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Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Visit our website for more information about medication reconciliation.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Visit our website for more information about medication reconciliation.

Physicians who rank poorly in their communication skills with patients were associated with reduced rates of medication adherence in a new report.

A cross-sectional study of nearly 9,4000 patients in the Diabetes Study of Northern California (DISTANCE) found roughly 30% of patients who gave their physicians poor ratings when it came to involving them in decisions, understanding their problems with medications, and eliciting their trust were less likely to refill their cardiometabolic medications than those whose doctors were deemed to be good communicators, researchers found. For each 10-point decrease in the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the prevalence of poor medication adherence increased by 0.9% (P +0.1), the researchers added.

“One of the tricks is that medication adherence is an inherently physician-centric concept,” says lead author Neda Ratanawongsa, MD, MPH, assistant professor in the department of medicine at the University of California at San Francisco (UCSF). “We’re asking you to take medicine that we think will be best for you. That’s been the way that physicians operate for years, often appropriately so. But part of this is figuring out how to encourage the patients to disclose their decision that ‘Yes, I do want to take that medicine’ or ‘No, here’s why I don’t want to take that medicine.’”

Dr. Ratanawongsa adds that hospitalists and other physicians have to develop a sense of trust with patients to build relationships. Future studies could then track patient satisfaction and adherence over time to see if a corollary exists. Also, she says, hospitalists shouldn’t be discouraged that most of their relationships aren’t long-term ones like those found in other specialties.

“I wouldn’t underestimate the impact a hospitalist could have, whether one-time interaction or not, to change an existing therapy program,” Dr. Ratanawongsa says. “It’s important for hospitalists to understand the power of their words.”

Visit our website for more information about medication reconciliation.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

A healthy collaboration between hospitalists and pharmacists can generate cost savings and promote positive outcomes, such as preventing adverse drug events and improving care transitions, says Jonathan Edwards, PharmD, BCPS, a clinical pharmacy specialist at Huntsville Hospital in Alabama.

At the 2012 national conference of the American College of Clinical Pharmacy in Hollywood, Fla., Edwards presented a poster that detailed the effectiveness of such interdisciplinary collaboration at Huntsville Hospital, where pharmacists and physicians developed six order sets, a collaborative practice, and a patient interaction program from November 2011 to February 2012. During the study period, researchers documented a total cost savings of $9,825 resulting from 156 patient interventions.

Edwards’ collaborative study at Huntsville started with two physicians who had launched a service teaching hospitalists what pharmacists do, and how they could help in their efforts.

“We got together and developed an order set for treating acute alcohol withdrawal. That went well, so we did five more order sets,” Edwards says. “Then we thought: What if pharmacists got more involved by meeting directly with patients in the hospital to optimize their medication management and help them reach their goals for treatment? We now evaluate patients on the hospitalist service in three units.”

For Edwards, key factors that make the hospitalist-pharmacist relationship work include communicating the pharmacist’s availability to help with the hospitalist’s patients, identifying the physician’s openness to help, and clarifying how the physician prefers to be contacted.

Last October, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) recognized eight care-transitions programs for best practices that improved patient outcomes and reduced hospital readmissions as part of the Medication Management in Care Transitions (MMCT) Project.

“The MMCT project highlights the valuable role pharmacists can play in addressing medication-related problems that can lead to hospital readmissions,” APhA chief executive officer Thomas E. Menighan, BSPharm, MBA, ScD (Hon), FAPhA, said in a news release. “By putting together these best practices, our goal is to provide a model for better coordination of care and better connectivity between pharmacists and healthcare providers in different practice settings that leads to improved patient health.”

Visit our website for more information about maximizing patient care through pharmacist-hospitalist collaboration.

Click here to listen to Sherri Dumford

Click here to listen to Sherri Dumford

Click here to listen to Sherri Dumford

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

Engage

For hospitalists, the first order of business should be ensuring that your group is participating in the Physician Quality Reporting System (PQRS) and receiving the current 0.5% participation bonus (in some cases, that may require an electronic billing system add-on that adds the necessary PQRS codes to claims). If not, you could be leaving an estimated $800 in reporting incentives per hospitalist on the table. Once the PQRS penalty phase begins in 2015, your group could lose 1.5% of CMS reimbursements. Eventually, failure to engage will spur an additional 1% penalty through the Value-Based Payment Modifier (VBPM).

Respond

SHM’s early feedback to CMS was based in part on a problematic Quality and Resource Use Report (QRUR) brought to the society’s attention by a member hospitalist. Dr. Torcson says SHM carefully reviewed that report to register its concerns about proper attribution, fair comparisons, relevant metrics, and other issues. In turn, CMS signaled its appreciation of SHM’s due diligence and has indicated a willingness to work with SHM to address its concerns. The lesson is that a constructive, collaborative process was eased by the willingness of an SHM member to help the society develop a thoughtful and thorough response—one that is more likely to yield sought-after changes by federal officials. “CMS reacts much better to physician groups that are willing to collaborate with them versus the ones that just want to deny, deny, deny that changes are coming,” Dr. Whitcomb says.

Communicate

CMS has indicated that lack of communication among individual physicians and groups won’t excuse anyone from the PQRS and VBPM programs. Hospitalists clearly have an advantage here, and experts say a continued focus on collaborative teamwork and making sure providers are on the same page could help ensure that everyone is making the necessary improvements in care. To keep the conversation going, initiate and take part in online discussions with fellow HM providers via the advocacy and public policy community of SHM’s Hospital Medical Exchange.

Plan

Which PQRS measures are most applicable to you and your colleagues? Make sure you review the final rules and develop a plan for how to address the performance measures that you can control, either directly or indirectly. For group practices with 100 or more eligible providers, the first performance year for the VBPM program begins Jan. 1.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

The intricacies of billing and coding typically aren’t taught in physician residency training programs.

“Residents want to learn how to take care of patients. They’re not really focused on learning [Centers for Medicare & Medicaid Services] rules,” says Balazs Zsenits, MD, FACP, SFHM, medical director of the Rochester General Hospitalist Group in Rochester, N.Y. As a result, “there’s a knowledge gap” between newly minted physicians and experienced practitioners when it comes to documenting their work.

To bridge that gap, some hospitalist groups offer training on the business side of medicine during physician orientation, as well as provide constructive reviews of hospitalists’ progress notes on a periodic basis. Some hospitals provide seminars in proper documentation.

“I’ve seen a lot of hospitals do ‘lunch and learn’” sessions on documentation requirements, says Angie Comfort, RHIT, CCS, a director of HIM Solutions at the American Health Information Management Association. The goal is to facilitate reimbursement for the hospital from patients’ insurance providers.

“If more specific documentation is not in the record, the coder must ask the physician for additional clarification,” Comfort says. “Without the clarification, sometimes the conditions are not able to be coded.”

The HM group in Rochester, which employs 46 hospitalists, provides about six hours of billing compliance education for new hires during orientation and holds regular, topic-based presentations at weekly staff meetings.

Physicians “need timely information as we submit our own charges, and we set up our productivity bonus so that it depends on our billing accuracy, not just volume,” Dr. Zsenits says. Using an internal Web portal, physicians can look up billing codes and explanations. “They realize the risks involved if they don’t do it right,” she says, so they also accept feedback from reviews of their patient charts.

Easy-to-access information is key to helping hospitalists learn coding requirements. “We have a Web-based documentation education module, so the provider is able to log on from home,” says David Grace, MD, FHM, senior medical officer at The Schumacher Group’s hospital medicine division in Lafayette, La. The practice management company employs hospitalists in 12 states.

Its initial module takes about an hour to review. For those who are already proficient in billing and coding, a test-out option lasting 10 to 15 minutes is available online as well. Pocket cards are provided as a reference thereafter.

“Documentation and coding is a complex entity, and certainly we don’t expect them to remember all the details after one educational module,” Dr. Grace says. “They do have access to be able to go back to it for a refresher whenever they want.”

Internal coding experts audit about 20% of the hospitalists’ work, and audited physicians are provided feedback on compliance. The Schumacher Group also uses a proprietary template to help hospitalists capture the important data points in their patient progress notes.

“Physicians are under a lot of scrutiny by regulatory agencies,” says Peter Thompson, MD, chief of clinical operations at Apogee Physicians, a national hospitalist management company based in Phoenix.

At new hospitalist orientation, called Apogee University, providers spend several hours learning the rules for documentation. The group follows up with regular reviews of hospitalists’ notes through an audit system. A program director “breaks down the components that make it a compliant note or not,” Dr. Thompson says. Audits are performed monthly on every physician.

“It takes a commitment to knowing what the requirements are,” he adds. “And it takes repetition and it takes practice to make something a habit.”

Susan Kreimer is a freelance medical writer in New York.

A new study in the Journal of Hospital Medicine is among the first to assess and characterize the effectiveness of teamwork in interdisciplinary rounds (IDR). The upshot: Varied performance on rounds suggests a need to improve the consistency of teamwork.

The report, "Assessment of Teamwork During Structured Interdisciplinary Rounds on Medical Units," adapted the Observational Teamwork Assessment for Surgery (OTAS) behavioral rating scale tool to evaluate and characterize teamwork of hospitalists. Mark Williams, MD, FACP, MHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, says the review shows that mere implementation of IDR is not enough. Physician leaders must occasionally check how the rounds operate to ensure against such roadblocks as a team member who dominates discussions, or the formation of hierarchal relationships that not everyone is comfortable participating in, he says.

"You can't just say, 'Oh, we're practicing teamwork, we have structured interdisciplinary rounds,'" says Dr. Williams, who credits the research to lead author Kevin O'Leary, MD, MS, also of Feinberg. "You need to ensure that it’s occurring."

The paper fills a gap in research, the authors write, as much of the prior work on IDR has focused on patient outcomes, cost, and length of stay. But Dr. Williams says he doesn't expect community hospital medicine groups to conduct similar research because of their busy schedules. Still, he hopes group leaders and administrators consider the research an impetus to periodically check those rounds.

"Even in an institution [like Northwestern] that has strong buy-in to this [teamwork], you need to go back and check," Dr. Williams adds. "We saw variation in performance and we realized we needed to do some retraining."

 Visit our website for more information about interdisciplinary rounds.

A new study in the Journal of Hospital Medicine is among the first to assess and characterize the effectiveness of teamwork in interdisciplinary rounds (IDR). The upshot: Varied performance on rounds suggests a need to improve the consistency of teamwork.

The report, "Assessment of Teamwork During Structured Interdisciplinary Rounds on Medical Units," adapted the Observational Teamwork Assessment for Surgery (OTAS) behavioral rating scale tool to evaluate and characterize teamwork of hospitalists. Mark Williams, MD, FACP, MHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, says the review shows that mere implementation of IDR is not enough. Physician leaders must occasionally check how the rounds operate to ensure against such roadblocks as a team member who dominates discussions, or the formation of hierarchal relationships that not everyone is comfortable participating in, he says.

"You can't just say, 'Oh, we're practicing teamwork, we have structured interdisciplinary rounds,'" says Dr. Williams, who credits the research to lead author Kevin O'Leary, MD, MS, also of Feinberg. "You need to ensure that it’s occurring."

The paper fills a gap in research, the authors write, as much of the prior work on IDR has focused on patient outcomes, cost, and length of stay. But Dr. Williams says he doesn't expect community hospital medicine groups to conduct similar research because of their busy schedules. Still, he hopes group leaders and administrators consider the research an impetus to periodically check those rounds.

"Even in an institution [like Northwestern] that has strong buy-in to this [teamwork], you need to go back and check," Dr. Williams adds. "We saw variation in performance and we realized we needed to do some retraining."

 Visit our website for more information about interdisciplinary rounds.

A new study in the Journal of Hospital Medicine is among the first to assess and characterize the effectiveness of teamwork in interdisciplinary rounds (IDR). The upshot: Varied performance on rounds suggests a need to improve the consistency of teamwork.

The report, "Assessment of Teamwork During Structured Interdisciplinary Rounds on Medical Units," adapted the Observational Teamwork Assessment for Surgery (OTAS) behavioral rating scale tool to evaluate and characterize teamwork of hospitalists. Mark Williams, MD, FACP, MHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, says the review shows that mere implementation of IDR is not enough. Physician leaders must occasionally check how the rounds operate to ensure against such roadblocks as a team member who dominates discussions, or the formation of hierarchal relationships that not everyone is comfortable participating in, he says.

"You can't just say, 'Oh, we're practicing teamwork, we have structured interdisciplinary rounds,'" says Dr. Williams, who credits the research to lead author Kevin O'Leary, MD, MS, also of Feinberg. "You need to ensure that it’s occurring."

The paper fills a gap in research, the authors write, as much of the prior work on IDR has focused on patient outcomes, cost, and length of stay. But Dr. Williams says he doesn't expect community hospital medicine groups to conduct similar research because of their busy schedules. Still, he hopes group leaders and administrators consider the research an impetus to periodically check those rounds.

"Even in an institution [like Northwestern] that has strong buy-in to this [teamwork], you need to go back and check," Dr. Williams adds. "We saw variation in performance and we realized we needed to do some retraining."

 Visit our website for more information about interdisciplinary rounds.

Clinical question: Is there a difference between aspirin and warfarin in preventing thromboembolic complications and risk of bleeding in patients with chronic kidney disease (CKD) and nonvalvular atrial fibrillation (NVAF)?

Background: Data are lacking on risks and benefits of aspirin and warfarin in CKD, as this group of patients largely has been excluded from anticoagulation therapy trials for NVAF. This study examined the risks and benefits of aspirin and warfarin in patients with CKD with NVAF.

Study design: Retrospective, observational cohort study.

Setting: Danish National Registries.

Synopsis: Of 132,372 patients with NVAF, 2.7% had CKD and 0.7% had end-stage renal disease (ESRD). Compared to patients with no CKD, there was increased risk of stroke or systemic thromboembolism in patients with ESRD (HR, 1.83; 95% CI, 1.57-2.14) and with non-end-stage CKD (HR 1.49; 95% CI 1.38-1.59).

In patients with CKD, warfarin significantly reduced stroke risk (HR, 0.76; 95% CI, 0.64-0.91) and significantly increased bleeding risk (HR, 1.33; 95% CI, 1.16-1.53); aspirin significantly increased bleeding risk (HR, 1.17; 95% CI, 1.02-1.34), with no reduction in stroke risk.

Bottom line: CKD was associated with an increased risk of stroke among NVAF patients. While both aspirin and warfarin were associated with increased risk of bleeding, there was a reduction in the risk of stroke with warfarin, but not with aspirin.

Citation: Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625-635.

Click here for more physician reviews of HM-relevant literature.

Clinical question: Is there a difference between aspirin and warfarin in preventing thromboembolic complications and risk of bleeding in patients with chronic kidney disease (CKD) and nonvalvular atrial fibrillation (NVAF)?

Background: Data are lacking on risks and benefits of aspirin and warfarin in CKD, as this group of patients largely has been excluded from anticoagulation therapy trials for NVAF. This study examined the risks and benefits of aspirin and warfarin in patients with CKD with NVAF.

Study design: Retrospective, observational cohort study.

Setting: Danish National Registries.

Synopsis: Of 132,372 patients with NVAF, 2.7% had CKD and 0.7% had end-stage renal disease (ESRD). Compared to patients with no CKD, there was increased risk of stroke or systemic thromboembolism in patients with ESRD (HR, 1.83; 95% CI, 1.57-2.14) and with non-end-stage CKD (HR 1.49; 95% CI 1.38-1.59).

In patients with CKD, warfarin significantly reduced stroke risk (HR, 0.76; 95% CI, 0.64-0.91) and significantly increased bleeding risk (HR, 1.33; 95% CI, 1.16-1.53); aspirin significantly increased bleeding risk (HR, 1.17; 95% CI, 1.02-1.34), with no reduction in stroke risk.

Bottom line: CKD was associated with an increased risk of stroke among NVAF patients. While both aspirin and warfarin were associated with increased risk of bleeding, there was a reduction in the risk of stroke with warfarin, but not with aspirin.

Citation: Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625-635.

Click here for more physician reviews of HM-relevant literature.

Clinical question: Is there a difference between aspirin and warfarin in preventing thromboembolic complications and risk of bleeding in patients with chronic kidney disease (CKD) and nonvalvular atrial fibrillation (NVAF)?

Background: Data are lacking on risks and benefits of aspirin and warfarin in CKD, as this group of patients largely has been excluded from anticoagulation therapy trials for NVAF. This study examined the risks and benefits of aspirin and warfarin in patients with CKD with NVAF.

Study design: Retrospective, observational cohort study.

Setting: Danish National Registries.

Synopsis: Of 132,372 patients with NVAF, 2.7% had CKD and 0.7% had end-stage renal disease (ESRD). Compared to patients with no CKD, there was increased risk of stroke or systemic thromboembolism in patients with ESRD (HR, 1.83; 95% CI, 1.57-2.14) and with non-end-stage CKD (HR 1.49; 95% CI 1.38-1.59).

In patients with CKD, warfarin significantly reduced stroke risk (HR, 0.76; 95% CI, 0.64-0.91) and significantly increased bleeding risk (HR, 1.33; 95% CI, 1.16-1.53); aspirin significantly increased bleeding risk (HR, 1.17; 95% CI, 1.02-1.34), with no reduction in stroke risk.

Bottom line: CKD was associated with an increased risk of stroke among NVAF patients. While both aspirin and warfarin were associated with increased risk of bleeding, there was a reduction in the risk of stroke with warfarin, but not with aspirin.

Citation: Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625-635.

Click here for more physician reviews of HM-relevant literature.

If you’re ready to demonstrate your commitment to HM and hospitalized patients, you still have time to submit your SHM fellowship application.

The deadline for 2013 applications is Jan. 18. To apply online or learn more, visit www.hospitalmedicine.org/fellows.

The class of 2013 Fellows will be inducted during a plenary session at SHM’s annual meeting in May in National Harbor, Md.

This year’s class will reach a milestone—not just for hospital medicine, but for all of healthcare. SHM has expanded eligibility in its Fellowship in Hospital Medicine program to include nurse practitioners (NPs), physician assistants (PAs), and HM practice administrators. By opening the designation to nonphysicians, SHM becomes the only medical society to offer a singular designation to the entire care team.

SHM members who meet eligibility criteria are recognized as Fellows each year at the annual meeting. Based on current membership, SHM estimates that more than 300 NPs, PAs, and administrators are eligible immediately; thousands more will be eligible after they meet the three-year membership requirement for fellow status.

“We are proud to be able to recognize excellence within the specialty and contributions to the field by nurse practitioners, physician assistants, and practice administrators,” says SHM President Shaun Frost, MD, SFHM. “The standards by which SHM fellows are measured promote the highest quality of patient care and systems efficiency. And they can be equally applied to physicians, NPs, PAs, and administrators within the hospital medicine specialty.”

SHM’s Fellows program is rooted in the society’s Core Competencies in Hospital Medicine, and those who earn the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation have demonstrated a commitment to hospital medicine, system change, and quality-improvement (QI) principles.

All candidates for the designation are required to submit applications that demonstrate experience, organizational teamwork and leadership, and a dedication to lifelong learning. Applicants must receive endorsement from practitioners in the field and are subject to committee review.

“Hospital medicine was built on the principle that caregivers must act as a team,” Dr. Frost says. “We are honored to recognize more members of that team today through our Fellows designation.”

Brendon Shank is associate vice president of communications for SHM.

If you’re ready to demonstrate your commitment to HM and hospitalized patients, you still have time to submit your SHM fellowship application.

The deadline for 2013 applications is Jan. 18. To apply online or learn more, visit www.hospitalmedicine.org/fellows.

The class of 2013 Fellows will be inducted during a plenary session at SHM’s annual meeting in May in National Harbor, Md.

This year’s class will reach a milestone—not just for hospital medicine, but for all of healthcare. SHM has expanded eligibility in its Fellowship in Hospital Medicine program to include nurse practitioners (NPs), physician assistants (PAs), and HM practice administrators. By opening the designation to nonphysicians, SHM becomes the only medical society to offer a singular designation to the entire care team.

SHM members who meet eligibility criteria are recognized as Fellows each year at the annual meeting. Based on current membership, SHM estimates that more than 300 NPs, PAs, and administrators are eligible immediately; thousands more will be eligible after they meet the three-year membership requirement for fellow status.

“We are proud to be able to recognize excellence within the specialty and contributions to the field by nurse practitioners, physician assistants, and practice administrators,” says SHM President Shaun Frost, MD, SFHM. “The standards by which SHM fellows are measured promote the highest quality of patient care and systems efficiency. And they can be equally applied to physicians, NPs, PAs, and administrators within the hospital medicine specialty.”

SHM’s Fellows program is rooted in the society’s Core Competencies in Hospital Medicine, and those who earn the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation have demonstrated a commitment to hospital medicine, system change, and quality-improvement (QI) principles.

All candidates for the designation are required to submit applications that demonstrate experience, organizational teamwork and leadership, and a dedication to lifelong learning. Applicants must receive endorsement from practitioners in the field and are subject to committee review.

“Hospital medicine was built on the principle that caregivers must act as a team,” Dr. Frost says. “We are honored to recognize more members of that team today through our Fellows designation.”

Brendon Shank is associate vice president of communications for SHM.

If you’re ready to demonstrate your commitment to HM and hospitalized patients, you still have time to submit your SHM fellowship application.

The deadline for 2013 applications is Jan. 18. To apply online or learn more, visit www.hospitalmedicine.org/fellows.

The class of 2013 Fellows will be inducted during a plenary session at SHM’s annual meeting in May in National Harbor, Md.

This year’s class will reach a milestone—not just for hospital medicine, but for all of healthcare. SHM has expanded eligibility in its Fellowship in Hospital Medicine program to include nurse practitioners (NPs), physician assistants (PAs), and HM practice administrators. By opening the designation to nonphysicians, SHM becomes the only medical society to offer a singular designation to the entire care team.

SHM members who meet eligibility criteria are recognized as Fellows each year at the annual meeting. Based on current membership, SHM estimates that more than 300 NPs, PAs, and administrators are eligible immediately; thousands more will be eligible after they meet the three-year membership requirement for fellow status.

“We are proud to be able to recognize excellence within the specialty and contributions to the field by nurse practitioners, physician assistants, and practice administrators,” says SHM President Shaun Frost, MD, SFHM. “The standards by which SHM fellows are measured promote the highest quality of patient care and systems efficiency. And they can be equally applied to physicians, NPs, PAs, and administrators within the hospital medicine specialty.”

SHM’s Fellows program is rooted in the society’s Core Competencies in Hospital Medicine, and those who earn the Fellow in Hospital Medicine (FHM) or Senior Fellow in Hospital Medicine (SFHM) designation have demonstrated a commitment to hospital medicine, system change, and quality-improvement (QI) principles.

All candidates for the designation are required to submit applications that demonstrate experience, organizational teamwork and leadership, and a dedication to lifelong learning. Applicants must receive endorsement from practitioners in the field and are subject to committee review.

“Hospital medicine was built on the principle that caregivers must act as a team,” Dr. Frost says. “We are honored to recognize more members of that team today through our Fellows designation.”

Brendon Shank is associate vice president of communications for SHM.

Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.

The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.

The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.

A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.

When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.

The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.

Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.

Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.

The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.

The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.

A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.

When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.

The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.

Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.

Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.

The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.

The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.

A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.

When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.

The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.

Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

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 course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].