Career

A recent Dartmouth Atlas Project report that highlights regional differences for prescription drug use among Medicare patients across the U.S. provides insights into best practices related to effective and high-risk prescription drug therapy.

The report [PDF] found geographic disparity in the total use of prescription medications, variations in effective prescription care, dissimilarities in the use of potentially harmful medications, and differences in total spending on prescription drugs.

Lead author Jeffrey Munson, MD, MSCE, says he expected some geographic variation in the use of discretionary medications, but was surprised by the discrepancy in patients' medication usage. For example, in San Angelo, Texas, 91.4% of heart attack survivors in 2008–2009 filled at least one prescription for beta blockers in the year after their discharge, compared with just 62.5% of the same population of patients in Salem, Ore.

"Clearly, there are regions of the country that have figured out how to best handle certain aspects of medication usage," says Dr. Munson, assistant professor at the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, N.H. "Instead of just looking at regions that are high performing and saying, 'Wow, that seems to be a really high bar they've set, I'm not sure we can achieve it,' I wonder if maybe it's time we look at those regions and say, 'How are you achieving those very high standards, and what about what you do can I do where I live.'"

The Dartmouth Atlas Project report documents geographic variation in healthcare utilization unrelated to outcome and offers an extensive database for comparison by state, county, region, and facility. Dr. Munson says he understands that healthcare reform is pushing hospitalists and other physicians to focus on many new issues, but that medication usage by patients is among the most pressing issues in healthcare.

"I know that everybody is under increasing time pressures," he adds, "but it’s hard to imagine a larger problem than not getting people the drugs they need to prevent really significant clinical outcomes."

Visit our website for more information on medication issues.

A recent Dartmouth Atlas Project report that highlights regional differences for prescription drug use among Medicare patients across the U.S. provides insights into best practices related to effective and high-risk prescription drug therapy.

The report [PDF] found geographic disparity in the total use of prescription medications, variations in effective prescription care, dissimilarities in the use of potentially harmful medications, and differences in total spending on prescription drugs.

Lead author Jeffrey Munson, MD, MSCE, says he expected some geographic variation in the use of discretionary medications, but was surprised by the discrepancy in patients' medication usage. For example, in San Angelo, Texas, 91.4% of heart attack survivors in 2008–2009 filled at least one prescription for beta blockers in the year after their discharge, compared with just 62.5% of the same population of patients in Salem, Ore.

"Clearly, there are regions of the country that have figured out how to best handle certain aspects of medication usage," says Dr. Munson, assistant professor at the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, N.H. "Instead of just looking at regions that are high performing and saying, 'Wow, that seems to be a really high bar they've set, I'm not sure we can achieve it,' I wonder if maybe it's time we look at those regions and say, 'How are you achieving those very high standards, and what about what you do can I do where I live.'"

The Dartmouth Atlas Project report documents geographic variation in healthcare utilization unrelated to outcome and offers an extensive database for comparison by state, county, region, and facility. Dr. Munson says he understands that healthcare reform is pushing hospitalists and other physicians to focus on many new issues, but that medication usage by patients is among the most pressing issues in healthcare.

"I know that everybody is under increasing time pressures," he adds, "but it’s hard to imagine a larger problem than not getting people the drugs they need to prevent really significant clinical outcomes."

Visit our website for more information on medication issues.

A recent Dartmouth Atlas Project report that highlights regional differences for prescription drug use among Medicare patients across the U.S. provides insights into best practices related to effective and high-risk prescription drug therapy.

The report [PDF] found geographic disparity in the total use of prescription medications, variations in effective prescription care, dissimilarities in the use of potentially harmful medications, and differences in total spending on prescription drugs.

Lead author Jeffrey Munson, MD, MSCE, says he expected some geographic variation in the use of discretionary medications, but was surprised by the discrepancy in patients' medication usage. For example, in San Angelo, Texas, 91.4% of heart attack survivors in 2008–2009 filled at least one prescription for beta blockers in the year after their discharge, compared with just 62.5% of the same population of patients in Salem, Ore.

"Clearly, there are regions of the country that have figured out how to best handle certain aspects of medication usage," says Dr. Munson, assistant professor at the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, N.H. "Instead of just looking at regions that are high performing and saying, 'Wow, that seems to be a really high bar they've set, I'm not sure we can achieve it,' I wonder if maybe it's time we look at those regions and say, 'How are you achieving those very high standards, and what about what you do can I do where I live.'"

The Dartmouth Atlas Project report documents geographic variation in healthcare utilization unrelated to outcome and offers an extensive database for comparison by state, county, region, and facility. Dr. Munson says he understands that healthcare reform is pushing hospitalists and other physicians to focus on many new issues, but that medication usage by patients is among the most pressing issues in healthcare.

"I know that everybody is under increasing time pressures," he adds, "but it’s hard to imagine a larger problem than not getting people the drugs they need to prevent really significant clinical outcomes."

Visit our website for more information on medication issues.

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day postoperative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10–1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51–1.81 vs. OR 1.20; CI, 1.09–1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40–1.51 vs. OR, 1.13; CI, 1.08–1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease postoperative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013;148:755-762.

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day postoperative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10–1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51–1.81 vs. OR 1.20; CI, 1.09–1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40–1.51 vs. OR, 1.13; CI, 1.08–1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease postoperative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013;148:755-762.

Clinical question: Is there an association between current and past smoking on outcomes among patients having major surgery?

Background: Smoking is associated with adverse postoperative outcomes, but it is not known whether the associations are dose-dependent or limited to patients with smoking-related diseases. Smoking-related effects on postoperative events among patients having major surgery are also not well established.

Study design: Retrospective cohort study.

Setting: Four hundred forty-eight non-VA hospitals across the U.S., Canada, Lebanon, and the United Arab Emirates.

Synopsis: Data from 607,558 adult patients undergoing major surgery were obtained from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. After adjusting for confounders (cardiopulmonary diseases and cancer), the effects of current and past smoking (quit >1 year prior) on 30-day postoperative outcomes were measured.

There were 125,192 (21%) current smokers and 78,763 (13%) past smokers. Increased odds of post-op mortality were noted in current smokers only (odds ratio [OR] 1.17; 95% CI, 1.10–1.24). The adjusted odds ratios were higher for arterial and respiratory events among current smokers compared with past smokers (OR 1.65; 95% CI, 1.51–1.81 vs. OR 1.20; CI, 1.09–1.31 for arterial events, respectively) and (OR, 1.45; CI, 1.40–1.51 vs. OR, 1.13; CI, 1.08–1.18, for respiratory events, respectively). No significant effects on venous events were observed.

There was an increased adjusted odds of mortality for current smokers with <10 pack-years, while the effects on arterial and respiratory events increased incrementally with increased pack-years. Smoking was associated with adverse post-op outcomes regardless of smoking-related diseases. Variability in hospital quality or surgical strategies may have confounded the results.

Bottom line: Among patients undergoing major surgery, current but not past smoking was associated with higher mortality; smoking cessation for at least a year prior to surgery may decrease postoperative adverse events.

Citation: Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013;148:755-762.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: Does the use of a standardized suite of post-operative pulmonary care guidelines decrease the incidence of adverse pulmonary outcomes in non-ventilated patients?

Background: Post-operative pulmonary complications are common and account for high costs and increased length of stay. Best practice guidelines for pulmonary care in general for patients undergoing non-cardiac surgery are scarce, compared to strategies to prevent ventilator-associated pneumonia (VAP).

Study design: Observational study.

Setting: Boston University Medical Center.

Synopsis: The I COUGH program emphasized Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient and family education), Getting out of bed at least three times daily, and Head-of-bed elevation.

I COUGH was implemented for one year for all general surgery and vascular surgery patients, and results were compared with the year prior using National Surgical Quality Improvement Program (NSQIP) data. The program reduced the incidence of post-operative pneumonia to 1.6% from 2.6% and the incidence of unplanned intubations to 1.2% from 2.0%. The results did show a trend but did not achieve statistical significance.

Bottom line: Post-operative implementation of I COUGH through consistent education of staff, patients, and family might reduce post-operative pneumonia and unplanned intubations.

Citation: Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148:740-745.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Clinical question: What are physicians’ attitudes toward addressing healthcare costs and which strategies do they most enthusiastically support?

Background: Physicians are expected to take a lead role in containing healthcare costs, especially in the face of healthcare reform; however, their attitudes regarding this role are unknown.

Study design: Cross-sectional survey.

Setting: U.S. physicians randomly selected from the AMA master file.

Synopsis: Among 2,556 physicians who responded to the survey (response rate: 65%), most believed stakeholders other than physicians (e.g., lawyers, hospitals, insurers, pharmaceutical manufacturers, and patients) have a “major responsibility” for reducing healthcare costs. Most physicians were likely to support such quality initiatives as enhancing continuity of care and promoting chronic disease care coordination. Physicians were also enthusiastic with regard to expanding the use of electronic health records.

The majority of physicians expressed agreement about their responsibility to address healthcare costs by adhering to clinical guidelines, limiting unnecessary testing, and focusing on the individual patient’s best interest. However, a majority expressed limited enthusiasm for strategies that involved cost cutting to physicians, such as eliminating fee-for-service payment models, reducing compensation for the highest paid specialties, and allowing Medicare payment cuts to doctors.

Of note, in the multivariate model, physicians receiving salary-based compensation were more likely to be enthusiastic about eliminating fee-for-service.

Bottom line: Physicians expressed considerable enthusiasm for addressing healthcare costs and are in general agreement but are not enthusiastic about changes that involve physician payment cuts.

Citation: Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013;310:380-388.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

click for large version

Physicians are exposed to a wide variety of cases that pique our interest. Cases that make you go home and read just a little bit more. Cases that prompt you to seek out your classmates and colleagues for further discussion, or trigger a call to someone from your past. Residents and students often ask, “Should I write this case up?” Our answer is, “Yes!”

Why do we recommend that you write the case up? Much of medical education is a clinical- or case-based exercise. Clinical cases provide context for the principles being taught. We use real cases to point out the nuance in a presentation of a particular illness or the management of a disease.

In clinical conferences, such as morning report or clinical-pathologic conferences (CPCs), we highlight the choices we make as physicians to provide the best care. Respected physicians and master clinicians at our own institutions often lead these discussions, which form the building blocks for how many of us will practice in our careers.

At grand rounds, the best speakers start with a case. These vignettes grab our attention, making us realize the importance of what the speaker teaches us.

Writing up a vignette will give you a skill set you need. You learn how to select a case, create a “teachable moment,” or hone a series of teaching points. You develop your skills in searching and critically appraising the literature. You become a content expert among your peers. This activity helps you to develop and master the academic skills that will drive your career and will be pivotal in your success.

Follow these eight steps to produce successful clinical vignette submissions:

click for large version

Step 1

Be a good doctor and make the correct diagnosis: Interesting cases will come to you. Don’t chase a zebra on every cough. Don’t send autoimmune panels for every rash. Read about each patient’s case that you see. Use the time to build your clinical acumen and develop your own illness scripts. Through the process of being a thoughtful student of medicine, you will come to distinguish the fascinoma from the merely fleeting infatuation with a diagnosis.

Step 2

Recognize the good case: The best way to recognize a good case is appreciate when it excites people locally. If you present it at morning report or CPC, are you inundated with requests to speak more after the conference has finished? Did it stump your colleagues (usually a pretty bright group)? Do you find that the consultants ask for others in their division to come and see the case? Clinically, did it take the team a while to come to the end diagnosis? If any of these are true, then you should move forward.

Step 3

Perform a literature search: How often does a similar situation arise? Is it 1 in 10,000, 1 in a million, or less? Even a case of 1 in 10,000 can be impactful to read about when you consider how long it may take a physician to see that many patients.

Step 4.

Develop two or three teaching points: Most abstracts for national and regional meetings have a restrictive word limit. When you consider all the information required of a thorough case presentation and adequate discussion, it can seem almost impossible to fit it all in. Start early, at least a month before the deadline if you can, and start big. Determine two or three key teaching points you wish to make. These will serve as your roadmap for the write-up.

Next, write down everything you want to say. Then cut the verbiage and descriptions that are not needed to tell your story. Focus on two or three take-home points. Each fact included or statement made should help to guide the reader to these lessons. As readers and authors, we also like to see prevalence and incidence of disease findings, or how good a test is with specificity and sensitivity values. Make sure the readers know what you want them to learn.

click for large version

Step 5

Keep the case concise, and focus on the discussion: The best write-ups keep the case description short and focused. Avoid trying to tell your readers everything about your case. Highlight what makes your case different without including extraneous information that does not support your teaching points. This leaves more room to focus on your discussion and explain to the reader the importance of your case. The discussion is where you create the “teachable moment” by elaborating on your teaching points.

Step 6

Keep your drafts and proofread your work carefully: The process of writing a clear and concise vignette will take many drafts. To do a great job, plan for at least three or four versions. Through the process of revisiting every word you use, you will start to hone your mastery of the topic; you will see the case in a new way with each draft.

As you do this, keep each edit as a separate file. You will inevitably edit something out early on that you will want to put back in later. Keeping your drafts will make this much easier.

At the final version, proofread carefully! Most reviewers will deduct points for poor grammar and misspellings. If it looks sloppy, then a reader will assume it represents sloppy thoughts.

Step 7

Get feedback: Have others read your work. It is always hard to put your writing out there for critique, particularly when it is such a personal representation of your own clinical thought. Hopefully, you have collaborated with others involved in the case; however, to avoid any “group think” about the work, it is best to have uninvolved individuals (e.g., trusted faculty member, program director, division chief) review your work before submission. The point of these vignettes is to help you develop skills as an author and academician. Since most meetings do not provide any feedback on the review of your submission, outside of “accepted” or “rejected,” it is important to get this from your own institution. It will also heighten your chances of acceptance. Take their suggestions openly, and use them to refine your abstract.

Step 8

Consider the following keys to a poster or oral presentation: The presentation at the meeting should be an expansion on the abstract. Remember, you have described the situation, but now you have the opportunity to use a picture. The old adage that a picture is worth a thousand words really rings true here.

Avoid copying and pasting your text. Concise statements will grab people’s eyes and leave you more space for charts and images. Visuals grab the reader’s eye better than small-font text.

Conclusion

Your first clinical vignette can be a truly great experience. Although it is a lot of hard work, presenting clinical thought is a skill that you must learn. Once you do this, you might find that you have “caught the bug,” and will find yourself well on your way to a role in medical education. You might even start a larger project based on this experience.

Dr. Burger is associate program director of internal medicine residency in the Department of Medicine at Beth Israel Medical Center and assistant dean and assistant professor of medicine at Albert Einstein College of Medicine, both in New York City. Dr. Paesch is a comprehensive care physician in the section of hospital medicine at the University of Chicago, and assistant professor at the University of Chicago Pritzker School of Medicine. Dr. Miller is director of student programs, associate program director, residency, and associate professor of medicine in the Department of Medicine at Tulane Health Sciences Center in New Orleans.

click for large version

Physicians are exposed to a wide variety of cases that pique our interest. Cases that make you go home and read just a little bit more. Cases that prompt you to seek out your classmates and colleagues for further discussion, or trigger a call to someone from your past. Residents and students often ask, “Should I write this case up?” Our answer is, “Yes!”

Why do we recommend that you write the case up? Much of medical education is a clinical- or case-based exercise. Clinical cases provide context for the principles being taught. We use real cases to point out the nuance in a presentation of a particular illness or the management of a disease.

In clinical conferences, such as morning report or clinical-pathologic conferences (CPCs), we highlight the choices we make as physicians to provide the best care. Respected physicians and master clinicians at our own institutions often lead these discussions, which form the building blocks for how many of us will practice in our careers.

At grand rounds, the best speakers start with a case. These vignettes grab our attention, making us realize the importance of what the speaker teaches us.

Writing up a vignette will give you a skill set you need. You learn how to select a case, create a “teachable moment,” or hone a series of teaching points. You develop your skills in searching and critically appraising the literature. You become a content expert among your peers. This activity helps you to develop and master the academic skills that will drive your career and will be pivotal in your success.

Follow these eight steps to produce successful clinical vignette submissions:

click for large version

Step 1

Be a good doctor and make the correct diagnosis: Interesting cases will come to you. Don’t chase a zebra on every cough. Don’t send autoimmune panels for every rash. Read about each patient’s case that you see. Use the time to build your clinical acumen and develop your own illness scripts. Through the process of being a thoughtful student of medicine, you will come to distinguish the fascinoma from the merely fleeting infatuation with a diagnosis.

Step 2

Recognize the good case: The best way to recognize a good case is appreciate when it excites people locally. If you present it at morning report or CPC, are you inundated with requests to speak more after the conference has finished? Did it stump your colleagues (usually a pretty bright group)? Do you find that the consultants ask for others in their division to come and see the case? Clinically, did it take the team a while to come to the end diagnosis? If any of these are true, then you should move forward.

Step 3

Perform a literature search: How often does a similar situation arise? Is it 1 in 10,000, 1 in a million, or less? Even a case of 1 in 10,000 can be impactful to read about when you consider how long it may take a physician to see that many patients.

Step 4.

Develop two or three teaching points: Most abstracts for national and regional meetings have a restrictive word limit. When you consider all the information required of a thorough case presentation and adequate discussion, it can seem almost impossible to fit it all in. Start early, at least a month before the deadline if you can, and start big. Determine two or three key teaching points you wish to make. These will serve as your roadmap for the write-up.

Next, write down everything you want to say. Then cut the verbiage and descriptions that are not needed to tell your story. Focus on two or three take-home points. Each fact included or statement made should help to guide the reader to these lessons. As readers and authors, we also like to see prevalence and incidence of disease findings, or how good a test is with specificity and sensitivity values. Make sure the readers know what you want them to learn.

click for large version

Step 5

Keep the case concise, and focus on the discussion: The best write-ups keep the case description short and focused. Avoid trying to tell your readers everything about your case. Highlight what makes your case different without including extraneous information that does not support your teaching points. This leaves more room to focus on your discussion and explain to the reader the importance of your case. The discussion is where you create the “teachable moment” by elaborating on your teaching points.

Step 6

Keep your drafts and proofread your work carefully: The process of writing a clear and concise vignette will take many drafts. To do a great job, plan for at least three or four versions. Through the process of revisiting every word you use, you will start to hone your mastery of the topic; you will see the case in a new way with each draft.

As you do this, keep each edit as a separate file. You will inevitably edit something out early on that you will want to put back in later. Keeping your drafts will make this much easier.

At the final version, proofread carefully! Most reviewers will deduct points for poor grammar and misspellings. If it looks sloppy, then a reader will assume it represents sloppy thoughts.

Step 7

Get feedback: Have others read your work. It is always hard to put your writing out there for critique, particularly when it is such a personal representation of your own clinical thought. Hopefully, you have collaborated with others involved in the case; however, to avoid any “group think” about the work, it is best to have uninvolved individuals (e.g., trusted faculty member, program director, division chief) review your work before submission. The point of these vignettes is to help you develop skills as an author and academician. Since most meetings do not provide any feedback on the review of your submission, outside of “accepted” or “rejected,” it is important to get this from your own institution. It will also heighten your chances of acceptance. Take their suggestions openly, and use them to refine your abstract.

Step 8

Consider the following keys to a poster or oral presentation: The presentation at the meeting should be an expansion on the abstract. Remember, you have described the situation, but now you have the opportunity to use a picture. The old adage that a picture is worth a thousand words really rings true here.

Avoid copying and pasting your text. Concise statements will grab people’s eyes and leave you more space for charts and images. Visuals grab the reader’s eye better than small-font text.

Conclusion

Your first clinical vignette can be a truly great experience. Although it is a lot of hard work, presenting clinical thought is a skill that you must learn. Once you do this, you might find that you have “caught the bug,” and will find yourself well on your way to a role in medical education. You might even start a larger project based on this experience.

Dr. Burger is associate program director of internal medicine residency in the Department of Medicine at Beth Israel Medical Center and assistant dean and assistant professor of medicine at Albert Einstein College of Medicine, both in New York City. Dr. Paesch is a comprehensive care physician in the section of hospital medicine at the University of Chicago, and assistant professor at the University of Chicago Pritzker School of Medicine. Dr. Miller is director of student programs, associate program director, residency, and associate professor of medicine in the Department of Medicine at Tulane Health Sciences Center in New Orleans.

click for large version

Physicians are exposed to a wide variety of cases that pique our interest. Cases that make you go home and read just a little bit more. Cases that prompt you to seek out your classmates and colleagues for further discussion, or trigger a call to someone from your past. Residents and students often ask, “Should I write this case up?” Our answer is, “Yes!”

Why do we recommend that you write the case up? Much of medical education is a clinical- or case-based exercise. Clinical cases provide context for the principles being taught. We use real cases to point out the nuance in a presentation of a particular illness or the management of a disease.

In clinical conferences, such as morning report or clinical-pathologic conferences (CPCs), we highlight the choices we make as physicians to provide the best care. Respected physicians and master clinicians at our own institutions often lead these discussions, which form the building blocks for how many of us will practice in our careers.

At grand rounds, the best speakers start with a case. These vignettes grab our attention, making us realize the importance of what the speaker teaches us.

Writing up a vignette will give you a skill set you need. You learn how to select a case, create a “teachable moment,” or hone a series of teaching points. You develop your skills in searching and critically appraising the literature. You become a content expert among your peers. This activity helps you to develop and master the academic skills that will drive your career and will be pivotal in your success.

Follow these eight steps to produce successful clinical vignette submissions:

click for large version

Step 1

Be a good doctor and make the correct diagnosis: Interesting cases will come to you. Don’t chase a zebra on every cough. Don’t send autoimmune panels for every rash. Read about each patient’s case that you see. Use the time to build your clinical acumen and develop your own illness scripts. Through the process of being a thoughtful student of medicine, you will come to distinguish the fascinoma from the merely fleeting infatuation with a diagnosis.

Step 2

Recognize the good case: The best way to recognize a good case is appreciate when it excites people locally. If you present it at morning report or CPC, are you inundated with requests to speak more after the conference has finished? Did it stump your colleagues (usually a pretty bright group)? Do you find that the consultants ask for others in their division to come and see the case? Clinically, did it take the team a while to come to the end diagnosis? If any of these are true, then you should move forward.

Step 3

Perform a literature search: How often does a similar situation arise? Is it 1 in 10,000, 1 in a million, or less? Even a case of 1 in 10,000 can be impactful to read about when you consider how long it may take a physician to see that many patients.

Step 4.

Develop two or three teaching points: Most abstracts for national and regional meetings have a restrictive word limit. When you consider all the information required of a thorough case presentation and adequate discussion, it can seem almost impossible to fit it all in. Start early, at least a month before the deadline if you can, and start big. Determine two or three key teaching points you wish to make. These will serve as your roadmap for the write-up.

Next, write down everything you want to say. Then cut the verbiage and descriptions that are not needed to tell your story. Focus on two or three take-home points. Each fact included or statement made should help to guide the reader to these lessons. As readers and authors, we also like to see prevalence and incidence of disease findings, or how good a test is with specificity and sensitivity values. Make sure the readers know what you want them to learn.

click for large version

Step 5

Keep the case concise, and focus on the discussion: The best write-ups keep the case description short and focused. Avoid trying to tell your readers everything about your case. Highlight what makes your case different without including extraneous information that does not support your teaching points. This leaves more room to focus on your discussion and explain to the reader the importance of your case. The discussion is where you create the “teachable moment” by elaborating on your teaching points.

Step 6

Keep your drafts and proofread your work carefully: The process of writing a clear and concise vignette will take many drafts. To do a great job, plan for at least three or four versions. Through the process of revisiting every word you use, you will start to hone your mastery of the topic; you will see the case in a new way with each draft.

As you do this, keep each edit as a separate file. You will inevitably edit something out early on that you will want to put back in later. Keeping your drafts will make this much easier.

At the final version, proofread carefully! Most reviewers will deduct points for poor grammar and misspellings. If it looks sloppy, then a reader will assume it represents sloppy thoughts.

Step 7

Get feedback: Have others read your work. It is always hard to put your writing out there for critique, particularly when it is such a personal representation of your own clinical thought. Hopefully, you have collaborated with others involved in the case; however, to avoid any “group think” about the work, it is best to have uninvolved individuals (e.g., trusted faculty member, program director, division chief) review your work before submission. The point of these vignettes is to help you develop skills as an author and academician. Since most meetings do not provide any feedback on the review of your submission, outside of “accepted” or “rejected,” it is important to get this from your own institution. It will also heighten your chances of acceptance. Take their suggestions openly, and use them to refine your abstract.

Step 8

Consider the following keys to a poster or oral presentation: The presentation at the meeting should be an expansion on the abstract. Remember, you have described the situation, but now you have the opportunity to use a picture. The old adage that a picture is worth a thousand words really rings true here.

Avoid copying and pasting your text. Concise statements will grab people’s eyes and leave you more space for charts and images. Visuals grab the reader’s eye better than small-font text.

Conclusion

Your first clinical vignette can be a truly great experience. Although it is a lot of hard work, presenting clinical thought is a skill that you must learn. Once you do this, you might find that you have “caught the bug,” and will find yourself well on your way to a role in medical education. You might even start a larger project based on this experience.

Dr. Burger is associate program director of internal medicine residency in the Department of Medicine at Beth Israel Medical Center and assistant dean and assistant professor of medicine at Albert Einstein College of Medicine, both in New York City. Dr. Paesch is a comprehensive care physician in the section of hospital medicine at the University of Chicago, and assistant professor at the University of Chicago Pritzker School of Medicine. Dr. Miller is director of student programs, associate program director, residency, and associate professor of medicine in the Department of Medicine at Tulane Health Sciences Center in New Orleans.

If he wasn’t a physician administrator working for one of the largest physician management companies in the country, or a clinical instructor at a medical school, or a pediatric hospitalist picking up shifts at a children’s hospital, Greg Harlan, MD, MPH, would have a very different life.

He says he’d “promote vegetable gardens to kindergartners, hike the West Coast Trail, fight the obesity epidemic, and play lots of golf.”

Oh, yeah, one more: “Give every kid a bicycle.”

It’s quite the altruistic—some might say enviable—list. Instead, Dr. Harlan is hard at work as director of medical affairs at North Hollywood, Calif.-based IPC The Hospitalist Company. He is also a clinical instructor at the University of Southern California Medical School and moonlights as a pediatric hospitalist in Los Angeles.

He says he chose to focus on hospital medicine as a career while working as a young faculty member at the University of Utah.

“I noticed that lots of innovation, experimentation, and energy was coming from the newly formed hospitalist division,” says Dr. Harlan, one of nine new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group. “I tried it out and loved it, especially getting to teach the students and residents for intense periods of time.”

At IPC, Dr. Harlan leads company-wide quality improvement (QI) initiatives, coordinates risk reduction activities, and directs the IPC-University of California San Francisco Fellowship for Hospitalist Leaders. He says he has a growing interest in “physician leadership, high-functioning teams, and physician groups’ well-being.”

I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

“I am using my QI background to apply these principles to better understanding how teams and leaders can thrive,” he says.

Question: Why did you choose a career in medicine?

A: Medicine is a cool combination of hard science, psychology, counseling, and teaching. It’s an amazing way to combine multiple passions and get to be involved on a very intimate level with many people.

Q: What do you like most about working as a hospitalist?

A: The focus on improving the system as a whole. Ultimately, the patients benefit, but so do many of the other stakeholders in the processes we touch.

Q: What do you dislike most?

A: It’s tough to take in-house call at night. It’s also hard to step in to many sick patients’ care for a short period of time, especially midway through their hospitalization.

Q: What’s the best advice you ever received?

A: Find the people who actually do the work. This is the concept of going to the front line, to see where the real work is being done. It never ceases to amaze me to find out the difference between what we think is going on and what is actually going on.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Providers are getting squeezed a little more each year. There are growing pressures from many sides, and the providers are feeling “crunched.”

Q: Why is it important for you to continue seeing patients?

A: Feeling the joy and pain of actually providing care for patients is integral to leading the hospitalist movement. By acutely experiencing an electronic health record, or dealing with medication authorizations or handoffs, one stays in the real world of hospital medicine.

Q: What is your biggest professional challenge?

A: Balancing my multiple passions. I love being a teacher and still teach young med students at USC med school (my alma mater). I still enjoy seeing patients, too. I am most excited by a growing interest in leadership and teamwork, but it’s still in its development stage as a career path.

Q: What is your biggest professional reward?

A: Being able to see others flourish. Whether it’s beginning med students, professional colleagues, or administrative staff, I truly beam when someone I’ve helped succeeds.

Q: When you aren’t working, what is important to you?

A: My family, my health, and staying balanced. I am learning the importance of listening to my body, trusting my intuition, and finding true “balance.” It’s not easy, but it’s imperative.

Q: What’s next professionally?

A: I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

Q: What’s the best book you’ve read recently? Why?

A: A few come to mind: “18 Minutes” by Peter Bregman offers some really easy steps to getting organized and focused; “Six Thinking Hats” by Edward de Bono is a great framework for approaching problems and innovations; “The Inner Game of Golf” by W. Timothy Gallwey makes me realize how amazing our bodies and minds truly are.

Q: How many Apple products do you interface with in a given week?

A: I only have an iPhone. Amazing little gadget, but I don’t want to become wedded to it. Maybe I’ll get a MacBook soon.

Q: What’s next in your Netflix queue?

A: We use Netflix mainly for their drama series. I prefer foreign films and documentaries. My wife and I love “Breaking Bad.” My kids and I are working our way through the “Star Wars” episodes.

Richard Quinn is a freelance writer in New Jersey.

If he wasn’t a physician administrator working for one of the largest physician management companies in the country, or a clinical instructor at a medical school, or a pediatric hospitalist picking up shifts at a children’s hospital, Greg Harlan, MD, MPH, would have a very different life.

He says he’d “promote vegetable gardens to kindergartners, hike the West Coast Trail, fight the obesity epidemic, and play lots of golf.”

Oh, yeah, one more: “Give every kid a bicycle.”

It’s quite the altruistic—some might say enviable—list. Instead, Dr. Harlan is hard at work as director of medical affairs at North Hollywood, Calif.-based IPC The Hospitalist Company. He is also a clinical instructor at the University of Southern California Medical School and moonlights as a pediatric hospitalist in Los Angeles.

He says he chose to focus on hospital medicine as a career while working as a young faculty member at the University of Utah.

“I noticed that lots of innovation, experimentation, and energy was coming from the newly formed hospitalist division,” says Dr. Harlan, one of nine new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group. “I tried it out and loved it, especially getting to teach the students and residents for intense periods of time.”

At IPC, Dr. Harlan leads company-wide quality improvement (QI) initiatives, coordinates risk reduction activities, and directs the IPC-University of California San Francisco Fellowship for Hospitalist Leaders. He says he has a growing interest in “physician leadership, high-functioning teams, and physician groups’ well-being.”

I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

“I am using my QI background to apply these principles to better understanding how teams and leaders can thrive,” he says.

Question: Why did you choose a career in medicine?

A: Medicine is a cool combination of hard science, psychology, counseling, and teaching. It’s an amazing way to combine multiple passions and get to be involved on a very intimate level with many people.

Q: What do you like most about working as a hospitalist?

A: The focus on improving the system as a whole. Ultimately, the patients benefit, but so do many of the other stakeholders in the processes we touch.

Q: What do you dislike most?

A: It’s tough to take in-house call at night. It’s also hard to step in to many sick patients’ care for a short period of time, especially midway through their hospitalization.

Q: What’s the best advice you ever received?

A: Find the people who actually do the work. This is the concept of going to the front line, to see where the real work is being done. It never ceases to amaze me to find out the difference between what we think is going on and what is actually going on.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Providers are getting squeezed a little more each year. There are growing pressures from many sides, and the providers are feeling “crunched.”

Q: Why is it important for you to continue seeing patients?

A: Feeling the joy and pain of actually providing care for patients is integral to leading the hospitalist movement. By acutely experiencing an electronic health record, or dealing with medication authorizations or handoffs, one stays in the real world of hospital medicine.

Q: What is your biggest professional challenge?

A: Balancing my multiple passions. I love being a teacher and still teach young med students at USC med school (my alma mater). I still enjoy seeing patients, too. I am most excited by a growing interest in leadership and teamwork, but it’s still in its development stage as a career path.

Q: What is your biggest professional reward?

A: Being able to see others flourish. Whether it’s beginning med students, professional colleagues, or administrative staff, I truly beam when someone I’ve helped succeeds.

Q: When you aren’t working, what is important to you?

A: My family, my health, and staying balanced. I am learning the importance of listening to my body, trusting my intuition, and finding true “balance.” It’s not easy, but it’s imperative.

Q: What’s next professionally?

A: I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

Q: What’s the best book you’ve read recently? Why?

A: A few come to mind: “18 Minutes” by Peter Bregman offers some really easy steps to getting organized and focused; “Six Thinking Hats” by Edward de Bono is a great framework for approaching problems and innovations; “The Inner Game of Golf” by W. Timothy Gallwey makes me realize how amazing our bodies and minds truly are.

Q: How many Apple products do you interface with in a given week?

A: I only have an iPhone. Amazing little gadget, but I don’t want to become wedded to it. Maybe I’ll get a MacBook soon.

Q: What’s next in your Netflix queue?

A: We use Netflix mainly for their drama series. I prefer foreign films and documentaries. My wife and I love “Breaking Bad.” My kids and I are working our way through the “Star Wars” episodes.

Richard Quinn is a freelance writer in New Jersey.

If he wasn’t a physician administrator working for one of the largest physician management companies in the country, or a clinical instructor at a medical school, or a pediatric hospitalist picking up shifts at a children’s hospital, Greg Harlan, MD, MPH, would have a very different life.

He says he’d “promote vegetable gardens to kindergartners, hike the West Coast Trail, fight the obesity epidemic, and play lots of golf.”

Oh, yeah, one more: “Give every kid a bicycle.”

It’s quite the altruistic—some might say enviable—list. Instead, Dr. Harlan is hard at work as director of medical affairs at North Hollywood, Calif.-based IPC The Hospitalist Company. He is also a clinical instructor at the University of Southern California Medical School and moonlights as a pediatric hospitalist in Los Angeles.

He says he chose to focus on hospital medicine as a career while working as a young faculty member at the University of Utah.

“I noticed that lots of innovation, experimentation, and energy was coming from the newly formed hospitalist division,” says Dr. Harlan, one of nine new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory group. “I tried it out and loved it, especially getting to teach the students and residents for intense periods of time.”

At IPC, Dr. Harlan leads company-wide quality improvement (QI) initiatives, coordinates risk reduction activities, and directs the IPC-University of California San Francisco Fellowship for Hospitalist Leaders. He says he has a growing interest in “physician leadership, high-functioning teams, and physician groups’ well-being.”

I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

“I am using my QI background to apply these principles to better understanding how teams and leaders can thrive,” he says.

Question: Why did you choose a career in medicine?

A: Medicine is a cool combination of hard science, psychology, counseling, and teaching. It’s an amazing way to combine multiple passions and get to be involved on a very intimate level with many people.

Q: What do you like most about working as a hospitalist?

A: The focus on improving the system as a whole. Ultimately, the patients benefit, but so do many of the other stakeholders in the processes we touch.

Q: What do you dislike most?

A: It’s tough to take in-house call at night. It’s also hard to step in to many sick patients’ care for a short period of time, especially midway through their hospitalization.

Q: What’s the best advice you ever received?

A: Find the people who actually do the work. This is the concept of going to the front line, to see where the real work is being done. It never ceases to amaze me to find out the difference between what we think is going on and what is actually going on.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Providers are getting squeezed a little more each year. There are growing pressures from many sides, and the providers are feeling “crunched.”

Q: Why is it important for you to continue seeing patients?

A: Feeling the joy and pain of actually providing care for patients is integral to leading the hospitalist movement. By acutely experiencing an electronic health record, or dealing with medication authorizations or handoffs, one stays in the real world of hospital medicine.

Q: What is your biggest professional challenge?

A: Balancing my multiple passions. I love being a teacher and still teach young med students at USC med school (my alma mater). I still enjoy seeing patients, too. I am most excited by a growing interest in leadership and teamwork, but it’s still in its development stage as a career path.

Q: What is your biggest professional reward?

A: Being able to see others flourish. Whether it’s beginning med students, professional colleagues, or administrative staff, I truly beam when someone I’ve helped succeeds.

Q: When you aren’t working, what is important to you?

A: My family, my health, and staying balanced. I am learning the importance of listening to my body, trusting my intuition, and finding true “balance.” It’s not easy, but it’s imperative.

Q: What’s next professionally?

A: I am really excited to put some science behind “leadership in medicine” and “optimal teamwork in medicine.” I think there is so much more we can learn and implement.

Q: What’s the best book you’ve read recently? Why?

A: A few come to mind: “18 Minutes” by Peter Bregman offers some really easy steps to getting organized and focused; “Six Thinking Hats” by Edward de Bono is a great framework for approaching problems and innovations; “The Inner Game of Golf” by W. Timothy Gallwey makes me realize how amazing our bodies and minds truly are.

Q: How many Apple products do you interface with in a given week?

A: I only have an iPhone. Amazing little gadget, but I don’t want to become wedded to it. Maybe I’ll get a MacBook soon.

Q: What’s next in your Netflix queue?

A: We use Netflix mainly for their drama series. I prefer foreign films and documentaries. My wife and I love “Breaking Bad.” My kids and I are working our way through the “Star Wars” episodes.

Richard Quinn is a freelance writer in New Jersey.

Two Research, Hospital Innovations, and Clinical Vignettes (RIV) scientific posters presented at HM13 shed new light on the opportunities and challenges of hospitalist-run post-discharge clinics, which a growing number of hospitals have adopted in an attempt to smooth care transitions and prevent rehospitalizations.

The Denver VA Medical Center (VAMC) started its post-discharge clinic, located on a floor above its medicine wards, in 2003. Open two afternoons, the clinic sees up to 16 patients a week. Discharging housestaff are paged to meet their patients in the clinic as part of required afternoon activities, explains the poster’s lead author, Robert Burke, MD, a hospitalist at the VAMC and assistant professor of medicine at affiliated University of Colorado. Every patient is seen by a rotating, supervising hospitalist attending.

The clinic is able to see patients for their first post-discharge clinical encounter within five days on average, much sooner than either urgent care clinics (9.4 days) or primary care physicians (13.7 days).

However, data presented at HM13 found no reduction in readmissions for the VA clinic’s patients.¹ Dr. Burke suggests that this finding reflects the challenges of connecting patients to their PCPs after the clinic visit. “Also, it’s not a full, multidisciplinary clinic—just housestaff and attendings,” he says. “The patients we see in the clinic are very ill.”

A second poster from the same team presented data from a national survey of hospitalists’ attitudes regarding post-discharge clinics.² Three-quarters of 228 respondents believed that these clinics would reduce ED visits, but only 38% said that hospitalists should be seeing patients after discharge, and about 75% said doing so should require additional compensation for the physician.

“In my experience, I find it very valuable to see patients post-discharge as part of the larger continuum of care,” Dr. Burke says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Burke RE, Prochazka AV. A VA hospitalist-run post-discharge clinic: patient outcomes and lessons learned [abstracts]. J Hosp Med. 2013;8 Suppl 1:691.
2. Ryan PP, Stickrath C, Burke RE. Post-discharge clinics: attitudes and experiences of hospitalists [abstracts]. J Hosp Med. 2013;8 Suppl 1:693.

Two Research, Hospital Innovations, and Clinical Vignettes (RIV) scientific posters presented at HM13 shed new light on the opportunities and challenges of hospitalist-run post-discharge clinics, which a growing number of hospitals have adopted in an attempt to smooth care transitions and prevent rehospitalizations.

The Denver VA Medical Center (VAMC) started its post-discharge clinic, located on a floor above its medicine wards, in 2003. Open two afternoons, the clinic sees up to 16 patients a week. Discharging housestaff are paged to meet their patients in the clinic as part of required afternoon activities, explains the poster’s lead author, Robert Burke, MD, a hospitalist at the VAMC and assistant professor of medicine at affiliated University of Colorado. Every patient is seen by a rotating, supervising hospitalist attending.

The clinic is able to see patients for their first post-discharge clinical encounter within five days on average, much sooner than either urgent care clinics (9.4 days) or primary care physicians (13.7 days).

However, data presented at HM13 found no reduction in readmissions for the VA clinic’s patients.¹ Dr. Burke suggests that this finding reflects the challenges of connecting patients to their PCPs after the clinic visit. “Also, it’s not a full, multidisciplinary clinic—just housestaff and attendings,” he says. “The patients we see in the clinic are very ill.”

A second poster from the same team presented data from a national survey of hospitalists’ attitudes regarding post-discharge clinics.² Three-quarters of 228 respondents believed that these clinics would reduce ED visits, but only 38% said that hospitalists should be seeing patients after discharge, and about 75% said doing so should require additional compensation for the physician.

“In my experience, I find it very valuable to see patients post-discharge as part of the larger continuum of care,” Dr. Burke says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Burke RE, Prochazka AV. A VA hospitalist-run post-discharge clinic: patient outcomes and lessons learned [abstracts]. J Hosp Med. 2013;8 Suppl 1:691.
2. Ryan PP, Stickrath C, Burke RE. Post-discharge clinics: attitudes and experiences of hospitalists [abstracts]. J Hosp Med. 2013;8 Suppl 1:693.

Two Research, Hospital Innovations, and Clinical Vignettes (RIV) scientific posters presented at HM13 shed new light on the opportunities and challenges of hospitalist-run post-discharge clinics, which a growing number of hospitals have adopted in an attempt to smooth care transitions and prevent rehospitalizations.

The Denver VA Medical Center (VAMC) started its post-discharge clinic, located on a floor above its medicine wards, in 2003. Open two afternoons, the clinic sees up to 16 patients a week. Discharging housestaff are paged to meet their patients in the clinic as part of required afternoon activities, explains the poster’s lead author, Robert Burke, MD, a hospitalist at the VAMC and assistant professor of medicine at affiliated University of Colorado. Every patient is seen by a rotating, supervising hospitalist attending.

The clinic is able to see patients for their first post-discharge clinical encounter within five days on average, much sooner than either urgent care clinics (9.4 days) or primary care physicians (13.7 days).

However, data presented at HM13 found no reduction in readmissions for the VA clinic’s patients.¹ Dr. Burke suggests that this finding reflects the challenges of connecting patients to their PCPs after the clinic visit. “Also, it’s not a full, multidisciplinary clinic—just housestaff and attendings,” he says. “The patients we see in the clinic are very ill.”

A second poster from the same team presented data from a national survey of hospitalists’ attitudes regarding post-discharge clinics.² Three-quarters of 228 respondents believed that these clinics would reduce ED visits, but only 38% said that hospitalists should be seeing patients after discharge, and about 75% said doing so should require additional compensation for the physician.

“In my experience, I find it very valuable to see patients post-discharge as part of the larger continuum of care,” Dr. Burke says.

Larry Beresford is a freelance writer in San Francisco.

References

1. Burke RE, Prochazka AV. A VA hospitalist-run post-discharge clinic: patient outcomes and lessons learned [abstracts]. J Hosp Med. 2013;8 Suppl 1:691.
2. Ryan PP, Stickrath C, Burke RE. Post-discharge clinics: attitudes and experiences of hospitalists [abstracts]. J Hosp Med. 2013;8 Suppl 1:693.

Click here to listen to more of our interview with Divya Parikh

Click here to listen to more of our interview with Divya Parikh

Click here to listen to more of our interview with Divya Parikh