealth University Community Memorial Hospital (South Hill, Va.). Dr. Guirkin, a Virginia native, returns to his home state after most recently overseeing the hospitalist group at Saint Francis Health System (Tulsa, Okla.).

Dr. Guirkin will have the opportunity to continue practicing medicine at CMH while helping to manage the quality management side of the business. He received his MBA from Virginia Commonwealth, working for James River Hospitalist Group in Richmond at the same time.

Alteon Health (Germantown, Md.) has become the manager of hospitalist services for three facilities in Maryland and Ohio, including Carroll Hospital (Westminster, Md.), Washington Adventist Hospital (Takoma Park, Md.), and University Hospitals Cleveland Medical Center.

At Carroll, Alteon physicians will provide critical care services in addition to hospitalist duties. Alteon has been Carroll’s emergency medicine provider for more than two decades.

At Washington Adventist, Alteon will take over the hospitalist program, adding to the emergency medicine services it has provided since 1991 and critical care services it has managed since 1996.

At UH Cleveland, Alteon will assume hospitalist management at its third University Hospitals facility. Alteon controls emergency medicine at 14 UH locations as well. UH Cleveland is an affiliate of Case Western Reserve University.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

Each July, the largest gathering of pediatric hospitalists occurs, and 2019 is no different! This year, hospitalists who care for children will gather at Pediatric Hospital Medicine (PHM) in Seattle from July 25 to 28, with the goal of enhancing participants’ knowledge and competence in the areas of innovation, clinical medicine, education, health services, practice management, quality improvement, and research.

But what makes this year particularly special is the launch of the subspecialty exam for certification in pediatric hospital medicine coming later this fall, solidifying its growth and importance within hospital medicine and the entire health care landscape. The American Board of Pediatrics (ABP) has approved PHM as the newest board subspecialty with a 2-year fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME). This conference will be a great opportunity to join with others to review competencies for board review, as well as to network with those who are also navigating the road ahead.

During 2019, the Pediatric Hospitalist Special Interest Group (SIG) of SHM has been working tirelessly on several initiatives, including a revision of the Pediatric Hospital Medicine Core Competencies as well as additional work to develop Choosing Wisely 2.0 recommendations. These will help us ensure we are developing the best curricula for the next generation of pediatric hospitalists, while cutting back on unnecessary tests and procedures for those practicing today. Each of these initiatives, as well as the July conference, highlights the opportunities that we have within SHM to work with other like-minded providers who care for children. While we partner with all professionals across many organizations, like the American Academy of Pediatrics and the Academic Pediatric Association to name a few, I wanted to share my reflections on SHM and my appreciation for the “big tent” philosophy that has served us so well thus far.

Having an opportunity to sit on the board of SHM has allowed me a chance to really appreciate the efforts that this organization invests in all who care for patients in the hospital; we have an active group of advanced-practice providers, practice administrators, residents, students, academic hospitalists, and the list goes on and on. We collaborate with a number of spectacular societies dedicated to medical specialties, and we are always open to new ways of improving the methods of delivering care to patients, in hospitals, post-acute care facilities, homes – you name it! As health care delivery models continue to evolve, I believe we are well positioned to be leaders in the delivery of acute care medicine in the hospital and beyond.

I have also learned of happenings at the grassroots level by attending SHM chapter meetings across the United States. For example, the Hampton Roads Chapter led a great Point-of-Care Ultrasound (POCUS) workshop, and influenced by that, I shared an idea at home in Nashville – borrowing my son as a model to demonstrate ultrasound techniques that hospitalists can use to assist in clinical care. I hope you, as pediatric hospitalists, will see if you have a local chapter and attend a meeting; whether you are a member of SHM or not, you can mingle with those who provide acute care treatments to all your communities and share best practices. If you don’t see an SHM chapter close by, let’s get one going! SHM is here to help launch a chapter that can help bring your community together and provide education and networking closer to home.

If you can’t attend PHM in Seattle this year, I hope you will make every effort to be at PHM 2020, where our own SIG leader, Dr. Jeffrey Grill from Louisville, Ky., will be chairing the next rendition of this amazing conference. The SHM Meetings team led by Michelle Kann will be working tirelessly to make it a great event with continued growth in content and attendance.

Dr. Rehm is associate professor, pediatrics, and director, division of pediatric outreach medicine at Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, both in Nashville, Tenn. She is also a member of the SHM board of directors.

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

SAN DIEGO – Eat a healthy lunch. Get more sleep. Move your body. How many times in the course of a week do you give patients gentle reminders to practice these most basic steps of self-care? And how many times in the course of a week do you allow these basics to go by the wayside for yourself?

Self-care is one of the elements that can defend against physician burnout, Carol Burke, MD, said at a session on physician burnout held during the annual Digestive Disease Week^®. Personal self-care can make a real difference, and shouldn’t be ignored as the profession works to reel back some of the institutional changes that challenge physicians today.

In the workplace, unhealthy stress levels can contribute to burnout, disruptive behavior, decreased productivity, and disengagement. Burnout – a response to chronic stress characterized by a diminished sense of personal accomplishment and emotional exhaustion – can result in cynicism, a lack of compassion, and feelings of depersonalization, said Dr. Burke.

Contributors to physician stress have been well documented, said Dr. Burke, a professor of gastroenterology at the Cleveland Clinic. These range from personal debt and the struggle for work-life balance to an increased focus on metrics and documentation at the expense of authentic patient engagement. All of these factors are measurable by means of the validated Maslach Burnout Inventory, said Dr. Burke. A recent survey that used this measure indicated that nearly half of physician respondents report experiencing burnout.

In 2017, Dr. Burke led a survey of American College of Gastroenterology members that showed 49.3% of respondents reported feeling emotional exhaustion and/or depersonalization. Some key themes emerged from the survey, she said. Women and younger physicians were more likely to experience burnout. Having children in the middle years (11-15 years old) and spending more time on domestic duties and child care increased the risk of burnout.

And doing patient-related work at home or having a spouse or partner bring work home also upped burnout risk. Skipping breakfast and lunch during the workweek was another risk factor, which highlights the importance of basic self-care as armor against the administrative onslaught, said Dr. Burke.

Measured by volume alone, physician work can be overwhelming: 45% of physicians in the United States work more than 60 hours weekly, compared with fewer than 10% of the general workforce, said Dr. Burke.

What factors within the control of an individual practitioner can reduce the risk of debilitating burnout and improve quality of life? Physicians who do report a high quality of life, said Dr. Burke, are more likely to have a positive outlook. They also practice basic self-care like taking vacations, exercising regularly, and engaging in hobbies outside of work.

For exhausted, overworked clinicians, getting a good night’s sleep is a critical form of self-care. But erratic schedules, stress, and family demands can all sabotage plans for better sleep hygiene. Still, attending to sleep is important, said Dr. Burke. Individuals with disturbed sleep are less mindful and have less self-compassion. Sleep disturbance is also strongly correlated with perceived stress.

She also reported that the odds ratio for burnout was 14.7 for physicians who reported insomnia when compared with those without sleep disturbance, and it was 9.9 for those who reported nonrestorative sleep.

Physical activity can help sleep and also help other markers of burnout. Dr. Burke pointed to a recent study of 4,402 medical students. Participants were able to reduce burnout risk when they met the Centers for Disease Control and Prevention recommendations of achieving at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous exercise, plus at least 2 days/week of strength training (P less than .001; Acad Med. 2017;92:1006).

These physician-targeted programs can work, she said: “Faciliated interventions improve well-being, attitudes associated with patient-centered care, meaning and engagement in work, and reduce burnout.”

Practice-focused interventions to reclaim a semblance of control over one’s time are varied, and some are easier to implement than others. Virtual visits and group visits are surprisingly well received by patients, and each can be huge time-savers for physicians, said Dr. Burke. There are billing and workflow pitfalls to avoid, but group visits, in particular, can be practice changing for those who have heavy backlogs and see many patients with the same condition.

Medical scribes can improve productivity and reduce physician time spent on documentation. Also, said Dr. Burke, visits can appropriately be billed at a higher level of complexity when contemporaneous documentation is thorough. Clinicians overall feel that they can engage more fully with patients, and also feel more effective, when well-trained scribes are integrated into a practice, she said.

Female physicians have repeatedly been shown to have patient panels that are more demanding, and male and female patients alike expect more empathy and social support from their physicians, said Dr. Burke. When psychosocial complexities are interwoven with patient care, as they are more frequently for female providers, a 15-minute visit can easily run twice that – or more. Dr. Burke is among the physicians advocating for recognition of this invisible burden on female clinicians, either through adaptive scheduling or differential productivity expectations. This approach is not without controversy, she acknowledged; still, practices should acknowledge that clinic flow can be very different for male and female gastroenterologists, she said.

Dr. Burke reported no relevant conflicts of interest.

[email protected]

It’s Monday morning, and Mrs. Jones still has abdominal pain. Your ward team decides to order a CT. On chart review you notice she’s had three other abdominal CTs for the same indication this year. How did this happen? What should you do?

High-value care has been defined by the Institute of Medicine as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”¹ With an estimated $700 billion dollars – 30% of medical expenditures – spent on wasted care, there are rising calls for a transformational shift.²

You are now asked to consider not just everything you can do for a patient, but also the benefits, harms, and costs associated with those choices. But where to start? We recommend that trainees integrate these tips for high-value care into their routine practice.
 

1. Use evidence-based resources that highlight value

A great place to begin is the “Six Things Medical Students and Trainees Should Question,” originally published in Academic Medicine and created by Choosing Wisely Canada™. Recommendations range from avoiding tests or treatments that will not change a patient’s clinical course to holding off on ordering tests solely based on what you assume your preceptor will want (see the full list in Table 1).³

Other ways to avoid low-value care include following the United States Choosing Wisely^™ campaign, which has collected more than 500 specialty society recommendations. Likewise, the American College of Radiology Appropriateness Criteria are designed to assist providers with ordering the appropriate imaging tests (for a more extensive list see Table 2).
 

2. Express your clinical reasoning

One driver of health care expenditures that is especially prevalent in academia is the pressure to demonstrate knowledge by recommending extensive testing. While these tests may rule out obscure diagnoses, they often do not change management.

You can still demonstrate a mastery of your patients’ care by expressing your thought process overtly. For instance, “I considered secondary causes of the patient’s severe hypertension but felt it was most reasonable to first treat her pain and restart her home medications before pursuing a larger work-up. If the patient’s blood pressure remains elevated and she is hypokalemic, we could consider testing for hyperaldosteronism.” If you explain why you think a diagnosis is less likely and order tests accordingly, others will be encouraged to consider value in their own medical decision making.
 

3. Hone your communication skills

One of the most cited reasons for providing unnecessary care is the time required to discuss treatment plans with patients – it’s much faster to just order the test than to explain why it isn’t needed. Research, however, shows that these cost conversations take 68 seconds on average.⁴ Costs of Care (see Table 2) has an excellent video series that highlights how effective communication allows for shared decision making, which promotes both patient engagement and helps avoid wasteful care.

Physicians’ first instincts are often defensive when a patient asks for care we perceive as unnecessary. However, exploring what the patient hopes to gain from said test or treatment frequently reveals concern for a specific, missed diagnosis or complication. Addressing this underlying fear, rather than defending your ordering patterns, can create improved rapport and may serve to provide more reassurance than a test ever could.⁵

As a physician-in-training, try to observe others having these conversations and take every opportunity to practice. By focusing on this key skill set, you will increase your comfort with in-depth discussions on the value of care.
 

4. Get involved in a project related to high-value care

While you are developing your own practice patterns, you may be inspired to tackle areas of overuse and underuse at a more systemwide level. If your hospital does not have a committee for high-value care, perhaps a quality improvement leader can support your ideas to launch a project or participate in an ongoing initiative. Physicians-in-training have been identified as crucial to these projects’ success – your frontline insight can highlight potential problems and the nuances of workflow that are key to effective solutions.⁶

5. Embrace lifelong learning and reflection

The process of becoming a physician and of practicing high-value care is not a sprint but a marathon. Multiple barriers to high-value care exist, and you may feel these pressures differently at various points in your career. These include malpractice concerns, addressing patient expectations, and the desire to take action “just to be safe.”⁶

Interestingly, fear of malpractice does not seem to dissipate in areas where tort reform has provided stronger provider protections.⁷ Practitioners may also inaccurately assume a patient’s desire for additional work-up or treatment.⁸ Furthermore, be aware of the role of “commission bias” by which a provider regrets not doing something that could have helped a previous patient. This regret can prove to be a stronger motivator than the potential harm related to unnecessary diagnostic tests or treatments.⁹

While these barriers cannot be removed easily, learners and providers can practice active reflection by examining their own fears, biases, and motivations before and after they order additional testing or treatment.

As a physician-in-training, you may feel that your decisions do not have a major impact on the health care system as a whole. However, the culture shift needed to “bend the cost curve” will come from the collective efforts of individuals like you. Practicing high-value care is not just a matter of ordering fewer tests – appropriate ordering of an expensive test that expedites a diagnosis may be more cost-effective and enhance the quality of care provided. Increasing your own awareness of both necessary and unnecessary practices is a major step toward realizing system change. Your efforts to resist and reform the medical culture that propagates low value care will encourage your colleagues to follow suit.

Dr. Lacy is assistant professor and associate clerkship director at the University of New Mexico, Albuquerque, as well as division director of high-value care for the division of hospital medicine. Dr. Goetz is assistant professor at Rush University Medical Center, Chicago. They met as 2015 Copello Fellows at the National Physician Alliance. Both have been involved in numerous high-value care initiatives, curricular development, and medical education at their respective institutions.

References

1. Committee on the Learning Health Care System in America, Institute of Medicine. “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Edited by Smith M, Saunders R, Stuckhardt L, and McGinnis JM. (Washington: National Academies Press, 2013). http://www.ncbi.nlm.nih.gov/books/NBK207225/.

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

3. Lakhani A et al. Choosing Wisely for Medical Education: Six things medical students and trainees should question. Acad Med. 2016 Oct;91(10):1374-8.

4. Hunter WG et al. Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates. BMC Health Serv Res. 2016;16:108.

5. van Ravesteijn H et al. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012;86(1):3-8.

6. Moriates C, Wong BM. High-value care programmes from the bottom-up… and the top-down. BMJ Qual Saf. 2016;25(11):821-3.

7. Snyder Sulmasy L, Weinberger SE. Better care is the best defense: High-value clinical practice vs. defensive medicine. Cleve Clin J Med. 2014;81(8):464-7.

8. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: Patients’ preferences matter. BMJ. 2012;345:e6572.

9. Scott IA. Cognitive challenges to minimising low value care. Intern Med J. 2017;47(9):1079-1083.
 

It’s Monday morning, and Mrs. Jones still has abdominal pain. Your ward team decides to order a CT. On chart review you notice she’s had three other abdominal CTs for the same indication this year. How did this happen? What should you do?

High-value care has been defined by the Institute of Medicine as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”¹ With an estimated $700 billion dollars – 30% of medical expenditures – spent on wasted care, there are rising calls for a transformational shift.²

You are now asked to consider not just everything you can do for a patient, but also the benefits, harms, and costs associated with those choices. But where to start? We recommend that trainees integrate these tips for high-value care into their routine practice.
 

1. Use evidence-based resources that highlight value

A great place to begin is the “Six Things Medical Students and Trainees Should Question,” originally published in Academic Medicine and created by Choosing Wisely Canada™. Recommendations range from avoiding tests or treatments that will not change a patient’s clinical course to holding off on ordering tests solely based on what you assume your preceptor will want (see the full list in Table 1).³

Other ways to avoid low-value care include following the United States Choosing Wisely^™ campaign, which has collected more than 500 specialty society recommendations. Likewise, the American College of Radiology Appropriateness Criteria are designed to assist providers with ordering the appropriate imaging tests (for a more extensive list see Table 2).
 

2. Express your clinical reasoning

One driver of health care expenditures that is especially prevalent in academia is the pressure to demonstrate knowledge by recommending extensive testing. While these tests may rule out obscure diagnoses, they often do not change management.

You can still demonstrate a mastery of your patients’ care by expressing your thought process overtly. For instance, “I considered secondary causes of the patient’s severe hypertension but felt it was most reasonable to first treat her pain and restart her home medications before pursuing a larger work-up. If the patient’s blood pressure remains elevated and she is hypokalemic, we could consider testing for hyperaldosteronism.” If you explain why you think a diagnosis is less likely and order tests accordingly, others will be encouraged to consider value in their own medical decision making.
 

3. Hone your communication skills

One of the most cited reasons for providing unnecessary care is the time required to discuss treatment plans with patients – it’s much faster to just order the test than to explain why it isn’t needed. Research, however, shows that these cost conversations take 68 seconds on average.⁴ Costs of Care (see Table 2) has an excellent video series that highlights how effective communication allows for shared decision making, which promotes both patient engagement and helps avoid wasteful care.

Physicians’ first instincts are often defensive when a patient asks for care we perceive as unnecessary. However, exploring what the patient hopes to gain from said test or treatment frequently reveals concern for a specific, missed diagnosis or complication. Addressing this underlying fear, rather than defending your ordering patterns, can create improved rapport and may serve to provide more reassurance than a test ever could.⁵

As a physician-in-training, try to observe others having these conversations and take every opportunity to practice. By focusing on this key skill set, you will increase your comfort with in-depth discussions on the value of care.
 

4. Get involved in a project related to high-value care

While you are developing your own practice patterns, you may be inspired to tackle areas of overuse and underuse at a more systemwide level. If your hospital does not have a committee for high-value care, perhaps a quality improvement leader can support your ideas to launch a project or participate in an ongoing initiative. Physicians-in-training have been identified as crucial to these projects’ success – your frontline insight can highlight potential problems and the nuances of workflow that are key to effective solutions.⁶

5. Embrace lifelong learning and reflection

The process of becoming a physician and of practicing high-value care is not a sprint but a marathon. Multiple barriers to high-value care exist, and you may feel these pressures differently at various points in your career. These include malpractice concerns, addressing patient expectations, and the desire to take action “just to be safe.”⁶

Interestingly, fear of malpractice does not seem to dissipate in areas where tort reform has provided stronger provider protections.⁷ Practitioners may also inaccurately assume a patient’s desire for additional work-up or treatment.⁸ Furthermore, be aware of the role of “commission bias” by which a provider regrets not doing something that could have helped a previous patient. This regret can prove to be a stronger motivator than the potential harm related to unnecessary diagnostic tests or treatments.⁹

While these barriers cannot be removed easily, learners and providers can practice active reflection by examining their own fears, biases, and motivations before and after they order additional testing or treatment.

As a physician-in-training, you may feel that your decisions do not have a major impact on the health care system as a whole. However, the culture shift needed to “bend the cost curve” will come from the collective efforts of individuals like you. Practicing high-value care is not just a matter of ordering fewer tests – appropriate ordering of an expensive test that expedites a diagnosis may be more cost-effective and enhance the quality of care provided. Increasing your own awareness of both necessary and unnecessary practices is a major step toward realizing system change. Your efforts to resist and reform the medical culture that propagates low value care will encourage your colleagues to follow suit.

Dr. Lacy is assistant professor and associate clerkship director at the University of New Mexico, Albuquerque, as well as division director of high-value care for the division of hospital medicine. Dr. Goetz is assistant professor at Rush University Medical Center, Chicago. They met as 2015 Copello Fellows at the National Physician Alliance. Both have been involved in numerous high-value care initiatives, curricular development, and medical education at their respective institutions.

References

1. Committee on the Learning Health Care System in America, Institute of Medicine. “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Edited by Smith M, Saunders R, Stuckhardt L, and McGinnis JM. (Washington: National Academies Press, 2013). http://www.ncbi.nlm.nih.gov/books/NBK207225/.

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

3. Lakhani A et al. Choosing Wisely for Medical Education: Six things medical students and trainees should question. Acad Med. 2016 Oct;91(10):1374-8.

4. Hunter WG et al. Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates. BMC Health Serv Res. 2016;16:108.

5. van Ravesteijn H et al. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012;86(1):3-8.

6. Moriates C, Wong BM. High-value care programmes from the bottom-up… and the top-down. BMJ Qual Saf. 2016;25(11):821-3.

7. Snyder Sulmasy L, Weinberger SE. Better care is the best defense: High-value clinical practice vs. defensive medicine. Cleve Clin J Med. 2014;81(8):464-7.

8. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: Patients’ preferences matter. BMJ. 2012;345:e6572.

9. Scott IA. Cognitive challenges to minimising low value care. Intern Med J. 2017;47(9):1079-1083.
 

It’s Monday morning, and Mrs. Jones still has abdominal pain. Your ward team decides to order a CT. On chart review you notice she’s had three other abdominal CTs for the same indication this year. How did this happen? What should you do?

High-value care has been defined by the Institute of Medicine as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”¹ With an estimated $700 billion dollars – 30% of medical expenditures – spent on wasted care, there are rising calls for a transformational shift.²

You are now asked to consider not just everything you can do for a patient, but also the benefits, harms, and costs associated with those choices. But where to start? We recommend that trainees integrate these tips for high-value care into their routine practice.
 

1. Use evidence-based resources that highlight value

A great place to begin is the “Six Things Medical Students and Trainees Should Question,” originally published in Academic Medicine and created by Choosing Wisely Canada™. Recommendations range from avoiding tests or treatments that will not change a patient’s clinical course to holding off on ordering tests solely based on what you assume your preceptor will want (see the full list in Table 1).³

Other ways to avoid low-value care include following the United States Choosing Wisely^™ campaign, which has collected more than 500 specialty society recommendations. Likewise, the American College of Radiology Appropriateness Criteria are designed to assist providers with ordering the appropriate imaging tests (for a more extensive list see Table 2).
 

2. Express your clinical reasoning

One driver of health care expenditures that is especially prevalent in academia is the pressure to demonstrate knowledge by recommending extensive testing. While these tests may rule out obscure diagnoses, they often do not change management.

You can still demonstrate a mastery of your patients’ care by expressing your thought process overtly. For instance, “I considered secondary causes of the patient’s severe hypertension but felt it was most reasonable to first treat her pain and restart her home medications before pursuing a larger work-up. If the patient’s blood pressure remains elevated and she is hypokalemic, we could consider testing for hyperaldosteronism.” If you explain why you think a diagnosis is less likely and order tests accordingly, others will be encouraged to consider value in their own medical decision making.
 

3. Hone your communication skills

One of the most cited reasons for providing unnecessary care is the time required to discuss treatment plans with patients – it’s much faster to just order the test than to explain why it isn’t needed. Research, however, shows that these cost conversations take 68 seconds on average.⁴ Costs of Care (see Table 2) has an excellent video series that highlights how effective communication allows for shared decision making, which promotes both patient engagement and helps avoid wasteful care.

Physicians’ first instincts are often defensive when a patient asks for care we perceive as unnecessary. However, exploring what the patient hopes to gain from said test or treatment frequently reveals concern for a specific, missed diagnosis or complication. Addressing this underlying fear, rather than defending your ordering patterns, can create improved rapport and may serve to provide more reassurance than a test ever could.⁵

As a physician-in-training, try to observe others having these conversations and take every opportunity to practice. By focusing on this key skill set, you will increase your comfort with in-depth discussions on the value of care.
 

4. Get involved in a project related to high-value care

While you are developing your own practice patterns, you may be inspired to tackle areas of overuse and underuse at a more systemwide level. If your hospital does not have a committee for high-value care, perhaps a quality improvement leader can support your ideas to launch a project or participate in an ongoing initiative. Physicians-in-training have been identified as crucial to these projects’ success – your frontline insight can highlight potential problems and the nuances of workflow that are key to effective solutions.⁶

5. Embrace lifelong learning and reflection

The process of becoming a physician and of practicing high-value care is not a sprint but a marathon. Multiple barriers to high-value care exist, and you may feel these pressures differently at various points in your career. These include malpractice concerns, addressing patient expectations, and the desire to take action “just to be safe.”⁶

Interestingly, fear of malpractice does not seem to dissipate in areas where tort reform has provided stronger provider protections.⁷ Practitioners may also inaccurately assume a patient’s desire for additional work-up or treatment.⁸ Furthermore, be aware of the role of “commission bias” by which a provider regrets not doing something that could have helped a previous patient. This regret can prove to be a stronger motivator than the potential harm related to unnecessary diagnostic tests or treatments.⁹

While these barriers cannot be removed easily, learners and providers can practice active reflection by examining their own fears, biases, and motivations before and after they order additional testing or treatment.

As a physician-in-training, you may feel that your decisions do not have a major impact on the health care system as a whole. However, the culture shift needed to “bend the cost curve” will come from the collective efforts of individuals like you. Practicing high-value care is not just a matter of ordering fewer tests – appropriate ordering of an expensive test that expedites a diagnosis may be more cost-effective and enhance the quality of care provided. Increasing your own awareness of both necessary and unnecessary practices is a major step toward realizing system change. Your efforts to resist and reform the medical culture that propagates low value care will encourage your colleagues to follow suit.

Dr. Lacy is assistant professor and associate clerkship director at the University of New Mexico, Albuquerque, as well as division director of high-value care for the division of hospital medicine. Dr. Goetz is assistant professor at Rush University Medical Center, Chicago. They met as 2015 Copello Fellows at the National Physician Alliance. Both have been involved in numerous high-value care initiatives, curricular development, and medical education at their respective institutions.

References

1. Committee on the Learning Health Care System in America, Institute of Medicine. “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” Edited by Smith M, Saunders R, Stuckhardt L, and McGinnis JM. (Washington: National Academies Press, 2013). http://www.ncbi.nlm.nih.gov/books/NBK207225/.

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-6.

3. Lakhani A et al. Choosing Wisely for Medical Education: Six things medical students and trainees should question. Acad Med. 2016 Oct;91(10):1374-8.

4. Hunter WG et al. Patient-physician discussions about costs: Definitions and impact on cost conversation incidence estimates. BMC Health Serv Res. 2016;16:108.

5. van Ravesteijn H et al. The reassuring value of diagnostic tests: a systematic review. Patient Educ Couns. 2012;86(1):3-8.

6. Moriates C, Wong BM. High-value care programmes from the bottom-up… and the top-down. BMJ Qual Saf. 2016;25(11):821-3.

7. Snyder Sulmasy L, Weinberger SE. Better care is the best defense: High-value clinical practice vs. defensive medicine. Cleve Clin J Med. 2014;81(8):464-7.

8. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: Patients’ preferences matter. BMJ. 2012;345:e6572.

9. Scott IA. Cognitive challenges to minimising low value care. Intern Med J. 2017;47(9):1079-1083.