Career

The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.

Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?

A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.

Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.

Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.

Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.

More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.

More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).

Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.

Change Efforts

One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.

The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).

As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.

Depending on the issues within a group, successful interventions could include:

• Decision support tools (for appropriate use of consultants and diagnostic tests)
• Display of testing costs (not just at the time of ordering)
• Efforts aimed at patient education (both as general consumers as well as at the point of care)
• Malpractice reform to support physicians trying to balance cost consciousness with patient welfare

In Sum

We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.

If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH

References

1. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.

The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.

Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?

A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.

Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.

Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.

Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.

More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.

More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).

Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.

Change Efforts

One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.

The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).

As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.

Depending on the issues within a group, successful interventions could include:

• Decision support tools (for appropriate use of consultants and diagnostic tests)
• Display of testing costs (not just at the time of ordering)
• Efforts aimed at patient education (both as general consumers as well as at the point of care)
• Malpractice reform to support physicians trying to balance cost consciousness with patient welfare

In Sum

We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.

If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH

References

1. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.

The healthcare industry is under major stress from steady declines in all sources of revenue. The drivers are multifactorial but include declining reimbursement from payors, a shift from fee-for-service to pay-for-performance, and state-by-state variability in patients covered by Medicaid, by high-deductible plans, or by being uninsured. In academic medical centers, rising overhead costs coupled with a reticence to raise student tuition and declining research funding streams have further compounded the situation.

Regardless of the actual numbers, all healthcare institutions are feeling the financial pinch. Most are intensely focused on cost-reduction efforts. The question is, what do physicians think about their role in these efforts, and what efforts will be most effective?

A recent survey of a large physician group practice found that many physicians do not know what their cost drivers are or do not think it is their role to participate in cost-reduction efforts.1 Of note, the group practice in the survey is a Pioneer Medicare accountable care organization (ACO) and participates in a combination of fee-for-service and capitated contracts.

Within the survey, the researchers embedded a cost-consciousness scale, which is a validated survey tool designed to assess daily cost consciousness. They also embedded other survey items to determine the physicians’ concerns for malpractice, comfort with diagnostic uncertainty, and perception of patient-family pressure for utilization of services. The average overall cost-consciousness score was 29 out of 44, with higher scores indicating more cost consciousness.

Almost all physicians agreed that they need to reduce unnecessary testing (97%), need to adhere to guidelines (98%), and have a responsibility to control costs (92%). However, 33% felt it was unfair for them to have to be both cost-conscious and concerned with the welfare of their patients.

Approximately a third of respondents also felt that there was too much emphasis on cost and that physicians are too busy to worry about costs.

More than a third (37%) said they did not have good knowledge about test-procedure cost within their system.

More than half of physicians felt pressure from patients to perform tests and procedures (from 68% of primary-care physicians, 58% of medical specialists, and 56% of surgical specialists) and felt pressure to refer to consultants (from 65% of primary-care physicians, 35% of medical specialists, and 34% of surgical specialists).

Based on this survey and other literature about physicians’ perceptions of their role and their ability to control costs, it is clear that the first step in understanding how to engage physicians in cost-reducing efforts is to understand what the drivers are for utilization and what the concerns are for reducing cost. Many hypothesize that the drivers to support the status quo include a fear of litigation, fear of missing a diagnosis, and patient demands for services. Another major driver of current utilization is that there is ongoing support for the status quo, as the majority of reimbursement for providers is still based on fee-for-service.

Change Efforts

One cost-reducing effort that has gained widespread enthusiasm from medical societies is the Choosing Wisely campaign. This campaign is an effort originally driven by the American Board of Internal Medicine (ABIM) Foundation to help physicians become aware of and reduce unnecessary utilization of resources. Each Choosing Wisely list is generated and endorsed by the relevant medical society and widely advertised to physicians via a variety of mechanisms. More than 70 medical societies have participated in the effort to date.

The recommendations are often widely accepted by those in the specialty since they are evidence-based and derived and advertised by their own specialty societies. In the survey mentioned above, almost all physicians agreed that their Choosing Wisely was a good source of guidance (ranging from 92% of surgical specialties to 97% of primary-care physicians). In order to drive the movement from the patient perspective, Consumer Reports has developed educational materials aimed at the consumer side of healthcare (ie, patients and families).

As Consumer Reports suggests, the first step to implementing cost-conscious care is to measure awareness of cost and causes of overutilization. By first understanding behaviors, a group can then work to impact such behaviors. It is highly likely that the drivers are different based on the specialty of the physician, the patient population being served, and the local healthcare market drivers. As such, there will not be a single, across-the-board solution to reducing unnecessary utilization of services (and therefore cost), but interventions will need to be tailored to different groups depending on the drivers of cost locally.

Depending on the issues within a group, successful interventions could include:

• Decision support tools (for appropriate use of consultants and diagnostic tests)
• Display of testing costs (not just at the time of ordering)
• Efforts aimed at patient education (both as general consumers as well as at the point of care)
• Malpractice reform to support physicians trying to balance cost consciousness with patient welfare

In Sum

We have a long way to go in engaging physicians in efforts to reduce unnecessary utilization and cost. I recommend that hospitalist practices utilize the survey tool used in this study to understand the perceived barriers and drivers of cost within their practice and work with their local administrative teams to better understand patterns of overutilization among their group. Then interventions can be designed to be evidence-based, tailored to local workflow, and both reliable and sustainable.

If done well, hospitalists can have a huge impact on utilization and cost and position their groups and their hospitals well to succeed in this cost-constrained era of healthcare. TH

References

1. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perception of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.

The Maker Movement, the 21st century's upgrade of do-it-yourself that includes 3D printers and "the Internet of Things," is showing up in hospitals in interesting ways. Clinical teams confronted with a nagging issue on the wards can work together to design and prototype physical-product solutions. Two Beth Israel Deaconess hospitalists talk about the Maker Movement, and how they've turned it into a team-based, near real-time collaborative process for addressing quality improvement challenges.

The Maker Movement, the 21st century's upgrade of do-it-yourself that includes 3D printers and "the Internet of Things," is showing up in hospitals in interesting ways. Clinical teams confronted with a nagging issue on the wards can work together to design and prototype physical-product solutions. Two Beth Israel Deaconess hospitalists talk about the Maker Movement, and how they've turned it into a team-based, near real-time collaborative process for addressing quality improvement challenges.

The Maker Movement, the 21st century's upgrade of do-it-yourself that includes 3D printers and "the Internet of Things," is showing up in hospitals in interesting ways. Clinical teams confronted with a nagging issue on the wards can work together to design and prototype physical-product solutions. Two Beth Israel Deaconess hospitalists talk about the Maker Movement, and how they've turned it into a team-based, near real-time collaborative process for addressing quality improvement challenges.

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

Larry Beresford is a freelance writer in Alameda, Calif.

How NPs, PAs Can Prepare for Greater Leadership Roles

Michael Huckabee, MPAS, PhD, PA-C, is director of the Division of Physician Assistant Education at the University of Nebraska Medical Center in Omaha, where he trains both entry-level students and mid-career practitioners pursuing distance learning.

“When PAs are group leaders, they need to have the ability and orientation to involve all of their physicians in decision making,” Huckabee says. “This is a collaborative model of leadership. A term we use in leadership training is called ‘persuasive mapping’—the ability to influence others through reasoning to do something greater.”

What does Huckabee look for in students who might have a knack for leadership but could use a nudge in that direction?

“It’s a person who is somewhat gregarious and who builds strong relationships with others. They come to him or her for advice and ideas. But also with some level of humility—aware and accepting of personal limitations. These are the folks where we can say, ‘Let’s talk about your leadership skills and where we can strengthen you to be better prepared for the opportunities that can come up,’” he explains.

Huckabee says PAs need to get their names into consideration for opportunities on hospital committees such as pharmacy, credentialing, or ethics.

“You have to be well-versed about where you fit as a professional, relative to other advanced practitioners, and how the system works,” he says. “You have to be at the table, looking for opportunities to move the organization forward.”

Laurie Benton, PhD, MPAS, PA-C, RN, DFAAPA, who is the system director of advanced practice professionals for the Baylor Scott & White Health in Dallas, offers some additional advice for PAs and NPs who would like to rise to positions of leadership in their hospital groups or health systems.

“I recommend taking as many leadership classes as your facility offers,” she says. “Also consider taking outside leadership courses and even getting a second degree in business.”

Benton also says NPs and PAs should get involved in state and national professional and specialty associations. For example, the National Commission on Certification of Physician Assistants now offers a certificate of added qualifications in hospital medicine.

“That is where you will learn a great deal about laws that govern PAs and upcoming legislation that could affect what PAs are allowed to do and how they get paid,” she says, as well as the credentialing and boarding of PAs and NPs, which vary from state to state and from hospital to hospital.

—Larry Beresford

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

Larry Beresford is a freelance writer in Alameda, Calif.

How NPs, PAs Can Prepare for Greater Leadership Roles

Michael Huckabee, MPAS, PhD, PA-C, is director of the Division of Physician Assistant Education at the University of Nebraska Medical Center in Omaha, where he trains both entry-level students and mid-career practitioners pursuing distance learning.

“When PAs are group leaders, they need to have the ability and orientation to involve all of their physicians in decision making,” Huckabee says. “This is a collaborative model of leadership. A term we use in leadership training is called ‘persuasive mapping’—the ability to influence others through reasoning to do something greater.”

What does Huckabee look for in students who might have a knack for leadership but could use a nudge in that direction?

“It’s a person who is somewhat gregarious and who builds strong relationships with others. They come to him or her for advice and ideas. But also with some level of humility—aware and accepting of personal limitations. These are the folks where we can say, ‘Let’s talk about your leadership skills and where we can strengthen you to be better prepared for the opportunities that can come up,’” he explains.

Huckabee says PAs need to get their names into consideration for opportunities on hospital committees such as pharmacy, credentialing, or ethics.

“You have to be well-versed about where you fit as a professional, relative to other advanced practitioners, and how the system works,” he says. “You have to be at the table, looking for opportunities to move the organization forward.”

Laurie Benton, PhD, MPAS, PA-C, RN, DFAAPA, who is the system director of advanced practice professionals for the Baylor Scott & White Health in Dallas, offers some additional advice for PAs and NPs who would like to rise to positions of leadership in their hospital groups or health systems.

“I recommend taking as many leadership classes as your facility offers,” she says. “Also consider taking outside leadership courses and even getting a second degree in business.”

Benton also says NPs and PAs should get involved in state and national professional and specialty associations. For example, the National Commission on Certification of Physician Assistants now offers a certificate of added qualifications in hospital medicine.

“That is where you will learn a great deal about laws that govern PAs and upcoming legislation that could affect what PAs are allowed to do and how they get paid,” she says, as well as the credentialing and boarding of PAs and NPs, which vary from state to state and from hospital to hospital.

—Larry Beresford

Since hospital medicine’s early days, hospitalist physicians have worked alongside physician assistants (PAs) and nurse practitioners (NPs). Some PAs and NPs have ascended to positions of leadership in their HM groups or health systems, in some cases even supervising the physicians.

The Hospitalist connected with six PA and NP leaders in hospital medicine to discuss their career paths as well as the nature and scope of their jobs. They described leadership as a complex, multidimensional concept, with often more of a collaborative model than a clear-cut supervisory relationship with clinicians. Most said they don’t try to be the “boss” of their group and have found ways to impact key decisions.

They also emphasized that PAs and NPs bring special skills and perspectives to team building. Many have supplemented frontline clinical experience with leadership training. And when it comes to decision making, their responsibilities can include hiring, scheduling, training, mentoring, information technology, quality improvement, and other essential functions of the group.

Edwin Lopez, MBA, PA-C

Workplace: St. Elizabeth is a 25-bed critical-access hospital serving a semi-rural bedroom community of 11,000 people an hour southeast of Seattle. It belongs to the nine-hospital CHI Franciscan Health system, and the HM group includes four physicians and four PAs providing 24-hour coverage. The physicians and PAs work in paired teams in the hospital and an 80-bed skilled nursing facility (SNF) across the street. Lopez heads St. Elizabeth’s HM group and is associate medical director of the SNF.

Background: Lopez graduated from the PA program at the University of Washington in 1982 and spent seven years as a PA with a cardiothoracic surgery practice in Tacoma. Then he established his own firm providing PA staffing services for six cardiac surgery programs in western Washington. In 1997, he co-founded an MD/PA hospitalist service covering three hospitals for a Seattle insurance company. That program grew into a larger group that was acquired by CHI Franciscan.

Lopez took time off to earn his MBA in health policy at the University of Washington and Harvard Kennedy School in Boston.

Eight years ago as part of an acquisition, CHI Franciscan asked Lopez to launch an HM program at St. Elizabeth. From the start, he developed the program as a collaborative model. The HM group now covers almost 90% of hospital admissions, manages the ICU, takes calls to admit patients from the ED, and rounds daily on patients in a small hospital that doesn’t have access to a lot of medical specialists.

St. Elizabeth’s has since flourished to become one of the health system’s top performers on quality metrics like HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. However, Lopez admits readmission rates remain high. He noticed that a big part of the readmission problem was coming from the facility across the street, so he proposed the HM group start providing daily coverage to the SNF. In the group’s first year covering the SNF, the hospital’s readmission rate dropped to 5% from 35%.

Listen: Edwin Lopez, PA-C, discusses post-acute Care in the U.S. health system

Responsibilities: Lopez spends roughly half his time seeing patients, which he considers the most satisfying half. The other half is managing and setting clinical and administrative direction for the group.

“My responsibility is to ensure that there is appropriate physician and PA coverage 24-7 in both facilities,” he says, adding he also handles hiring and personnel issue. “We have an understanding here. I help guide, mentor, and direct the team, with the support of our regional medical director.”

The story: Lopez credits his current position to Joe Wilczek, a visionary CEO who came to the health system 18 years ago and retired in 2015.

“Joe and Franciscan’s chief medical officer and system director of hospital medicine came to me and said, ‘We’d like you to go over there and see what you can do at St. Elizabeth.’ There was a definite mandate, with markers they wanted me to reach. They said, ‘If you succeed, we will build you a new hospital building.’”

The new building opened in 2012.

Lopez says he has spent much of his career in quiet oblivion.

“It took five or six years here before people started noticing that our quality and performance were among the highest in the system,” he says. “For my entire 33-year career in medicine, I was never driven by the money. I grew up believing in service and got into medicine to make a difference, to leave a place better than I found it.”

He occasionally fields questions about his role as a PA group leader, which he tries to overcome by building trust, just as he overcame initial resistance to the hospital medicine program at St. Elizabeth from community physicians.

“I am very clear, we as a team are very clear, that we’re all worker bees here. We build strong relationships. We consider ourselves family,” he says. “When family issues come up, we need to sit down and talk about them, even when it may be uncomfortable.”

Laurie Benton, RN, MPAS, PhD, PA-C, DFAAPA

Workplace: Baylor Scott & White Health is the largest nonprofit health system in Texas, with 46 hospitals and 500 multispecialty clinics. Scott & White Memorial Hospital is a 636-bed specialty care and teaching hospital. Its hospital medicine program includes 40 physicians and 34 NP/PAs caring for an average daily census of 240 patients. They cover an observation service, consult service, and long-term acute-care service.

Background: Benton has a PhD in health administration. She has practiced hospital medicine at Scott & White Memorial Hospital since 2000 and before that at Emanuel Hospital in Portland, Ore. Currently an orthopedic hospitalist PA, she has worked in cardiothoracic surgery, critical care, and nephrology settings.

She became the system director for APPs in September 2013. In that role, she leads and represents 428 APPs, including hospitalist, intensivist, and cardiology PAs, in the system’s 26-hospital Central Region. She sits on the board of directors of the American Academy of Physician Assistants and has been on workforce committees for the National Commission on Certification of Physician Assistants and on the CME committee of the National Kidney Foundation.

Responsibilities: Benton coordinates everything, including PAs, advanced practice nurses, and nurse anesthetists, in settings across the healthcare continuum.

“I was appointed by our hospital medicine board and administration to be the APP leader. I report to the chief medical officer,” she says. “But I still see patients; it’s my passion. I’m not ready to give it up completely.”

Benton’s schedule includes two 10-hour clinical shifts per week. The other three days she works on administrative tasks. She attends board meetings as well as regular meetings with the system’s top executives and officers, including the chair of the board and the senior vice president for medical affairs.

“I have a seat on staff credentialing, benefits, and compensation committees, and I’m part of continuing medical education and disaster planning. Pretty much any of the committees we have here, I’m invited to be on,” she says. “I make sure I’m up-to-date on all of the new regulations and have information on any policies that have to do with APPs.”

The story: Benton says her PA training, including mentorship from Edwin Lopez, placed a strong emphasis on helping students develop leadership skills and interests.

“While I was working in nephrology, my supervising physician mentored me and encouraged me to move forward with my education,” she says. Along the way, she participated in a yearlong executive-education program and taught at the University of Texas McCombs School of Business. “Right off, it was not easy because while people saw me as a very strong, very confident provider, they didn’t see me as an administrator. When I worked with administrators, they were speaking a different language. I’d speak medicine, and they’d speak administration. It took a while to learn how to communicate with them.”

She says non-physician professionals traditionally have reported up through a physician and “never had their own voice. … Now that we have our leadership ladder here, it’s still new to some administrators,” she says. “I want to make sure PAs are part of the solution to high-quality healthcare.

“When I’m at the leadership table, we’re working together. The physicians respect my opinion, giving me the opportunity to interact like anyone else at the table.”

Catherine Boyd, MS, PA-C

Workplace: Essex is a private hospitalist group founded in 2007 by James Tollman, MD, FHM, who remains its CEO. It has 34 clinical members, including 16 physicians, 12 PAs, and six NPs. It began providing hospitalist medical care to several hospitals on Massachusetts’ North Shore under contract, then to a psychiatric hospital and a detox treatment center. In recent years, it has expanded into the post-acute arena, providing coverage to 14 SNFs, which now constitute the majority of its business. It also is active with two accountable-care organization networks.

Background: After three years as a respiratory therapist, Boyd enrolled in a PA program at Massachusetts College of Pharmacy and Health Sciences. After graduating in 2005, she worked as a hospitalist and intensivist, including as team leader for the medical emergency team at Lahey Health & Medical Center in Burlington, Mass., and in the PACE (Program of All-Inclusive Care for the Elderly) Internal Medical Department with Partners HealthCare until mid-2014, when she was invited to join Essex.

Responsibilities: “This job is not one thing; I dabble in everything,” says Boyd, who describes herself as the group’s chief operating officer for professional affairs. “I provide direct supervision to our PAs and NPs but also to our independent contractors, including moonlighting physicians. And I help to supervise the full-time physicians.”

She works on system issues, on-site training and mentorship, and implementation of a new electronic health record (EHR) and charge capture system while trying to improve bed flow and quality and decrease clinicians’ job frustrations. She also monitors developments in Medicare regulations.

“I check in with every one of our full-time providers weekly, and I try to offset some of the minutiae of their workday so that they can focus on their patients,” she explains. “Dr. Tollman and I feel that we bring a healthy work-lifestyle balance to the group. We encourage that in our staff. If they are happy in their jobs, it makes quality of care better.”

Boyd also maintains a clinical practice as a hospitalist, with her clinical duties flexing up and down based on patient demand and management needs.

The story: When Boyd was a respiratory therapist at a small community hospital, she worked one-on-one with a physician assistant who inspired her to change careers.

“I really liked what she did. As a PA, I worked to broaden my skill set on a critical care service for seven years,” she says. “But then my two kids got older and I wanted a more flexible schedule. Dr. Tollman came across my résumé when he was looking for a clinician to run operations for Essex.”

Building on 10 years of clinical experience, Boyd has tried to earn the trust of the other clinicians.

“They know they can come to me with questions. I like to think I practice active listening. When there is a problem, I do a case review and try to get all the facts,” she says. “When you earn their trust, the credentials tend to fall away, especially with the doctors I work with on a daily basis.”

Daniel Ladd, PA-C, DFAAPA

Workplace: Founded in 1993 as Hospitalists of Northern Michigan, iNDIGO Health Partners is one of the country’s largest private hospitalist companies, employing 150 physicians, PAs, and NPs who practice at seven hospitals across the state. The program also provides nighttime hospitalist services via telehealth and pediatric hospital medicine. It recently added 10 post-acute providers to work in SNFs and assisted living facilities.

Background: While working as a nurse’s aide, meeting and being inspired by some of the earliest PAs in Michigan, Ladd pursued PA training at Mercy College in Detroit. After graduating in 1984, he was hired by a cardiology practice at Detroit Medical Center. When he moved upstate to Traverse City in 1997, he landed a position as lead PA at another cardiology practice, acting as its liaison to PAs in the hospital. He joined iNDIGO in 2006.

“Jim Levy, one of the first PA hospitalists in Michigan, was an integral part of founding iNDIGO and now is our vice president of human resources,” Ladd says. “He asked me to join iNDIGO, and I jumped at the chance. Hospital medicine was a new opportunity for me and one with more opportunities for PAs to advance than cardiology.”

In 2009, when the company reorganized, the firm’s leadership recognized the need to establish a liaison group as a buffer between the providers and the company. Ladd became president of its new board of managers.

“From there, my position evolved to what it is today,” he says.

Levy calls Ladd a role model and leader, with great credibility among site program directors, hospital CMOs, and providers.

Responsibilities: Ladd gave up his clinical practice as a hospitalist in 2014 in response to growing management responsibilities.

“I do and I don’t miss it,” he says. “I miss the camaraderie of clinical practice, the foxhole mentality on the front lines. But I feel where I am now that I am able to help our providers give better care.

“Concretely, what I do is to help our practitioners and our medical directors at the clinical sites, some of whom are PAs and NPs, supporting them with leadership and education. I listen to their issues, translating and bringing to bear the resources of our company.”

Those resources include staffing, working conditions, office space, and the application of mobile medical technology for billing and clinical decision support.

“A lot of my communication is via email. I feel I am able to make a point without being inflammatory, by stating my purpose—the rationale for my position—and asking for what I need,” Ladd says. “This role is very accepted at iNDIGO. The corollary is that physician leaders who report to me are also comfortable in our relationship. It’s not about me being a PA and them being physicians but about us being colleagues in medicine.

“I’m in a position where I understand their world and am able to help them.”

The story: Encouraged by what he calls “visionary” leaders, Ladd has taken a number of steps to ascend to his current position as chief clinical officer.

“Even going back to the Boy Scouts, I was always one to step forward and volunteer for leadership,” he says. “I was president of my PA class in college and involved with the state association of PAs, as well as taking leadership training through the American Academy of Physician Assistants. I had the good fortune to be hired by a brilliant cardiologist at Detroit Medical Center. … He was the first to encourage me to be not just an excellent clinician but also a leader. He got me involved in implementing the EHR and in medication reconciliation. He promoted me as a PA to his patients and allowed me to become the face of our clinical practice, running the clinical side of the practice.”

Ladd also credits iNDIGO’s leaders for an approach of hiring the best people regardless of degree.

“If they happen to be PAs, great. The company’s vision is to have people with vision and skills to lead, not just based on credentials,” he says. “They established that as a baseline, and now it’s the culture here. We have PAs who are key drivers of the efficiency of this program.”

It hasn’t eliminated the occasional “I’m the physician, I’m delegating to you, and you have to do what I say,” Ladd admits. But he knows handling those situations is part of his job as a practice leader.

“It requires patience and understanding and the ability to see the issue from multiple perspectives,” he says, “and then synthesize all of that into a reasonable solution for all concerned.”

Arnold Facklam III, MSN, FNP-BC, FHM

Workplace: United Memorial has 100 beds and is part of the four-hospital Rochester Regional Health System. Kaleida Health has four acute-care hospitals in western New York. Based an hour apart, they compete, but both now get hospitalist services from Infinity Health Hospitalists of Western New York, a hospitalist group of 30 to 35 providers privately owned by local hospitalist John Patti, MD.

Background: Facklam has been a nocturnist since 2009, when he completed an NP program at D’Youville College in Buffalo. He worked 15 to 17 night shifts a month, first at Kaleida’s DeGraff Memorial Hospital and then at United Memorial, starting in 2013 as a per diem and vacation fill-in, then full-time since 2015. He now works for Infinity Health Hospitalists.

While working as a hospitalist, Facklam became involved with the MSO of Kaleida Health, starting on its Advanced Practice Provider Committee, which represents more than 600 NPs and PAs. Now chair of the committee, he leads change in the scope of practice for NPs and PAs and acts as liaison between APPs and the hospitals and health system.

Responsibilities: As a full-time nocturnist, Facklam has to squeeze in time for his role as director of advanced practice providers. He offers guidance and oversight, under the direction of the vice president of medical affairs, to all NPs, PAs, nurse midwives, and nurse anesthetists. He also is in charge of its rapid response and code blue team coverage at night, plus provides clinical education to family practice medical students and residents overnight in the hospital. He has worked on hospital quality improvement projects since 2012.

Facklam, who acknowledges type A personality tendencies, also maintains two to three night shifts per month at Kaleida’s Millard Suburban Hospital.

In 2012, he became a member, eventually a voting member, of Kaleida’s system-wide MSO Medical Executive Committee, which is responsible for rule making, disciplinary action, and the provision of medical care within the system.

“The MSO is the mechanism for accountability for professional practice,” he says. He is also active in SHM’s NP/PA Committee and now sits on SHM’s Public Policy Committee.

The story: “Working as a nocturnist has given me the flexibility to look into advanced management training,” he says, including Six Sigma green belt course work and certificate training. While at DeGraff, he heard about a call for membership on the NP/PA committee.

“They quickly realized the benefits of having someone with a background like mine on board,” he said. “As a nocturnist, I started going to more meetings and getting involved when the easier thing to do might have been to drive home and go to bed.”

Along the way, he learned a lot about hospital systems and how they work.

“Having been in healthcare for 23 years, I know the hierarchical approach,” Facklam says. “But the times are changing. As medicine becomes broader and more difficult to manage, it has to become more of a team approach. If you look at the data, there won’t be enough physicians in the near future. PAs and NPs can help fill that need.”

Crystal Therrien, MS, ACNP-BC

Workplace: UMass Medical Center encompasses three campuses in central Massachusetts, including University, Memorial, and Marlborough. The hospital medicine division covers all three campuses with 40 to 45 FTEs of physicians and 20 of APPs. Therrien has been with the department since October 2009—her first job after completing NP training—and assumed her leadership role in June 2012.

Responsibilities: Therrien supervises the UMass hospital medicine division’s Affiliate Practitioner Group. She works with physicians on the executive council, coordinates the medicine service, and coordinates cross-coverage with other services in the hospital, including urology, neurology, surgery, GI, interventional radiology, and bone marrow transplants.

Hospitalist staff work 12-hour shifts, providing 24-hour coverage in the hospital, with one physician and two APPs scheduled at night.

“Because we are available 24-7 in house, I work closely with our scheduler. There is also a lot of coordination with subspecialty services in the hospital and on the observation unit,” she says. “I’m also responsible for interviewing and hiring AP candidates, including credentialing, and with the mentorship program. I chair the rapid response program and host our monthly staff meetings,” which involve both business and didactic presentations. She also serves on the hospital’s NP advisory council.

Before Therrien became the lead NP, her predecessor was assigned at 5% administrative.

“I started out 25% administrative because the program has expanded so quickly,” she says, noting that now she is 50% clinic and 50% administrative. “To be a good leader, I think I need to keep my feet on the ground in patient care.”

The story: Therrien worked as an EMT, a volunteer firefighter, and an ED tech before pursuing a degree in nursing.

“I grew up in a house where my dad was a firefighter and my mom was an EMT,” she says. “We were taught the importance of helping others and being selfless. I always had a leadership mentality.”

Therrien credits her physician colleagues for their commitment and support.

“It can be a little more difficult outside of our department,” she says. “They don’t always understand my role. Some of the attendings have not worked with affiliated providers before, but they have worked with residents. So there’s an interesting dynamic for them to learn how to work with us.”

Kimberly Eisenstock, MD, FHM, the clinical chief of hospital medicine, says that when she was looking for someone new to lead the affiliated practitioners, she wanted “a leader who understood their training and where they could be best utilized. Crystal volunteered. Boy, did she! She was the most experienced and enthusiastic candidate, with the most people-oriented skills.”

Dr. Eisenstock says she doesn’t start new roles or programs for the affiliated practitioners without getting the green light from Therrien.

“Crystal now represents the voice for how the division decides to employ APPs and the strategies we use to fill various roles,” she says. TH

Larry Beresford is a freelance writer in Alameda, Calif.

How NPs, PAs Can Prepare for Greater Leadership Roles

Michael Huckabee, MPAS, PhD, PA-C, is director of the Division of Physician Assistant Education at the University of Nebraska Medical Center in Omaha, where he trains both entry-level students and mid-career practitioners pursuing distance learning.

“When PAs are group leaders, they need to have the ability and orientation to involve all of their physicians in decision making,” Huckabee says. “This is a collaborative model of leadership. A term we use in leadership training is called ‘persuasive mapping’—the ability to influence others through reasoning to do something greater.”

What does Huckabee look for in students who might have a knack for leadership but could use a nudge in that direction?

“It’s a person who is somewhat gregarious and who builds strong relationships with others. They come to him or her for advice and ideas. But also with some level of humility—aware and accepting of personal limitations. These are the folks where we can say, ‘Let’s talk about your leadership skills and where we can strengthen you to be better prepared for the opportunities that can come up,’” he explains.

Huckabee says PAs need to get their names into consideration for opportunities on hospital committees such as pharmacy, credentialing, or ethics.

“You have to be well-versed about where you fit as a professional, relative to other advanced practitioners, and how the system works,” he says. “You have to be at the table, looking for opportunities to move the organization forward.”

Laurie Benton, PhD, MPAS, PA-C, RN, DFAAPA, who is the system director of advanced practice professionals for the Baylor Scott & White Health in Dallas, offers some additional advice for PAs and NPs who would like to rise to positions of leadership in their hospital groups or health systems.

“I recommend taking as many leadership classes as your facility offers,” she says. “Also consider taking outside leadership courses and even getting a second degree in business.”

Benton also says NPs and PAs should get involved in state and national professional and specialty associations. For example, the National Commission on Certification of Physician Assistants now offers a certificate of added qualifications in hospital medicine.

“That is where you will learn a great deal about laws that govern PAs and upcoming legislation that could affect what PAs are allowed to do and how they get paid,” she says, as well as the credentialing and boarding of PAs and NPs, which vary from state to state and from hospital to hospital.

—Larry Beresford

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

It’s July, the month that marks the annual rite of passage for both newly minted physicians starting their internships and somewhat-less-fresh trainees completing their residencies and moving on to the next stage of their professional journey. I would imagine that many of you, like me, spend at least a fleeting moment this time of year thinking back to your first days as interns and, hopefully, extend at least a little empathy to those anxious souls who are being called upon to serve as “doctors” for the very first time.

When I reflect a little further, I am also reminded of the immense power and influence of role models over the course of our training. Although internal medicine was certainly interesting to me, even during medical school, I will candidly also say that the residents and attendings who I served with on teams during medical school at the University of Pennsylvania had at least as much if not more to do with my choice to match in internal medicine. I remember many of their names to this day. While I am not in touch with them, I will always be grateful for the way they demonstrated enthusiasm for medicine; compassion for their patients; partnership with nurses, therapists, and the many other members of our teams; and a genuine love for teaching and conveying a sense of mission in what they did.

I had many great teachers in other areas (particularly, I have to admit, surgery, where some of us students were so enamored of the clinical clerkship director that we memorialized him in a sendup of Forrest Gump in our annual comedy show). However, the consistency of this enthusiasm in the medicine teams was incomparable. In short, these were physicians who I wanted to be like, to emulate. They were role models.

Likewise, during residency, it was those attendings who were among the earliest of academic hospitalists who demonstrated those same skills. I will always remember an encounter with one of my chief residents at the Veterans Affairs early in my internship, when I was struggling with a particular issue. Perhaps it was a foreshadowing of my ultimate career choice, but I was disappointed with my ambulatory clinic experience. As a chief resident, he could have dismissed my frustration or told me to suck it up. He didn’t. He empathized, acknowledging my exasperation and assuring me that I wasn’t alone in how I felt. He also helped me frame the experience to find positive learning aspects—after all, it wasn’t a problem he could just fix and make go away.

Most important, he listened and didn’t judge.

Long before we started thinking of empathy as a teachable communication skill, I experienced it firsthand, and it turned my entire experience around. To this day, I try to emulate that empathy when frustrated physicians or employees come to me with issues.

As hospitalists and physicians, the spotlight is on us almost every minute of every day. We are watched (yes, we are judged) all the time by nurses, pharmacists, case managers, and our patients to see if we live the values of teamwork, collaboration, and emotional intelligence that we claim to embody as system thinkers and system reformers.

But no one watches us more closely than those who we are charged with training. From the very earliest medical student to the most seasoned resident and fellow, how we act is how they will act. When we demonstrate that the bar is highest for us in terms of professionalism, collegiality, and empathy, we imprint upon our trainees those same behaviors and the values that they reflect.

We also show trainees a way of practicing medicine that has the ability to be profoundly satisfying to not only ourselves but also to those who collaborate with us and the patients who benefit from that teamwork. And, hopefully, by doing so we are guiding students, interns, and residents to become hospitalists like us.

So, this July, I call upon all of us in the hospitalist teaching community to reach out and welcome the new trainees in your institution and to remember what it was like to be where they are now. Appreciate the profound impact that you have on them by not only the medicine you teach but the way you practice and communicate and your body language and attitude.

As we think about the continuous need to focus on building up the pipeline of future hospital-based practitioners, there is no better way to develop that bench strength than by using our presence as role models to positively influence our new trainees.

Happy July, everyone! TH

Due to many reasons, the healthcare paradigm has shifted, dictating alternative staffing models to manage the burgeoning inpatient census of hospital-based physicians. Herein, we will briefly describe the Emory University Division of Hospital Medicine (EDHM) approach to utilizing advanced practice providers (APPs) in the care of inpatients and summarize key components of the program that improve sustainability for providers.

The EDHM in Atlanta matriculated APPs into its service in 2004. Currently, there are 22 APPs across all Emory HM sites. The largest group is at Emory University Hospital Midtown (EUHM).

At EUHM, the addition of a renal service created concern for increased workload for the physicians. APPs were recruited to bridge the gap in 2011. Initially, the role was ill-defined, but over time, with physician and administrative leadership buy-in and support, the role has evolved. Currently at EUHM, APPs are practicing in other HM services, allowing them to practice near or at the top of their scope of practice. The 12 hospitalist APPs at EUHM practice in four roles: nocturnist, frontline provider in the observation unit, dedicated renal service, and generalist on an overflow team.

Along with the rapid growth of APPs on the service came the need for structured leadership, improved onboarding procedures, competency maintenance, advocacy, and professional development activities. Essentially, we needed to create a career track parallel to that of the physicians without compromising the portion of our scopes of our practice that overlap (i.e., patient care) while supporting our regulatory differences.

The professional development plans incorporated findings from APP exit interviews at the University of Maryland Medical Center highlighting the following retention issues:1

1. Length of time for credentialing
2. Role clarity
3. Inadequate clinical orientation
4. Feelings of clinical incompetence
5. Feelings of isolation

With the instillation of APP leadership, the team created a comprehensive APP program. The Hospital Medicine APP program at EUHM includes the following components:

• APP representation at monthly clinical operation meetings and quarterly education council meetings to ensure that APP competency and regulatory issues are always represented.
• Orientation personally tailored to the APP’s level of clinical expertise, with a post-orientation meeting with leadership and remediation, if needed.
• APP incentives to teach NP or PA students, conduct in-services, join committees, or participate in other leadership opportunities.
• APPs invited to attend and/or present at all divisional small and large group learning opportunities (e.g., Grand Rounds, Lunch and Learn, Journal Club).
• APPs allocated time and space to meet and discuss practice issues.
• Newly developed Mini-Hospitalist Academy, which offers monthly workshops to all hospitalist physicians and APPs, from novice to expert.
• Dedicated APP Ongoing Professional Performance Evaluation (OPPE) program.
• In addition to the annual monetary support offered for educational opportunities, the division offers an annual Faculty Development Award. This award is by application for eligible educational opportunities; APPs are welcome to apply and have consistently been awarded support to pursue myriad opportunities.

This successful APP-physician collaboration is driven by a committed group of professionals who are sensitive to the shifting healthcare paradigm. Our APPs and physicians are constantly adapting their practice so that our collaboration is safe, evidence-based, and professionally fulfilling. TH

Yvonne Brown, DNP, MSN, ACNP-C, FNP-C, nurse practitioner, lead advanced practice provider, Division of Hospital Medicine, Emory Healthcare, Emory University Hospital Midtown, Atlanta

Reference

1. Bahouth MN, Esposito-Herr MB. Orientation program for hospital-based nurse practitioners. AACN Adv Crit Care. 2009;20(1):82-90.

Due to many reasons, the healthcare paradigm has shifted, dictating alternative staffing models to manage the burgeoning inpatient census of hospital-based physicians. Herein, we will briefly describe the Emory University Division of Hospital Medicine (EDHM) approach to utilizing advanced practice providers (APPs) in the care of inpatients and summarize key components of the program that improve sustainability for providers.

The EDHM in Atlanta matriculated APPs into its service in 2004. Currently, there are 22 APPs across all Emory HM sites. The largest group is at Emory University Hospital Midtown (EUHM).

At EUHM, the addition of a renal service created concern for increased workload for the physicians. APPs were recruited to bridge the gap in 2011. Initially, the role was ill-defined, but over time, with physician and administrative leadership buy-in and support, the role has evolved. Currently at EUHM, APPs are practicing in other HM services, allowing them to practice near or at the top of their scope of practice. The 12 hospitalist APPs at EUHM practice in four roles: nocturnist, frontline provider in the observation unit, dedicated renal service, and generalist on an overflow team.

Along with the rapid growth of APPs on the service came the need for structured leadership, improved onboarding procedures, competency maintenance, advocacy, and professional development activities. Essentially, we needed to create a career track parallel to that of the physicians without compromising the portion of our scopes of our practice that overlap (i.e., patient care) while supporting our regulatory differences.

The professional development plans incorporated findings from APP exit interviews at the University of Maryland Medical Center highlighting the following retention issues:1

1. Length of time for credentialing
2. Role clarity
3. Inadequate clinical orientation
4. Feelings of clinical incompetence
5. Feelings of isolation

With the instillation of APP leadership, the team created a comprehensive APP program. The Hospital Medicine APP program at EUHM includes the following components:

• APP representation at monthly clinical operation meetings and quarterly education council meetings to ensure that APP competency and regulatory issues are always represented.
• Orientation personally tailored to the APP’s level of clinical expertise, with a post-orientation meeting with leadership and remediation, if needed.
• APP incentives to teach NP or PA students, conduct in-services, join committees, or participate in other leadership opportunities.
• APPs invited to attend and/or present at all divisional small and large group learning opportunities (e.g., Grand Rounds, Lunch and Learn, Journal Club).
• APPs allocated time and space to meet and discuss practice issues.
• Newly developed Mini-Hospitalist Academy, which offers monthly workshops to all hospitalist physicians and APPs, from novice to expert.
• Dedicated APP Ongoing Professional Performance Evaluation (OPPE) program.
• In addition to the annual monetary support offered for educational opportunities, the division offers an annual Faculty Development Award. This award is by application for eligible educational opportunities; APPs are welcome to apply and have consistently been awarded support to pursue myriad opportunities.

This successful APP-physician collaboration is driven by a committed group of professionals who are sensitive to the shifting healthcare paradigm. Our APPs and physicians are constantly adapting their practice so that our collaboration is safe, evidence-based, and professionally fulfilling. TH

Yvonne Brown, DNP, MSN, ACNP-C, FNP-C, nurse practitioner, lead advanced practice provider, Division of Hospital Medicine, Emory Healthcare, Emory University Hospital Midtown, Atlanta

Reference

1. Bahouth MN, Esposito-Herr MB. Orientation program for hospital-based nurse practitioners. AACN Adv Crit Care. 2009;20(1):82-90.

Due to many reasons, the healthcare paradigm has shifted, dictating alternative staffing models to manage the burgeoning inpatient census of hospital-based physicians. Herein, we will briefly describe the Emory University Division of Hospital Medicine (EDHM) approach to utilizing advanced practice providers (APPs) in the care of inpatients and summarize key components of the program that improve sustainability for providers.

The EDHM in Atlanta matriculated APPs into its service in 2004. Currently, there are 22 APPs across all Emory HM sites. The largest group is at Emory University Hospital Midtown (EUHM).

At EUHM, the addition of a renal service created concern for increased workload for the physicians. APPs were recruited to bridge the gap in 2011. Initially, the role was ill-defined, but over time, with physician and administrative leadership buy-in and support, the role has evolved. Currently at EUHM, APPs are practicing in other HM services, allowing them to practice near or at the top of their scope of practice. The 12 hospitalist APPs at EUHM practice in four roles: nocturnist, frontline provider in the observation unit, dedicated renal service, and generalist on an overflow team.

Along with the rapid growth of APPs on the service came the need for structured leadership, improved onboarding procedures, competency maintenance, advocacy, and professional development activities. Essentially, we needed to create a career track parallel to that of the physicians without compromising the portion of our scopes of our practice that overlap (i.e., patient care) while supporting our regulatory differences.

The professional development plans incorporated findings from APP exit interviews at the University of Maryland Medical Center highlighting the following retention issues:1

1. Length of time for credentialing
2. Role clarity
3. Inadequate clinical orientation
4. Feelings of clinical incompetence
5. Feelings of isolation

With the instillation of APP leadership, the team created a comprehensive APP program. The Hospital Medicine APP program at EUHM includes the following components:

• APP representation at monthly clinical operation meetings and quarterly education council meetings to ensure that APP competency and regulatory issues are always represented.
• Orientation personally tailored to the APP’s level of clinical expertise, with a post-orientation meeting with leadership and remediation, if needed.
• APP incentives to teach NP or PA students, conduct in-services, join committees, or participate in other leadership opportunities.
• APPs invited to attend and/or present at all divisional small and large group learning opportunities (e.g., Grand Rounds, Lunch and Learn, Journal Club).
• APPs allocated time and space to meet and discuss practice issues.
• Newly developed Mini-Hospitalist Academy, which offers monthly workshops to all hospitalist physicians and APPs, from novice to expert.
• Dedicated APP Ongoing Professional Performance Evaluation (OPPE) program.
• In addition to the annual monetary support offered for educational opportunities, the division offers an annual Faculty Development Award. This award is by application for eligible educational opportunities; APPs are welcome to apply and have consistently been awarded support to pursue myriad opportunities.

This successful APP-physician collaboration is driven by a committed group of professionals who are sensitive to the shifting healthcare paradigm. Our APPs and physicians are constantly adapting their practice so that our collaboration is safe, evidence-based, and professionally fulfilling. TH

Yvonne Brown, DNP, MSN, ACNP-C, FNP-C, nurse practitioner, lead advanced practice provider, Division of Hospital Medicine, Emory Healthcare, Emory University Hospital Midtown, Atlanta

Reference

1. Bahouth MN, Esposito-Herr MB. Orientation program for hospital-based nurse practitioners. AACN Adv Crit Care. 2009;20(1):82-90.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.

During our stay at this family-owned ranch, two things really stood out and made me think:

1. The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
2. The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.

One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.

Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.

The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.

One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.

Test Drives

Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.

The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.

And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).

Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.

With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.

HM Takeaway

Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.

After all, we can’t—and shouldn’t—all be horses. TH

Reference

1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.

My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.

During our stay at this family-owned ranch, two things really stood out and made me think:

1. The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
2. The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.

One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.

Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.

The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.

One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.

Test Drives

Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.

The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.

And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).

Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.

With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.

HM Takeaway

Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.

After all, we can’t—and shouldn’t—all be horses. TH

Reference

1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.

My family and I recently took a spring break trip out west to see a few national parks. During the trip, we stayed on a family ranch in Utah. It had a wide variety of livestock, including a large number of mules and horses.

During our stay at this family-owned ranch, two things really stood out and made me think:

1. The guesthouse we stayed in had an inordinate volume of collections dedicated to the science and art of raising horses and mules. Everywhere one looked you could find a wall-mounted picture, poem, or coffee table book about these species. My favorite, written by the owner of the ranch, John Hauer, was The Natural Superiority of Mules.1
2. The second thing I noticed was that every member of the ranch-owning family had fairly strong opinions about which was better—horse or mule. Just to recap the biology, a horse is the product of two horses, whereas a mule is the progeny of a male donkey and a female horse. It turns out that their physical structure and demeanors are very different.

One of the oldest members of the ranch family (who I believe was a “distant uncle”) had a very strong opinion about the superiority of the mule. His opinion was based on selected facts, including that mules are “steadier on their feet” in unstable ground, require less volume and less frequent food and water, and very rarely became ill or need costly veterinary care.

Another mule-favoring family member told us how mules get a “bad rap” for being stubborn when they actually are much smarter and better decision makers than horses. She recalled a famous folklore of a farmer who took his mule out to gather materials from across a field. When the farmer and the mule approached a wooden bridge, the mule absolutely refused to cross the bridge. After much back and forth between the farmer and the mule (involving both coaxing and cussing), the farmer gave up and returned to the farm with the mule. He then took his horse on the same errand. When they came to the same bridge, the horse also hesitated but required little bargaining from the farmer to coax it to cross the bridge. When barely halfway across, a rotten board in the bridge gave way, almost sending both the horse and the farmer to their deaths in the ravine below.

The moral of the folklore is that mules cannot be coaxed (or cussed) into performing behaviors that will put themselves or those around them at risk of injury or death. Mules will stop when exhausted or profoundly dehydrated, for example, whereas a horse will continue on if ordered by their farmer, even to the point of running themselves to their eventual demise.

One of the younger members of the family-owned ranch, however, had very strong opinions on the superiority of the horse. Horses are loyal and unwavering in their dedication to please those that they serve. They will put the needs of others before themselves in most situations and therefore almost always “outperform” a mule in all respects. They are willing and (usually) able to perform in uncertain conditions, even despite some reservations. They are loyal and loving, and they have unique and inquisitive personalities, which makes them fun to raise and to ride any day.

Test Drives

Our family of four went on a ride with some of these animals and randomly got two horses and two mules. Interestingly, during our ride, we all did indeed notice the differences between the horses and the mules.

The horses were seemingly easygoing and quick to please, easily following cues to change direction or course. The mules were more hesitant and seemed to need to understand why they were being asked to do something before they acquiesced to the demand.

And when we approached a narrow rocky downslope, the mules were slow, steady, and confident, whereas the horses were seemingly uncomfortable and less agile. And, indeed in researching mules, they seem to have gotten a very bad rap over time (as evidenced by the term “stubborn as a mule”).

Charles Darwin actually categorized mules as an example of “hybrid vigor,” which is a rare example of when an offspring is actually better in most ways than either of its parents. Compared to its parental species, mules have more intelligence, endurance, longevity, health, speed, height, and agility. Also to their advantage, they have harder skin and hooves, allowing them to weather and endure more treacherous conditions.

With all of this newfound knowledge of the mule, it struck me what remarkable similarity some physicians have with mules and the role that these mules are likely serving within our organizations. These physicians are probably labeled as stubborn, obstinate, resistant, or impatient. But maybe they are actually intelligent, agile, and appropriately cautious. Maybe the resistance they express in the organization is serving to warn others about the rotten wooden bridges.

HM Takeaway

Similar to a ranch, most hospitals probably function best with a healthy combination of horses and mules. So if you get an opportunity, next time you encounter physicians at your hospital acting like mules, you should congratulate them and appreciate their mule-like characteristics. Recognize the contribution these types of physicians are making, in their own way, to the greater good of the organization.

After all, we can’t—and shouldn’t—all be horses. TH

Reference

1. Hauer J. The Natural Superiority of Mules: A Celebration of One of the Most Intelligent, Sure-footed, and Misunderstood Animals in the World. New York, NY: Skyhorse Publishing; 2006.

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

I use the teach-back method to confirm my patients’ understanding.

Why I Do It

Teach-back allows me to address my patients’ uncertainty about the plan and clarify any misunderstandings.

As doctors, one of our most important jobs is explaining in ways our patients understand. It doesn’t matter how brilliant our treatment plan is if our patients do not understand it. We all want to feel like we’re making a difference in our patients’ lives. Yet it’s hard for our patients to do what we recommend if they don’t understand.

Unfortunately, many patients are too embarrassed to ask questions, or they simply do not know what to ask. Patients will also say they understand everything even when they do not because they fear appearing uneducated.

This is why the teach-back method is so valuable. The teach-back method allows you to better assess your patients’ understanding of their medical problems. It allows you to uncover and clarify any misunderstandings your patients may have about the plan. It also helps you to engage in a more collaborative relationship with your patients.

How I Do It

Teach-back helps me to test my effectiveness as a teacher by allowing me to assess whether my patient understands; if not, I explain in a different way.

One of the common mistakes clinicians make when assessing for understanding is asking, “Do you have any questions?” or “Does this make sense?” The problem with these questions is that they are closed-ended. The only responses are yes or no. Your patients may say they understand even when they do not. In reality, it does not matter how brilliant your treatment plans are if patients do not follow them because they do not understand.

Teach-back encourages the doctor to check for understanding by using open-ended instead of closed-ended questions.

Example one: “This is a new diagnosis for you, so I want to make sure you understand. Will you tell me in your own words what congestive heart failure is?”

Example two: “I want to make sure I explained this clearly. I know your daughter helps you manage your health. What will you tell her about the changes we made to your blood pressure medication?”

Teach-back steps:

1. I explain the concept to my patients, avoiding medical jargon.
2. I assess my patients’ understanding by asking them to explain the concept in their own words.
3. I clarify anything my patients did not understand and reassess their understanding.
4. If my patients still do not understand, I find a new way to explain the concept.
5. I repeat the process of explaining and assessing for understanding until my patients are able to accurately state their understanding.

There are a few key things to remember as you perform teach-back. The first is to ensure you use a caring tone when speaking with your patients. Next, if you have several concepts you want to teach, break it into small pieces. Use teach-back for the first concept before moving on to the next. Finally, one of the most common questions I get from other doctors about teach-back is how to assess patients’ understanding without sounding condescending. I address this by making it about me and my effectiveness as a teacher. I tell my patients it is my responsibility to explain things in a way they understand, so if they do not, I will explain it in a different way. When I frame it this way, patients are not offended by my asking them to perform teach-back because they realize I’m doing it as a test of my effectiveness as a teacher.

Example: “Mr. Johnson, as your doctor, one of my top priorities is to ensure I’m explaining things in a way you understand. I want to make sure my instructions about how to take your new medication are clear. Would you mind telling me in your own words how you will take this new medication?”

Now that you know what teach-back is and understand how helpful it can be, start incorporating it into your practice. Think about a few concepts that you teach again and again, such as disease management, medication changes, and self-care instructions. Next, think about how you could use teach-back in these scenarios. Practice what you will say when you ask patients to engage in teach-back. Finally, commit to using teach-back with your next few patients. The more you practice, the easier it becomes.

For more information on teach-back, visit www.teachbacktraining.org.

Dr. Dorrah is regional medical director for quality and the patient experience, Baylor Scott & White Health, Round Rock, Texas.

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

I use the teach-back method to confirm my patients’ understanding.

Why I Do It

Teach-back allows me to address my patients’ uncertainty about the plan and clarify any misunderstandings.

As doctors, one of our most important jobs is explaining in ways our patients understand. It doesn’t matter how brilliant our treatment plan is if our patients do not understand it. We all want to feel like we’re making a difference in our patients’ lives. Yet it’s hard for our patients to do what we recommend if they don’t understand.

Unfortunately, many patients are too embarrassed to ask questions, or they simply do not know what to ask. Patients will also say they understand everything even when they do not because they fear appearing uneducated.

This is why the teach-back method is so valuable. The teach-back method allows you to better assess your patients’ understanding of their medical problems. It allows you to uncover and clarify any misunderstandings your patients may have about the plan. It also helps you to engage in a more collaborative relationship with your patients.

How I Do It

Teach-back helps me to test my effectiveness as a teacher by allowing me to assess whether my patient understands; if not, I explain in a different way.

One of the common mistakes clinicians make when assessing for understanding is asking, “Do you have any questions?” or “Does this make sense?” The problem with these questions is that they are closed-ended. The only responses are yes or no. Your patients may say they understand even when they do not. In reality, it does not matter how brilliant your treatment plans are if patients do not follow them because they do not understand.

Teach-back encourages the doctor to check for understanding by using open-ended instead of closed-ended questions.

Example one: “This is a new diagnosis for you, so I want to make sure you understand. Will you tell me in your own words what congestive heart failure is?”

Example two: “I want to make sure I explained this clearly. I know your daughter helps you manage your health. What will you tell her about the changes we made to your blood pressure medication?”

Teach-back steps:

1. I explain the concept to my patients, avoiding medical jargon.
2. I assess my patients’ understanding by asking them to explain the concept in their own words.
3. I clarify anything my patients did not understand and reassess their understanding.
4. If my patients still do not understand, I find a new way to explain the concept.
5. I repeat the process of explaining and assessing for understanding until my patients are able to accurately state their understanding.

There are a few key things to remember as you perform teach-back. The first is to ensure you use a caring tone when speaking with your patients. Next, if you have several concepts you want to teach, break it into small pieces. Use teach-back for the first concept before moving on to the next. Finally, one of the most common questions I get from other doctors about teach-back is how to assess patients’ understanding without sounding condescending. I address this by making it about me and my effectiveness as a teacher. I tell my patients it is my responsibility to explain things in a way they understand, so if they do not, I will explain it in a different way. When I frame it this way, patients are not offended by my asking them to perform teach-back because they realize I’m doing it as a test of my effectiveness as a teacher.

Example: “Mr. Johnson, as your doctor, one of my top priorities is to ensure I’m explaining things in a way you understand. I want to make sure my instructions about how to take your new medication are clear. Would you mind telling me in your own words how you will take this new medication?”

Now that you know what teach-back is and understand how helpful it can be, start incorporating it into your practice. Think about a few concepts that you teach again and again, such as disease management, medication changes, and self-care instructions. Next, think about how you could use teach-back in these scenarios. Practice what you will say when you ask patients to engage in teach-back. Finally, commit to using teach-back with your next few patients. The more you practice, the easier it becomes.

For more information on teach-back, visit www.teachbacktraining.org.

Dr. Dorrah is regional medical director for quality and the patient experience, Baylor Scott & White Health, Round Rock, Texas.

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

I use the teach-back method to confirm my patients’ understanding.

Why I Do It

Teach-back allows me to address my patients’ uncertainty about the plan and clarify any misunderstandings.

As doctors, one of our most important jobs is explaining in ways our patients understand. It doesn’t matter how brilliant our treatment plan is if our patients do not understand it. We all want to feel like we’re making a difference in our patients’ lives. Yet it’s hard for our patients to do what we recommend if they don’t understand.

Unfortunately, many patients are too embarrassed to ask questions, or they simply do not know what to ask. Patients will also say they understand everything even when they do not because they fear appearing uneducated.

This is why the teach-back method is so valuable. The teach-back method allows you to better assess your patients’ understanding of their medical problems. It allows you to uncover and clarify any misunderstandings your patients may have about the plan. It also helps you to engage in a more collaborative relationship with your patients.

How I Do It

Teach-back helps me to test my effectiveness as a teacher by allowing me to assess whether my patient understands; if not, I explain in a different way.

One of the common mistakes clinicians make when assessing for understanding is asking, “Do you have any questions?” or “Does this make sense?” The problem with these questions is that they are closed-ended. The only responses are yes or no. Your patients may say they understand even when they do not. In reality, it does not matter how brilliant your treatment plans are if patients do not follow them because they do not understand.

Teach-back encourages the doctor to check for understanding by using open-ended instead of closed-ended questions.

Example one: “This is a new diagnosis for you, so I want to make sure you understand. Will you tell me in your own words what congestive heart failure is?”

Example two: “I want to make sure I explained this clearly. I know your daughter helps you manage your health. What will you tell her about the changes we made to your blood pressure medication?”

Teach-back steps:

1. I explain the concept to my patients, avoiding medical jargon.
2. I assess my patients’ understanding by asking them to explain the concept in their own words.
3. I clarify anything my patients did not understand and reassess their understanding.
4. If my patients still do not understand, I find a new way to explain the concept.
5. I repeat the process of explaining and assessing for understanding until my patients are able to accurately state their understanding.

There are a few key things to remember as you perform teach-back. The first is to ensure you use a caring tone when speaking with your patients. Next, if you have several concepts you want to teach, break it into small pieces. Use teach-back for the first concept before moving on to the next. Finally, one of the most common questions I get from other doctors about teach-back is how to assess patients’ understanding without sounding condescending. I address this by making it about me and my effectiveness as a teacher. I tell my patients it is my responsibility to explain things in a way they understand, so if they do not, I will explain it in a different way. When I frame it this way, patients are not offended by my asking them to perform teach-back because they realize I’m doing it as a test of my effectiveness as a teacher.

Example: “Mr. Johnson, as your doctor, one of my top priorities is to ensure I’m explaining things in a way you understand. I want to make sure my instructions about how to take your new medication are clear. Would you mind telling me in your own words how you will take this new medication?”

Now that you know what teach-back is and understand how helpful it can be, start incorporating it into your practice. Think about a few concepts that you teach again and again, such as disease management, medication changes, and self-care instructions. Next, think about how you could use teach-back in these scenarios. Practice what you will say when you ask patients to engage in teach-back. Finally, commit to using teach-back with your next few patients. The more you practice, the easier it becomes.

For more information on teach-back, visit www.teachbacktraining.org.

Dr. Dorrah is regional medical director for quality and the patient experience, Baylor Scott & White Health, Round Rock, Texas.

Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

Dr. Geeta Arora is a locum tenens hospitalist; James Levy is a PA who hires locums as the VP of Human Resources for Indigo Health Partners in Northern Michigan. They share their experiences navigating "freelance hospital medicine," from both the medical practice and business perspective.

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.

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

I explain my role as a hospitalist and my connection to the patient’s primary care physician (PCP) on first meeting the patient. I look for ways to reinforce this throughout the hospitalization.

Why I Do It

Even when I was hospitalized at my own institution, it was difficult for me to remember all of the providers involved in my care and their roles. My injuries and the large number of doctors caring for me interfered with my ability to absorb this information. I imagine that this is amplified for patients who have little or no experience with the medical system and are unfamiliar with the role that we play in their care.

During a recent initiative to improve the patient experience at my institution, we found it difficult to collect specific feedback on individual providers because many patients did not know their inpatient doctors’ names, frequently referencing their PCPs when asked for feedback on their care. This is common: A 2009 study showed that 75% of patients were unable to name the inpatient physician in charge of their care. Of those who could identify a name, only 40% correctly identified a member of their primary inpatient team, often identifying the PCP or a specialist instead.1

Clarifying our role on the care team, identifying ourselves as the point person for questions or concerns, and reinforcing our relationship with the PCP can help engender trust in the relationship, eliminate confusion, and improve the patient experience.

How I Do It

After introducing myself, I explain to patients that I will notify their PCP of the admission, and I state that I will be acting as the head of the inpatient team on behalf of their PCP. I often explain that most PCPs do not see their own patients in the hospital.

When multiple teams or house staff are involved in care, I clarify my role in relation to other team members. I look for opportunities throughout the hospitalization to reinforce this. For example, I tell patients when I have updated their PCP on significant events, and I clarify my role in simple terms, such as “quarterback,” when there are multiple subspecialists involved in care. I try to avoid terms like “attending,” which are often meaningless to patients.

In my hospitalist group, we help to reinforce our role and identity by providing a business card that includes a headshot. TH

Dr. Moore is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School, both in Boston. She is a member of SHM’s Patient Experience Committee.

Reference

1. Arora V, Gangireddy S, Mehrotra A, Ginde R, Tormey M, Meltzer D. Ability of hospitalized patients to identify their in-hospital physicians. Arch Intern Med. 2009;169(2):199-201.