Career

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

From celebrating the 20th anniversary of hospital medicine’s arrival to rapid reimbursement reform to sought-after clarity for observation rules, the past 12 months have been eventful. The Hospitalist asked more than a dozen industry leaders what they thought were the biggest highlights of 2016. Here is what they said:

1. Happy Birthday, HM

August 15 marked the 20th anniversary of “The Emerging Role of ‘Hospitalists’ in the American Health Care System,”1 a New England Journal of Medicine paper authored by Lee Goldman, MD, and Robert Wachter, MD, MHM.2 It was the first time anyone defined what a hospitalist was, putting a sobriquet to an inpatient care model that had organically and independently started happening nationwide.

The paper laid the groundwork for a specialty that spread like a proverbial wildfire over the next 20 years. The model overcame early opposition from residents fearful they’d lose the ability to learn and critical-care specialists who wanted to maintain the caseloads they’d fought to build. The field has now swelled to an estimated 52,000 practitioners.

“I reflect back … and think today about what the hospitalist model brings to us,” James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division, told The Hospitalist. “It is an amazing transformation on how the hospitalist model really delivers.”1

2. Its Own Specialty Code

Hospitalist medicine received federal approval for its first dedicated specialty code3 in a decision hailed by many. The code, approved by the Centers for Medicare & Medicaid Services (CMS), should allow hospitalist-specific billing in 2017.

SHM leaders have long pushed for the code, particularly as healthcare transitions from fee-for-service (FFS) to quality-based payment models. Public Policy Committee Chair Ron Greeno, MD, MHM, says that a dedicated code is necessary to ensure that hospitalists are properly reimbursed for their work.

Historically, hospitalists have used codes more in line with the workload of general internal medicine, family medicine, and other specialties. But those codes don’t account for the complexity of what hospitalists deal with on a daily basis.

“We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties,” Dr. Greeno said.3

SHM pushed for the change and has said it is committed to educating members about how best to use it. Scott Sears, MD, FHM, CPE, MBA, chief clinical officer for Sound Physicians of Tacoma, Wash., said the move is great for HM but that more needs to be done to tailor billing and coding to the specialty’s actual workflow.

“A pediatric hospitalist may not want to be compared to an adult hospitalist. A critical-access hospitalist doesn’t want to be compared to a hospitalist in a tertiary academic medical center,” Dr. Sears said. “I don’t think it’s an end-all, be-all, but it’s a place to start.”3

3. Down with SGR, Long Live MACRA

While it’s unlikely hospitalists have that printed on bumper stickers, 2016 brought the end of the oft-maligned Sustainable Growth Rate (SGR) formula. This was the first year under the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA.4

MACRA changes the ways hospitalists and other physicians are reimbursed by Medicare by continuing the broader trend of moving from volume-based reimbursements toward a value-based payment (VBP) system. Its two tracks for physicians to change how they get paid are the Merit-Based Incentive Payment System (MIPS) and the Alternative Payments Model (APM).

MIPS probably looks familiar because it is similar to the traditional FFS model. But to make value a more important factor in the reimbursement formula, MIPS will account for both volume and quality. APM allows physicians to opt out of MIPS by participating in other approved programs where providers take on “more than nominal” financial risk, report on their quality measures, and use certified electronic health record (EHR) technology.

4. The Surgeon General Is a Hospitalist

Any specialty’s annual meeting would be lucky to get the U.S. Surgeon General as a plenary speaker, but HM16 featured one of its own in hospitalist and U.S. Surgeon General Vivek Murthy, MD, MBA.

Dr. Murthy kicked off the confab in San Diego, and some 4,000 hospitalists listened to one of their own talk about ascending the highest perch a physician can attain in the federal government.7 Dr. Murthy, previously a hospitalist at Brigham and Women’s Hospital in Boston, was confirmed as the 19th Surgeon General in December 2014.

In an address titled “Bringing Health to America,” Dr. Murthy inspired with tales of hope and encouraged hospitalists to make the pursuit of healthy appealing while improving the safety of our communities. In particular, he suggested hospitalists look to leverage their leadership to improve systems and to be a powerful force of change both inside the walls of their institution and in their communities.

“In the end, the world gets better when people choose to come together to make it better,” he said.8

5. Nurse Practitioner Joins SHM Board of Directors

At HM16, Tracy Cardin, ACNP-BC, SFHM, was the first nurse practitioner (NP) or physician assistant (PA) given voting privileges on the society’s oversight panel.

“I can’t describe to you how passionately I believe that [NPs and PAs] have a huge role moving forward,” Cardin said. “I think our representation, our visibility, has sort of been flabby and kind of under the wire for a long time. We can really impact the design of care models at the bedside in a way that’s innovative and more efficient and in a way that’s really huge. I think there’s a transformation that’s going to be coming, and we’re going to be a huge part of it.”9

With Cardin’s ascension, it has added the voice of another constituency to its board. She was previously chair of SHM’s Nurse Practitioner/Physician Assistant Committee and in 2015 received the society’s Award in Excellence in Hospital Medicine for NPs and PAs. She has been at the University of Chicago for about 10 years.

“It does send a message to the rest of our membership that SHM values those other constituencies and that this is not a physician membership organization but rather a membership organization comprised of people who are interested in improving healthcare for our hospitalized patients,” immediate past president Robert Harrington Jr., MD, SFHM said.10

6. The State of Hospital Medicine Is Strong

According to the biennial 2016 State of Hospital Medicine Report6 from SHM and partially populated by data from the Medical Group Management Association (MGMA), median compensation for adult hospitalists rose 10% to $278,746 from 2013 to 2015. The double-digit increase continues the steady climb of hospitalist pay, which is up 30% since 2010. At the same time, productivity is flattening.

And nearly all HM groups (HMGs)—96%—are still getting financial support, mostly from their host hospitals, in addition to their professional fee revenue. However, that median support, $157,535 per full-time employee (FTE), increased just 1%.

The slowing growth in that contribution is a harbinger that the level of financial support can no longer grow unabated, said Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee.

“We’re pretty close to that breaking point,” she said. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”6

7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More

CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.

The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.

For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”

But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.

8. Medicaid Expansion Takes Hold

Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14

“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15

While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.

9. Antimicrobial Stewardship Rules Upgrade

In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.

“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16

The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.

Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.

10. Febrile-Infant Care Draws a Crowd

One of the most well-attended sessions at 2016 Pediatric Hospital Medicine in Chicago was an update on the anticipated American Academy of Pediatricians (AAP) guidelines for febrile infants.18

The guidelines, for infants 7–90 days old, are aimed at providing pediatric hospitalists and others evidence-based guidelines, not rules, from the most recent literature available. The PHM16 session, presented by Kenneth Roberts, MD, highlighted the need to separate individual components of serious bacterial infections such as urinary tract infections (UTIs), bacteremia, and meningitis. Dr. Roberts noted that the incidence and clinical course can vary greatly for the different diagnoses.

The new criteria would be for full-term infants (37–43 weeks’ gestation) who are well-appearing and present with a temperature of 38°C. Exclusion criteria would include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

In particular, the new guidelines will look to risk-stratify management by age groups of 7–28 days, 29–60 days, and 61–90 days. The criteria are expected to be released in the next year.

Richard Quinn is a freelance writer in New Jersey.

References

1. Quinn R. HM turns 20: a look at the evolution of hospitalist medicine. The Hospitalist website. Accessed November 14, 2016.
2. Wachter M, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
3. Tyrrell KA. New hospitalist billing code should benefit hospitalists, patients. The Hospitalist website. Accessed November 14, 2016.
4. Doctoroff L, Dutta S. MACRA provides new direction for U.S. healthcare. The Hospitalist website. Accessed November 14, 2016.
5. Quinn R. Everything you need to know about the Bundled Payments for Care Improvement Initiative. The Hospitalist website. Accessed November 14, 2016.
6. Quinn R. The state of hospital medicine is strong. The Hospitalist website. Accessed November 14, 2016.
7. Scheurer D. U.S. surgeon general encourages hospitalists to remain hopeful, motivated. The Hospitalist website. Accessed November 14, 2016.
8. Collins TR. HM16 speakers focus on public health, leadership, future of hospital medicine. The Hospitalist website. Accessed November 14, 2016.
9. Quinn R. SHM seats its first non-physician board member. The Hospitalist website. Accessed at November 14, 2016.
10. Carris J. Centers for Medicare & Medicaid Services (CMS) eliminates two-midnight rule’s inpatient payment cuts: report. The Hospitalist website. Accessed November 14, 2016.
11. Schencker L. Judge tells HHS to revisit two-midnight rule’s inpatient pay cut. Healh Affairs website. Accessed November 14, 2016.
12. Tyrrell KA. Physicians critical of proposed changes to Medicare’s two-midnight rule. The Hospitalist website. Accessed November 14, 2016.
13. Tyrrell KA. Ann Sheehy, MD, MS, FHM, outlines to lawmakers hospitalist concerns about two-midnight rule, Medicare policies. The Hospitalist website. Accessed November 14, 2016.
14. Nikpay S, Buchmueller T, Levy HG. Affordable Care Act Medicaid expansion reduced uninsured hospital stays in 2014. Health Aff (Millwood). 2016;35(1):106-110.
15. Tyrrell KA. Benefits of Medicaid expansion for hospitalists. The Hospitalist website. Accessed November 14, 2016.
16. Bopp S. New standard announced for antimicrobial stewardship. The Hospitalist website. Accessed November 14, 2016.
17. Prepublication standards – new antimicrobial stewardship standard. The Joint Commission website. Accessed November 14, 2016.
18. 18. DeZure C. PHM16: the new AAP clinical practice guideline on evaluating, managing febrile infants. The Hospitalist website. Accessed November 14, 2016.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

At every opportunity, I position and endorse my colleagues who are or will be participating in my patient’s care by describing their roles and expressing my confidence in their abilities.

Why I Do It

It is vital that our patients feel assured they are being cared for by a high-functioning team of experts. During any given hospital stay, our patients will meet consulting physicians, nurses, therapists, case managers … The list goes on and on. Each person plays a vital part in patients’ care. But it can be difficult for patients to understand every person’s role and to feel assured that each person is highly skilled and aligned with the care plan.

As hospitalists, we are in a unique position to provide a foundation of assuredness and confidence that is a cornerstone of patient experience before our teammates meet patients. When we miss this opportunity, our patients perceive us as a sea of white coats passing in and out of their rooms rather than a cohesive team with their best interests at heart.

How I Do It

Let’s take the example of an elderly patient admitted for a hip fracture after a fall. Alongside the hospitalist will be the orthopedic surgeon, nurse, physical therapist, and case manager, all working toward an optimal outcome. In each case, the hospitalist can choose to provide no information about these team members or to position them for a positive first impression.

Here are the steps to take when positioning colleagues with patients:

1. Identify team members and explain their roles.
2. Endorse colleagues by expressing honest confidence in their expertise and ability.
3. Describe how communication between you and your team members will work.
4. Assure the patient that during handoff, your colleagues will be up-to-date and aligned with the plan.
5. Tell your patients they are part of a team dedicated to a safe and effective hospitalization.

Mark Shapiro, MD, is medical director for hospital medicine at St. Joseph Health Medical Group in Santa Rosa, Calif., and producer and host of Explore the Space podcast (explorethespaceshow.com).

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.

Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.

And hospitalists are right in the middle of this changing dynamic.

Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.

At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.

Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.

But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.

Palliative Care

There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.

Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.

Critical Care

Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.

Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.

Post-Acute Care

For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.

In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.

Preoperative Care

Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.

Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.

SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.

Working through a Dilemma

The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.

SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.

Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Choosing hospital medicine as a specialty means choosing between practicing community HM or academic HM. Or does it? Elizabeth Cook, MD, of Hospital Medicine Associates in Lynchburg VA; Stella Fitzgibbon, MD, FACP, FHM, with Memorial Hermann Hospital in The Woodlands, TX; and Chris Moriates, MD, of Dell Medical School at UT Austin, talk about the options available in community and academic HM, and moving between them during an HM career.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

With my team, I use whiteboards as a tool to enhance communication: 1) I introduce myself and my team members, then write our names on the whiteboard paired with an explanation of my role as the attending physician for the hospital medicine service; 2) on a daily basis, I ask the patient and family/support what their primary concerns and goals are and write those on the whiteboard; and 3) I invite the patient and family/support to use the whiteboard to write additional concerns or questions as they arise.

Why I Do It

Hospitals are confusing places. One of our key roles as hospitalists is to coordinate and clarify all of the moving pieces and to communicate clearly to patients and their family that there is someone doing that work on their behalf. The whiteboard can help to accomplish that and to visually indicate “reflective listening.” If I ask patients what their concerns and goals are on a daily basis, I can better address them, and writing those on the whiteboard is a way to visually let patients know I have heard them—and heard them accurately. Finally, as we know from experience at our institution, when patients are invited to write on the whiteboard, they are likely to do so and will often write important information that hasn’t come up during routine rounding.

How I Do It

The key to effectiveness is to build whiteboard use into the clinical workflow and patient conversation rather than create an extra task to complete. I have developed a routine using the whiteboard that is more or less the same for every patient.

Also, whiteboard design can influence the use of the whiteboard as a communication tool. I favor designs that have few prescriptive boxes and more space for writing. I have found whiteboards labeled with a “What are your goals?” section to be helpful.

Patrick Kneeland, MD, is medical director for patient and provider experience and director of the Excellence in Communication Curriculum, University of Colorado Hospital and Clinics.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

The Joint Council of Pediatric Hospital Medicine (JCPHM), successor to the Strategic Planning (STP) Committee, recently recommended submitting a petition for two-year pediatric hospital medicine (PHM) fellowship certification to the American Board of Pediatrics (ABP), which was completed in 2014. In December 2015, the ABP Board of Directors voted to (1) approve the proposal for a two-year PHM fellowship incorporating scholarly activity with the provision that entrustable professional activities (EPAs) be used as the framework for assessing competencies and (2) not require those who achieve and maintain PHM certification to maintain general pediatrics certification. The proposal for certification of a two-year PHM fellowship will now be submitted to the American Board of Medical Specialties (ABMS). Concerns regarding the formal certification of PHM as an ABMS-recognized subspecialty have been raised by many stakeholders, including community pediatric hospitalists, pediatric residency program directors, and med-peds physicians.

We feel that the “first, do no harm” guiding principle seems to have been forgotten by the ABP as it attempts to formalize the training of pediatric hospitalists. In December 2015, the ABP voted in favor of a two-year ACGME-accredited PHM fellowship. The intent was to “assure the best care of hospitalized children,” “assure the public,” “accelerate improvements and innovation in quality improvement,” and “raise the level of care of all hospitalized children by establishing best practices in clinical care.” To be clear, these goals are shared by all of us (although there is no indication that the public is seeking additional assurance). Prior to launching broad-scale, time-intensive, and financially costly initiatives, we should ensure that our efforts would achieve—rather than obstruct—their intended aims. In addition to a lack of evidence supporting that subspecialty certification will advance our path toward achieving these goals, there are numerous reasons a required PHM fellowship is unnecessary and potentially even harmful to the hospitalist workforce. The negative unintended consequences need to be weighed heavily.

We have found no data to support that children would receive inferior inpatient care from pediatric hospitalists due to lack of formal certification. Hospital medicine physicians are paving the way in quality improvement, high-value care, medical education, palliative care, and global health, supported in part through training in various non-accredited hospital medicine fellowships. There is nothing stopping pediatric hospitalists from establishing and disseminating best practices in clinical care. Hospitalists are already making strides in providing high-quality care at low costs, as demonstrated by the abundant PHM scholarly work described in the ABP application to the ABMS. The alleged problem of needing to build trust within the community is yet to be demonstrated, as we have leaders at local, regional, and national levels. The chief medical officer of the Centers for Medicare & Medicaid Services is a hospitalist as is our surgeon general. Hospital medicine is the fastest-growing specialty in the history of medicine,1 and we should seek to propel rather than fetter our future colleagues.

Below are our reasons for opposing this formal certification.

We already have a fellowship system.

As we all know, advanced training opportunities already exist for those interested in pursuing extra research and quality improvement training. Similar to other pediatric subspecialty fellowships, these PHM fellowships are undersubscribed (20% of PHM fellowships did not fill in 2016),2 with the majority of graduating pediatric residents transitioning to hospitalists opting not to pursue fellowship training. We should continue to let graduating pediatric residents vote with their feet without the undue influence of subspecialty certification.

Subspecialization has opportunity costs that may reduce the PHM pipeline.

Even if we assume an adequate number of fellowship programs could be developed and funded, our fear is that the decision to turn PHM into an accredited subspecialty could paradoxically reduce the pipeline of inpatient providers. Residency is already a three- to four-year endeavor (pediatrics and med-peds) that is poorly compensated and time-intensive. In the absence of evidence supporting the value of additional training, tacking on another two years seems unreasonable in the face of the student loan debt crisis, reduced compensation, and lost time for career advancement. These are significant opportunity costs. While most specialties lead to a significant pay raise to compensate for the added training time, pediatrics remains the lowest-paid physician specialty.3 Should PHM follow the trend of most pediatric subspecialties, pursuit of fellowship training would be a negative financial decision for residency graduates.4 For the health system, increasing debt-to-income ratios runs the risk of creating a medical education bubble market.5

More than 25% of med-peds graduates pursue careers in hospital medicine, a percentage that continues to grow, accounting for more than 100 new hospitalists per year.6 As a result, med-peds-trained hospitalists constitute more than 10% of the pediatric hospitalist workforce.6 Requiring PHM fellowship training may reduce this crucial pipeline of practitioners. In a 2014 unpublished survey of 225 med-peds practitioners, 78% of residents and 96% of attendings responded that they would not consider pursuing an ACGME-accredited PHM fellowship.7 This is compounded by a lack of parity with the practice of adult hospital medicine both in compensation and required training and is heightened by the fact that the training in question does not incorporate care for adult patients. There is clear consensus by 96% of med-peds hospitalists that the creation of an ACGME-certified PHM subspecialty will negatively affect the likelihood of med-peds providers pursuing PHM.7

Certification will pose a potential risk to specific patient populations.

We are also concerned that a reduced PHM workforce could disproportionately impact young adults with special healthcare needs and those children cared for in rural or community-based hospitals. Med-peds training equips providers to care for children with chronic diseases that then transition into adulthood; more than 25% provide care for young adults with special healthcare needs.6 With the increasing number of children with chronic health conditions surviving into adulthood,8 med-peds hospitalists serve essential roles in providing care and coordination for this vulnerable population. Furthermore, hospital medicine groups in medical systems that cannot support a full-time categorical pediatric hospitalist tend to employ med-peds physicians or family practitioners. Concerns with PHM certification are thus extended to those family medicine physicians who practice PHM.

Pediatric residency trains pediatricians in inpatient care.

We feel that the decision to move forward on PHM subspecialty certification calls into question the value of pediatric residency training. There is no evidence that clinical inpatient training in pediatrics residency is inadequate. If one leaves residency trained to do anything, it is practicing hospital medicine. A significant portion of residency takes place inpatient, both on wards and in the intensive care units. The 2009 ABP Foundation–funded study of PHM reported that 94% of pediatric hospitalist respondents rated their training in general clinical skills during residency as fully adequate, 85% rated their training in communication skills as fully adequate, and 73% did not believe any additional training beyond residency should be required.9 With respect to med-peds graduates, more than 90% feel equipped to care for children and adults upon residency completion.10 If the ABMS carries forward with this decision, the only clinical work one would be “certified” to do after residency is primary care. However, after completion of residency training, most of us feel at least as comfortable, if not more comfortable, caring for children in the inpatient setting.

Primary care should require subspecialty certification as well.

Furthermore, the decision to create a certified subspecialty begs the question as to why fellowship should not be mandated for those entering the field of primary care. Does the field of primary care not require research to move it forward? Does the field of primary care not require providers who can adeptly apply quality improvement methodologies to improve primary-care delivery? Does the public not require the same type of assurance? By these measures, primary care should require subspecialty certification as well. These arguments could easily be construed as an indictment of residency training.

The target should be residency training.

The PHM ABMS application describes a clinical curriculum consisting of eight core clinical rotations in various settings. That small number emphasizes the fact that extra clinical training is really not needed and that we do not require a complete overhaul of the current training system. The skills in question for the accredited PHM fellowship include communication, negotiation, leadership, quality improvement, pain management, sedation, procedures, transport, billing/coding, autonomous decision making, and scholarly practice. Are most of these not skills that we should foster in all practicing pediatricians? If graduating pediatric residents lack competence in core pediatric skills (e.g., communication, pain management, autonomous decision making), we should target improvements in residency education rather than require years of further training. Pediatrics residency training already requires training in quality improvement and is incorporating “tracks” that target areas of perceived deficiency. Those physicians who actually require specialized hospital-based skills (e.g., sedation, procedures, and transport) could receive core training during residency (e.g., through PHM tracks or electives) and further hone these skills through faculty development efforts. While non-PhD researchers may benefit from additional training in research methodologies, this training comes at the expense of time spent caring for patients on the wards and should not be required training for the majority of pediatric hospitalists pursuing purely clinical roles.

Broad-based support for a PHM subspecialty has not been demonstrated.

While approximately 40 pediatric hospitalists originated the PHM certification petition, we have not seen clear support for subspecialty certification from the community. PHM certification runs the risk of alienating the general pediatrics community, as many outpatient pediatricians continue to care for their patients in the inpatient setting. Furthermore, at tertiary-care medical centers, pediatric subspecialists often serve as hospitalists, yet this stakeholder group has not entered into this conversation. Importantly, the Association of Pediatric Program Directors (APPD) did not endorse this proposal. Many of the APPD members were quite concerned about the harm this certification could cause. While the APA Board and the AAP Board of Directors support PHM subspecialty certification, it is not clear that the rank-and-file members do. The Society of Hospital Medicine did not support or oppose certification. In an era of controversy surrounding certification requirements, prior to making a decision that will alter the direction of an entire field and impact all future residency graduates interested in entering that field, we should ensure there is broad-based support for this decision.

An alternative path has already been established and validated.

A more prudent, cost-effective, and universally acceptable approach would be to follow in the footsteps of the American Board of Internal Medicine (ABIM) and American Board of Family Medicine (ABFM) in establishing a Focused Practice in Pediatric Hospital Medicine program. This approach respects the unique body of knowledge required of those who care for hospitalized children while maintaining the required flexibility to nurture and help to mature existing training pipelines. Core hospital medicine skills should be further honed through residency curricular changes and faculty development efforts, while hospital-based physicians interested in developing niche skills could still do so via already existing fellowships.

When it comes to pediatric hospital medicine, first, do no harm.

Pediatric hospitalists are inpatient generalists by training and clinical approach. Our practices vary from large academic medical centers with every imaginable subspecialty consult service available to remote rural settings that require hospitalists to possess unique and specific skills. Some pediatric hospitalists participate in newborn care, some perform sedations, and some perform a variety of diagnostic and therapeutic procedures. The current system is meeting the needs of the vast majority of our PHM community. Changes to the residency curriculum that are already under way can address any clinical and quality improvement gaps. More than enough PHM fellowships are available to those who choose to pursue them. The public is not requesting reassurance, and the field is already advancing at a rapid rate both clinically and scholarly. Subspecialty recognition is not necessary and will likely lead to negative unintended consequences. Given the financial constraints on our current system and the need for pediatric hospitalists to be stewards of high-value care, we should make collective decisions that will clearly benefit our patients and health system. As medical professionals, our priority should always be first, do no harm.

Weijen W. Chang, MD, is chief of the Division of Pediatric Hospital Medicine at Baystate Children’s Hospital and associate professor of pediatrics at the University of Massachusetts Medical School.

Leonard Samuel Feldman, MD, is director of the Medicine-Pediatrics Urban Health Residency Program and associate professor of medicine and pediatrics at Johns Hopkins School of Medicine.

Bradley Monash, MD, is associate chief of medicine at University of California, San Francisco and assistant clinical professor of medicine and pediatrics at UCSF School of Medicine.

Archna Eniasivam, MD, is assistant clinical professor of medicine at UCSF School of Medicine.

References

1. Chen C, Eagle S. “Should Pediatric HM Pursue Subspecialty Certification, Required Fellowship Training?” The Hospitalist. July 31, 2012
2. Results and Data: Specialties Matching Service 2016 Appointment Year. National Resident Matching Program website. Accessed May 15, 2016.
3. Medscape Pediatrician Compensation Report 2015. Medscape website.  Accessed April 29, 2016.
4. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2001;127(2):254-260.
5. Asch DA, Nicholson S, Vujicic M. Are we in a medical education bubble market? N Engl J Med. 2013;369(21):1973-1975.
6. O’Toole JK, Friedland AR, Gonzaga AM, et al. The practice patterns of recently graduated internal medicine-pediatric hospitalists. Hosp Pediatr. 2015;5(6):309-314.
7. Society of Hospital Medicine: Survey of Med-Peds Physicians about PHM Certification. May 2014 (unpublished).
8. Goodman DM, Hall M, Levin A, et al. Adults with chronic health conditions originating in childhood: inpatient experience in children’s hospitals. Pediatrics. 2011;128(1):5-13.
9. Freed GL, Dunham KM, Research Advisory Committee of the American Board of P. Pediatric hospitalists: training, current practice, and career goals. J Hosp Med. 2009;4(3):179-186.
10. Donnelly MJ, Lubrano L, Radabaugh CL, Lukela MP, Friedland AR, Ruch-Ross HS. The med-peds hospitalist workforce: results from the American Academy of Pediatrics Workforce Survey. Hosp Pediatr. 2015;5(11):574-579.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

Before entering a patient’s room, I take a “mindful moment,” a brief mindfulness practice to boost empathy. This is a quick, simple, and effective way for me to rehab my empathy muscle.

Why I Do It

From empathy comes our desire to care about another human being, to connect with them, and to understand and be understood.

Many of the colleagues I talk to about patient experience echo the same sentiment: They feel powerless to change someone else’s experience, which is bundled with the immovable variables of their own perceptions and contexts.

While I believe there is truth to that, we can certainly change our experience, and that is what matters to patients. As my mentor and coach Anya Sophia Mann reminded me recently, “We are not responsible for the patient experience. We are responsible for our own experience, which we then bring to our patients. Your heart connection to your own empathic center is beautifully contagious and will spread to those around you throughout your day.”

How I Do It

We may think that empathy is an innate talent, but the literature supports that it is a skill like any other that can be taught, practiced, and deliberately and consciously turned up and down like the brightness on your smartphone.

A heartfelt patient experience starts with the feeling of connection to our own heart. But we can’t think our way into a feeling. If I let my head lead the way, I shield my heart from participating in true communication with the patient. We are both left without connection, without a sense of purpose, without fulfillment—empty and tired.

For the antidote, I choose to create an experience for my body to feel rather than an idea for my head to think about. Ironically, mindfulness starts not with the mind but with the body and, more precisely, with the breath.

Before entering the patient’s room, usually as I’m rubbing the hand sanitizer between my fingers, I take a deep breath that expands my belly instead of my chest, then I exhale, leaving plenty of time for the complete out breath. Next, I make the choice to be curious about the sensations in my body: “What have I carried with me from my interaction with the previous patient (or the nurse or the driver in front of me during my commute)? Does my jaw feel tight? Where do I feel stuck? Where exactly does that lump in my throat begin and end?”

The instruction here is just to notice without judgment. From that place of noticing, I have done a quick erasing of my emotional whiteboard to create space where I can respond rather than react to what is most important to my patient. I invite you to try these steps and notice what shifts happen for you and your patients. You won’t know it until you try it—and feel it—for yourself.

1. Pause long enough to feel the ground supporting you under both feet.
2. Take a deep, cleansing belly breath. Exhale fully without added effort.
3. Notice, without judgment, the sensations in your body.
4. Feel the space created by the melting and releasing of those feelings.
5. Bring that feeling of space with you as you begin the conversation with the patient.

Michael Donlin, ACNP-BC, FHM, is an inpatient nurse practitioner for the Department of Medicine, VA Boston Healthcare System.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

Before entering a patient’s room, I take a “mindful moment,” a brief mindfulness practice to boost empathy. This is a quick, simple, and effective way for me to rehab my empathy muscle.

Why I Do It

From empathy comes our desire to care about another human being, to connect with them, and to understand and be understood.

Many of the colleagues I talk to about patient experience echo the same sentiment: They feel powerless to change someone else’s experience, which is bundled with the immovable variables of their own perceptions and contexts.

While I believe there is truth to that, we can certainly change our experience, and that is what matters to patients. As my mentor and coach Anya Sophia Mann reminded me recently, “We are not responsible for the patient experience. We are responsible for our own experience, which we then bring to our patients. Your heart connection to your own empathic center is beautifully contagious and will spread to those around you throughout your day.”

How I Do It

We may think that empathy is an innate talent, but the literature supports that it is a skill like any other that can be taught, practiced, and deliberately and consciously turned up and down like the brightness on your smartphone.

A heartfelt patient experience starts with the feeling of connection to our own heart. But we can’t think our way into a feeling. If I let my head lead the way, I shield my heart from participating in true communication with the patient. We are both left without connection, without a sense of purpose, without fulfillment—empty and tired.

For the antidote, I choose to create an experience for my body to feel rather than an idea for my head to think about. Ironically, mindfulness starts not with the mind but with the body and, more precisely, with the breath.

Before entering the patient’s room, usually as I’m rubbing the hand sanitizer between my fingers, I take a deep breath that expands my belly instead of my chest, then I exhale, leaving plenty of time for the complete out breath. Next, I make the choice to be curious about the sensations in my body: “What have I carried with me from my interaction with the previous patient (or the nurse or the driver in front of me during my commute)? Does my jaw feel tight? Where do I feel stuck? Where exactly does that lump in my throat begin and end?”

The instruction here is just to notice without judgment. From that place of noticing, I have done a quick erasing of my emotional whiteboard to create space where I can respond rather than react to what is most important to my patient. I invite you to try these steps and notice what shifts happen for you and your patients. You won’t know it until you try it—and feel it—for yourself.

1. Pause long enough to feel the ground supporting you under both feet.
2. Take a deep, cleansing belly breath. Exhale fully without added effort.
3. Notice, without judgment, the sensations in your body.
4. Feel the space created by the melting and releasing of those feelings.
5. Bring that feeling of space with you as you begin the conversation with the patient.

Michael Donlin, ACNP-BC, FHM, is an inpatient nurse practitioner for the Department of Medicine, VA Boston Healthcare System.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

View a chart outlining key communication tactics

What I Say and Do

Before entering a patient’s room, I take a “mindful moment,” a brief mindfulness practice to boost empathy. This is a quick, simple, and effective way for me to rehab my empathy muscle.

Why I Do It

From empathy comes our desire to care about another human being, to connect with them, and to understand and be understood.

Many of the colleagues I talk to about patient experience echo the same sentiment: They feel powerless to change someone else’s experience, which is bundled with the immovable variables of their own perceptions and contexts.

While I believe there is truth to that, we can certainly change our experience, and that is what matters to patients. As my mentor and coach Anya Sophia Mann reminded me recently, “We are not responsible for the patient experience. We are responsible for our own experience, which we then bring to our patients. Your heart connection to your own empathic center is beautifully contagious and will spread to those around you throughout your day.”

How I Do It

We may think that empathy is an innate talent, but the literature supports that it is a skill like any other that can be taught, practiced, and deliberately and consciously turned up and down like the brightness on your smartphone.

A heartfelt patient experience starts with the feeling of connection to our own heart. But we can’t think our way into a feeling. If I let my head lead the way, I shield my heart from participating in true communication with the patient. We are both left without connection, without a sense of purpose, without fulfillment—empty and tired.

For the antidote, I choose to create an experience for my body to feel rather than an idea for my head to think about. Ironically, mindfulness starts not with the mind but with the body and, more precisely, with the breath.

Before entering the patient’s room, usually as I’m rubbing the hand sanitizer between my fingers, I take a deep breath that expands my belly instead of my chest, then I exhale, leaving plenty of time for the complete out breath. Next, I make the choice to be curious about the sensations in my body: “What have I carried with me from my interaction with the previous patient (or the nurse or the driver in front of me during my commute)? Does my jaw feel tight? Where do I feel stuck? Where exactly does that lump in my throat begin and end?”

The instruction here is just to notice without judgment. From that place of noticing, I have done a quick erasing of my emotional whiteboard to create space where I can respond rather than react to what is most important to my patient. I invite you to try these steps and notice what shifts happen for you and your patients. You won’t know it until you try it—and feel it—for yourself.

1. Pause long enough to feel the ground supporting you under both feet.
2. Take a deep, cleansing belly breath. Exhale fully without added effort.
3. Notice, without judgment, the sensations in your body.
4. Feel the space created by the melting and releasing of those feelings.
5. Bring that feeling of space with you as you begin the conversation with the patient.

Michael Donlin, ACNP-BC, FHM, is an inpatient nurse practitioner for the Department of Medicine, VA Boston Healthcare System.

Dr. Marianne Green and Dr. Jeffrey Wiese, two members of the ABIM Council, talk about ABIM's Maintenance of Certification process, and the importance of professional assessment. Dr. Green works on Internal Medicine MOC, Dr. Wiese was part of the team that developed the Focused Practice in Hospital Medicine MOC.

Dr. Marianne Green and Dr. Jeffrey Wiese, two members of the ABIM Council, talk about ABIM's Maintenance of Certification process, and the importance of professional assessment. Dr. Green works on Internal Medicine MOC, Dr. Wiese was part of the team that developed the Focused Practice in Hospital Medicine MOC.

Dr. Marianne Green and Dr. Jeffrey Wiese, two members of the ABIM Council, talk about ABIM's Maintenance of Certification process, and the importance of professional assessment. Dr. Green works on Internal Medicine MOC, Dr. Wiese was part of the team that developed the Focused Practice in Hospital Medicine MOC.

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.

One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.

Think again.

“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”

The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.

“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”

Compensation Data

Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.

“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”

Promises like that are getting more expensive to keep.

Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.

Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).

In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.

“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”

To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.

Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.

“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”

Productivity Stalls

While compensation continues to climb, productivity flattened out in this year’s report.

Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.

Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.

“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”

Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.

For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.

“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”

Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.

“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.

The report’s subsections are also critical for comparing one HMG to others, Dr. White says.

“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”

Survey Limitations

Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.

“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.

For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.

“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.

That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.

These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”

Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.

“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.

In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.

“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.

Alternative Payment Models

Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.

“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.

Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.

“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”

In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.

“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”

Richard Quinn is a freelance writer in New Jersey.

Is Burnout a Problem?

Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.

But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”

The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.

Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.

“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.

Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.

“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”

—Richard Quinn

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.

One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.

Think again.

“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”

The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.

“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”

Compensation Data

Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.

“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”

Promises like that are getting more expensive to keep.

Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.

Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).

In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.

“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”

To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.

Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.

“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”

Productivity Stalls

While compensation continues to climb, productivity flattened out in this year’s report.

Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.

Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.

“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”

Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.

For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.

“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”

Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.

“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.

The report’s subsections are also critical for comparing one HMG to others, Dr. White says.

“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”

Survey Limitations

Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.

“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.

For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.

“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.

That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.

These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”

Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.

“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.

In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.

“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.

Alternative Payment Models

Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.

“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.

Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.

“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”

In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.

“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”

Richard Quinn is a freelance writer in New Jersey.

Is Burnout a Problem?

Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.

But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”

The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.

Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.

“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.

Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.

“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”

—Richard Quinn

Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.

2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.

One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.

Think again.

“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”

The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.

“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”

Compensation Data

Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.

“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”

Promises like that are getting more expensive to keep.

Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.

Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).

In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.

“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”

To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.

Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.

“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”

Productivity Stalls

While compensation continues to climb, productivity flattened out in this year’s report.

Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.

Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.

“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”

Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.

For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.

“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”

Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.

“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.

The report’s subsections are also critical for comparing one HMG to others, Dr. White says.

“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”

Survey Limitations

Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.

“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.

For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.

“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.

That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.

These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”

Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.

“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.

In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.

“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.

Alternative Payment Models

Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.

Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.

“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.

Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.

“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”

In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.

“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”

Richard Quinn is a freelance writer in New Jersey.

Is Burnout a Problem?

Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.

But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”

The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.

Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.

“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.

Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.

“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”

—Richard Quinn