Practice Management

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.

THE FUNDAMENTALS

As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

• Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
• Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
• Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
• Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
• Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
• Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
• Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
• Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
• Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

I work with a number of health systems on determining full-market-value (FMV) compensation related to stipends paid to hospital-based specialists. What is your opinion on how compensation should be determined for the physicians to staff hospitals? Would you say that the busier the location, the higher the compensation? Would you say that the more hours the physician works (regardless of productivity), the more pay they receive? Would you say that the more years of experience that a physician has should result in higher compensation?

Curtis H. Bernstein, CPA/ABV, ASA, CVA, MBA,

director, valuation services,

Sinaiko Healthcare Consulting Inc.,

Los Angeles

Dr. Hospitalist responds:

The topic of physician compensation and workload comes up frequently, but this question frames it a bit differently. Namely, what are the external and internal factors at work in determining compensation? Let’s tackle the response in two parts: 1) How do you account for the variability across sites? and 2) How does physician pay vary within a single site? The crux of the first question comes down to trying to interpret physician workload across disparate locations. It’s not laden with quite the same complexity as Gordian’s knot, but it’s close. One could easily answer this question with a lot of “Yes, but ... ” in reference to the all the factors that go into determining compensation. Yes, a busier site would generate more encounters, thus more revenue, and thus more pay. However, that same site might also be so busy as to require more than one physician on at night. A higher-paid, but lower-volume, nocturnist would then skew the workload/pay scale. Same thing with the ICU; if it is fully staffed with intensivists (more likely in a higher-volume setting), then that would remove the single highest paying code for a hospitalist (the 99291: critical care time 35-74 minutes, 4.50 wRVU), and that has the potential to drop reimbursement. Practice management columnist John Nelson, MD, MHM, has written more than a few fantastic columns addressing just these sorts of issues, but let’s concentrate on just the key factors:

• Volume;
• Payor mix/collections;
• Ratio of day shifts to night shifts (optimal is 4:1), assuming that there are dedicated night shifts; and
• Value-added services.

Volume is fairly straightforward, with most hospitalists seeing around 15 patients per day. Now, an average is just that, and practices exist where the daily number is 10 and where the census is 25. Still, it’s an easy number to understand.

Payor mix is a little more complex but should not vary substantially quarter by quarter, though it could vary greatly year to year. (Note: This is independent of collection rate percentage, which is a completely artificial variable.) If Medicare pays $1 for a certain code and the charges are set at $1, then the collection rate is 100%. If the charges are set at $2, then the collection rate will be 50% but bring in the same amount of money. Arcane billing convention aside, from hospital to hospital and region to region, the payor mix and attendant collections will vary. Ratio of day shifts to night shifts posits that there is an optimal ratio of roughly four day shifts for every one night shift. Night shifts are more expensive, in general, so the more day shifts you have to cover your fixed cost of covering the nights, the better. The reason the ratio can’t be 10:1 is that 10 day-rounding hospitalists would generate a daily service of 150+ patients, and there is no way for one nocturnist to safely cross-cover all those folks, much less see new admissions.

Lastly, there are the value-added services that provide the raison d’être for hospitalists. We are fundamentally different from the procedure-based specialties in that our value comes not from increasing revenue (more procedures) but from decreasing costs. Initially, a lot of this focused on length of stay, and now it’s shifting to discussions of core measures, readmission rates, and other quality metrics. What a hospital is willing to pay for this service, which goes above and beyond taking call for unassigned patients, will go a long way toward determining the overall stipend and resultant physician compensation. (For more information on hospitalist compensation and productivity, check out the 2011 State of Hospital Medicine report, www.hospitalmedicine.org/survey)

Those are the basic underpinnings that will determine most of the variable compensation across disparate sites. Still, there can be other local factors (ancillary services, specialty support, EMRs, etc.) that come into play. Any practicing hospitalist can quickly discourse on what makes their job unique. And they are probably right—healthcare, like politics, is local.

I’ve run out of room to answer the second part of the question, which addresses the variable pay for physicians at the same site. Check back for that response next month.

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

One of the questions I am often asked is “What is the typical distribution of CPT codes for hospitalists?” Prior to publication of the 2011 State of Hospital Medicine report, no one could answer that question with any authority. The Centers for Medicare & Medicaid Services (CMS) publishes some Healthcare Procedure Code (HCPC) distribution information by specialty, but because CMS does not recognize HM as a specialty, the closest proxies are the reported distributions for internal medicine (or pediatrics). And hospitalists argue that because their patient population and the work they do are different, typical distributions for those specialties might not be applicable to hospitalists.

“Coding for hospitalists has to be different from other internists,” says SHM Practice Analysis Committee (PAC) member Rachel Lovins, MD, SFHM. “Because we take responsibility for unfamiliar patients that we hand back to other providers, our level of admission and discharge documentation in particular needs to be higher, in order to ensure excellent communication between hospitalists and PCPs.”

We finally have information about hospitalist coding practices, because both the academic and non-academic Hospital Medicine Supplements captured information about the distribution of inpatient admissions (CPT codes 99221, 99222, and 99223), subsequent visits (99231, 99232, and 99233), and discharges (99238 and 99239). Figure 1 shows the average CPT code distribution for non-academic HM groups serving adults only.

click for large version

The 2011 State of Hospital Medicine report also shows how CPT distribution varied based on some key practice characteristics. For example, HM practices that are not owned by hospitals/integrated delivery systems tend to code more of their services at higher service levels than do hospital-owned practices. And practices in the Western section of the country tend to code more services at higher levels than other parts of the country.

Other factors are certainly at play as well. “Whether a physician receives training in documentation and coding can have a tremendous impact on CPT distributions,” PAC member Beth Papetti says. “Historically, there has been a tendency for hospitalists to under-code, but through education and enhancements like electronic charge capture, hospitalists can more accurately substantiate the services they provided to the patient.”

Other committee members have speculated that a hospitalist’s compensation model might influence coding patterns, with those who receive less of their total compensation in the form of base salary (and more in the form of productivity and/or performance-based pay) tending to code more of their services at higher levels. But, in fact, the survey data don’t reveal any clear relationship between compensation structure and the average number of work RVUs (relative value units) per encounter.

Interestingly, coding patterns of academic HM practices were similar to those of non-academic practices for admissions and subsequent visits, but academic hospitalists tend to code a higher proportion of discharges at the <30-minute level (99238). PAC members speculate that residents and hospital support staff might perform a larger portion of the discharge coordination and paperwork in academic centers, and attendings can only bill based on their personal time, not time spent by others.

To contribute to a robust CPT distribution database, be sure to participate in the next State of Hospital Medicine survey, scheduled to launch in January 2012.

Leslie Flores, SHM senior advisor, practice management

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

I think 70% to 80% of U.S. hospitals now have a hospitalist practice. (Some have more than one hospitalist group operating within their walls.) I arrived at this estimate by relying on both my anecdotal experience and on the annual American Hospital Association survey, which in 2009 showed 58% of hospitals have hospitalists, with an ongoing rapid rate of adoption.

No regular reader of The Hospitalist should be surprised that most U.S. hospitals now have hospitalists, but some might be surprised that 20% to 30% don’t. There are about 5,800 hospitals in the U.S. (a ballpark figure), so that means about 1,100 to 1,800 don’t have hospitalists. What is unique about them?

For some hospitals, the answer is easy. For example, the U.S. has something like 450 psychiatric hospitals. They vary a lot, but many simply don’t accept patients with active medical problems, so these facilities would have little need for medical hospitalists.

Variations in how the term “hospitalist” is used probably account for some facilities reporting no hospitalists. For example, long-term acute-care hospitals (LTACs) might have dedicated inpatient providers but simply don’t call them hospitalists.

Even accounting for these things, there are still a lot of “med-surg” hospitals that say they don’t have hospitalists.

The Holdouts

My experience suggests the two most important reasons some hospitals have not yet developed a hospitalist practice are an oversupply of primary-care physicians (PCPs) and an attractive payor mix in the unassigned patient population. In fact, it is hard for me to imagine a hospital that enjoys both of these attributes ever being able to support hospitalists.

Although it isn’t a common problem, an excess of PCPs (or dearth of patients) removes the most universal and powerful stimulus to develop a hospitalist practice: the desire of PCPs to be relieved of hospital work. And in most cases, those PCPs can offset the loss of hospital work and its associated revenue, with more work in the office. This can mean a better lifestyle (e.g. no trips to the hospital on nights and weekends) and the same or higher income. But if there are too many PCPs in the community, they may be unwilling to give up the hospital work, as there might be no way to replace it in the office. End result: no hospitalists.

For the rare hospital that has an attractive ED-unassigned payor mix, PCPs are more likely to want to continue taking ED call and not support a proposal to develop a hospitalist practice. And access to the ED call roster can be important to new PCPs building a community practice. I have seen situations in which a hospital has addressed the poor reimbursement of unattached ED admissions by paying PCPs to provide that care. Even though that same hospital might want a hospitalist practice, the ED call payment it is providing to PCPs may create a barrier that can’t be overcome. Such a hospital will face the very difficult decision of terminating the payments for ED call and redirecting that money to a hospitalist practice—something that is likely to lead to a lot of frustration on the part of PCPs who depend on the pay-for-call arrangement. A common outcome: no hospitalists.

An occasional reason hospitals are late to the hospitalist party is one or two (rarely more than that) of its private PCPs have simply chosen to work heroic amounts, and in addition to office and hospital care of their private patients, they accept referrals from other PCPs. I have met a number of doctors like this. Some are terrific doctors who actively participate in hospital initiatives; many appear chronically tired and harried, and hospital staff express frustration that they do things like make rounds at 3 a.m., take hours to respond to urgent calls, refuse to use protocols, etc. But because they’ve responded to the PCPs’ desire to be relieved of hospital work, other doctors may rally to their support and prevent the hospital from moving forward with a hospitalist program.

Will Every Hospital Have Hospitalists Eventually?

It is really interesting to think about whether every hospital, outside narrow specialty hospitals, will have hospitalists in the future. I wonder what informed people in the 1970s and early 1980s were predicting for emergency medicine’s future. At that point it probably wasn’t clear that, in the future, dedicated ED doctors essentially would staff every ED in the country, but I think that is exactly what has happened. (I once worked with an approximately 100-bed rural hospital that didn’t have ED physicians until 1999. I wonder if they were the last adopter.)

I think hospitalists are critically important for nearly all med-surg hospitals; however, maybe there will always be a small number that either have PCPs continue to practice in the traditional model, working both outpatient and inpatient, or some other effective configuration that makes hospitalists less necessary. We’ll have to wait and see. But I’m pretty confident

that almost no institutions that have hospitalists will ever return to the pre-hospitalist model of care. It seems there is no going back.

For those hospitals without hospitalists currently who will at some future time have hospitalists, the right time for this to happen is dependent on a combination of local factors. It could be something like the departure (i.e. relocation or retirement) of some of the current doctors, or simply the arrival of someone who has a vision and energy to successfully navigate the obstacles to build one. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.</p>

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Gregory Misky, MD, describes it as a “deer in the headlights” moment. About four years ago, Dr. Misky, assistant professor of medicine at the University of Colorado Denver, and Mark Reid, MD, assistant professor at Denver Health Medical Center, were trying to figure out what being an academic hospitalist was all about. What were the expectations of them, and how could they combine their clinical duties with scholarly work, especially given the significant lack of mentorship?

The duo wondered if other young hospitalists were feeling the same uncertainty about their chosen career, and whether there were any variables that might help predict success or burnout among their fellow doctors.

They haven’t been alone. Regardless of the practice model and location, physicians within the fastest-spreading medical specialty in the U.S. have noted both the promise and unsettled nature of HM. “We are still a relatively young profession, and I think over the past five to 10 years, we’ve been seeing the growing pains of the profession,” says Tosha Wetterneck, MD, MS, FACP, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison.

In response to mounting concerns over multiple career-satisfaction-related issues, SHM assembled a Career Satisfaction Task Force that produced a detailed white paper at the end of 2006 (available from the “White Papers” tab under the “Publications” heading at www.hospitalmedicine.org).

One tangible outcome of the paper was the establishment of “Four Pillars of Career Satisfaction” for hospitalists:

• Reward and recognition;
• Workload and schedule;
• Autonomy and control; and
• Community and environment.

The paper included definitions for each pillar, and assembled scorecards, action steps, tools, and recommendations for both HM leaders and individual hospitalists to help shore up perceived weak spots.

So how strong are those pillars in practice? If hospitalists are the future of healthcare, as SHM and other medical groups assert, what do current studies suggest about the prospects of HM solidifying into a satisfying and sustainable career choice?

The Evidence

One outgrowth of Dr. Misky and Dr. Reid’s frustration was a study in which they and their collaborators emailed a 61-question survey to hospitalists at 20 academic medical centers. Among the results, the researchers found that 75% of respondents reported either “high” or “somewhat high” satisfaction with their current job. At the same time, though, 67% felt “high” or “somewhat high” stress levels at work, and nearly 1 in 4 (24%) reported some degree of burnout, based on their own definition of the word.¹

As one of the first hospitalists in his group, Dr. Misky recalls the stress he felt over whether the hospital, division, and department would all buy into the idea of an academic hospitalist, and what his role would be. “I think we spent a lot of our early years trying to carve out our niche and proving ourselves and trying to balance the clinical needs that people had for us with other expectations of being an academic,” he says. Dr. Misky likens the experience to the adrenaline rush of mountain-biking straight down a hill. The feeling that too many things are going on at once, though, might also partially explain the apparent dichotomy of high overall satisfaction but a worrisome degree of burnout.

The profession hasn’t been around long enough for good longitudinal studies, and surveys have worded questions on satisfaction and burnout in different ways, complicating attempts at direct comparisons over time. A 2001 study, for example, reported that 12.9% of community and academic hospitalists were burned out, with another 25% at risk, but the survey was limited to dues-paying members of the National Association of Inpatient Physicians, the precursor to SHM.²

Nor has it been easy to compare hospitalist satisfaction and burnout levels to those of other specialists. “We haven’t really defined what a sustained, long-term career in hospital medicine is going to be,” Dr. Wetterneck says. “And in that way, it’s hard to say, ‘Compared to other professions, are we happier or not?’”

Listen to Greg Misky, MD

One of her recent studies, however, generally agrees with the handful of surveys addressing satisfaction and burnout among hospitalists. Overall, 63% of respondents reported high satisfaction with their job, while 69% were highly satisfied with their specialty. Roughly 30%, however, also reported feeling symptom of job burnout.³

Kelki Hinami, MD, MS, assistant of professor of medicine at Northwestern University Feinberg School of Medicine in Chicago and a coauthor of the study, says one take-home message is that hospitalists do fairly well in finding jobs that match their individual needs. “To further illustrate this, we found that hospitalists working in various practice models have different ideas about what is most important to their job,” he says.

Autonomy, for example, is considered most important by more local group hospitalists than by those of any other model, while recognition by leaders and having a variety of tasks at work are particularly important to academic hospitalists. Unlike other hospitalists, however, fewer academics consider pay to be the most important job characteristic.

A third study, led by John Yoon, MD, assistant professor in the section of hospital medicine at the University of Chicago, has examined career satisfaction, burnout, and morale among primary-care physicians (PCPs) and hospitalists. So far, the results he reported at HM11 largely agree with the other recent surveys: Combined, 85% of hospitalists report being either somewhat or very satisfied with their overall career. Conversely, 24% of hospitalists regretted choosing medicine as a career and 38% say they would have chosen a different medical specialty if they had to do it over again.⁴

Dr. Yoon says his data, compiled from two survey samples of about 1,000 generalists each, have revealed few differences between hospitalists and PCPs. “I thought hospitalists would be more satisfied than primary-care physicians, given the declining satisfaction rates of PCPs that we know about, and that students and trainees are less likely to go into primary care,” he says. Even burnout rates are similar, however; Dr. Yoon says he’s noticed a trend toward hospitalists reporting less burnout than PCPs, but the difference is not yet statistically significant.

Choice of a New Generation?

HM’s attractiveness to medical residents offers other clues about its ability to provide a sustainable and satisfying career choice. Salary, part of the “reward and recognition” pillar, has long been one perceived weakness. Anecdotally, however, Dr. Yoon says many general medicine residents see HM as a better financial option than primary care. “Some of the residents I work with, when I asked them, ‘Will you be a primary-care physician or a hospitalist?’ a lot of them say, ‘Probably hospitalist,’” he says. “And generally the reason is because they have to pay off their debt.”

It’s true that hospitalists’ salaries lag behind that of most of other specialists. Nevertheless, researchers like Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., say many medical residents are prioritizing financial considerations as relatively low on the scale of general preferences.

One loss I’m starting to feel keenly as an academic hospitalist … really is the loss of having long-term relationships with patients. My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.

—John Yoon, MD, assistant professor, section of hospital medicine, University of Chicago

Dr. West, an associate program director for the internal-medicine residency program at Mayo, sees a generational sea change in the career considerations deemed most important. Based on a career decision survey filled out by nearly 15,000 internal-medical residents, he found that roughly 70% of respondents said time with family was of “high” or “very high” importance to their career decisions.⁵ The category, which relates to SHM’s “workload and schedule” pillar, beat out eight others as the most important factor overall, while global financial considerations scored relatively low.

Residents who placed high value on time with family were more likely to choose careers in more predictable, outpatient-based specialties, such as endocrinology or rheumatology. HM also fared well in this category. Dr. West says the results suggest that residents considering a hospitalist career are attracted to the specialty’s flexibility and predictability of the largely shift-based scheduling.

William Cors, MD, chief medical quality officer at Pocono Health System in East Stroudsburg, Pa., says more physicians are looking for job security, predictable shifts, and a better work-life balance. As HM matures and demonstrates that it can address those needs, Dr. Cors sees it becoming more attractive for medical students and residents.

In practice, though, other research suggests a career in HM doesn’t always meet expectations. Dr. Wetterneck and Dr. Hinami, for example, highlighted both compensation and work-life balance as points of concern in their study: For both factors, only about 30% of hospitalists were optimally satisfied.

Separately, Dr. Misky and his colleagues reported that roughly half of academic hospitalists were satisfied with the ability to control their schedule, and with their amount of personal and family time. Those who were unsatisfied with either of these categories, the survey found, were at higher risk for burnout. Similarly, Dr. Yoon found that physicians who reported having no control over their work hours or their call schedule, part of SHM’s “autonomy and control” pillar, were more likely to report burnout.

So why is HM stumbling on perceived selling points like family friendliness and autonomy? Dr. Wetterneck believes too many unfilled jobs and rapid turnover could be putting more pressure on existing hospitalists and interfering with their ability to balance home and work life. “There’s a huge need for hospitalists everywhere,” she says, and reliance on them has been especially acute at academic centers and large community hospitals contending with the recently imposed limits on residents’ work hours.

Listen to Greg Misky, MD

The Hospitalist: A People Person

Another shift may be occurring in the types of relationships necessary for a satisfying work environment, a big part of the “community and environment” pillar. Although Dr. Yoon says long-term connections with students and trainees have added meaning to his job, he is mourning the absence of other bonds. “One loss I’m starting to feel keenly as an academic hospitalist, having spent my early training years as a primary-care doc, really is the loss of having long-term relationships with patients,” he says. “My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.”

Dr. Yoon has pondered whether the HM field can rearrange practice settings to promote more satisfying relationships. Such a change, he says, might occur through innovative models that aid coordination with medical homes, or provide more chronic care for high-risk patients. “In my view, the trajectory of hospital medicine is pretty wide open for creativity and new models of care,” he says. “I think it will be partly driven by the need to want to have more meaningful interactions with patients.”

Those relationships need not be long-term, however. One recent study found high satisfaction among hospitalists and laborists working within the fast-growing OBGYN hospitalist field.⁶

Dr. Hinami says collaborative care that involves close working relationships with specialists and other care providers might help propel the hospitalist movement forward. In his survey with Dr. Wetterneck, hospitalists ranked relationships with staff and colleagues among the most satisfying of any of the domains; hospitalists also indicated high levels of satisfaction with their patient relationships. “Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships,” Dr. Hinami says.

Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships.

—Keiki Hinami, MD, assistant professor of medicine, Northwestern University Feinberg School of Medicine, Chicago

A 2002 survey-based study reinforces the importance of such bonds. Job burnout and intent to remain in the hospitalist career, its authors concluded, were more highly influenced by “favorable social relations” involving colleagues, coworkers, and patients than by such factors as reduced autonomy and the use of financial incentives.⁷

The focus on maintaining multiple relationships fits well with the collaborative approach to care that many hospitalists say they value highly. One big satisfier for hospitalists, Dr. Cors says, will be “a sense that they’re really part of a healthcare team and not just punching the clock and doing their shifts.”

The Verdict

Despite the difficulty in discerning long-term trends, studies suggest that overall satisfaction with the specialty of hospital medicine remains high, a promising sign for the maturing field. Career hospitalists also seem adept at relationships with peers and other providers, a skill that will serve them well as collaborative-care models gain steam.

Nonetheless, surveys also suggest a worrisome rate of burnout and less-than-optimal satisfaction with elements that should be the strong suits of HM, such as work-life balance and autonomy. Academics are searching for their own clinical-research balance. And Dr. West says the jury’s still out on the future pitfalls that might get in the way of a sustainable career path for older practitioners, such as overnight shifts.

Hospitalist-led efforts, however, may be starting to pay dividends. At the University of California at San Francisco, a faculty development program for first-year hospitalists has included a coaching relationship with a senior faculty member, a teaching course, newly established divisional grand rounds, and a framework for meeting scholarly expectations. Upon its implementation, the program has led to higher job satisfaction, skill-set comfort, and academic production among participants.⁸

Given the expanding range of HM duties and practice models, hospitals, division chiefs, and team leaders cannot rely on a single recipe for happy and productive hospitalists. “I don’t know if there is a cookbook; I think it’s highly variable depending on your institution and the needs of the academic facility where you are,” Dr. Misky says.

SHM’s 2006 white paper stated that the best career satisfaction strategy is to find a job that fits an individual’s preferences and attitudes. “People who are unhappy with their job don’t tend to stay in it, and from what we know about hospital medicine right now, you can find pretty much any type of job anywhere you want, so the job market is very open,” Dr. Wetterneck says.

Ensuring the right fit for doctors within HM, though, will require institutional support. “It’s going to be up to hospitals and hospitalist programs to create jobs that are sustainable that people like,” she says, “so that hospitalists will stay long in their job and in the profession.”

Bryn Nelson is a freelance medical writer based in Seattle.

More Mentorship in Hospital Medicine? It’s Academic

Within the 2011 State of Hospital Medicine report, one statistic in particular points to the youth of the medical specialty: Just over 10% of surveyed hospitalists had reached the rank of associate professor or higher.

How might the potential lack of mentorship within this immature field affect the ability of hospitalists to successfully navigate academia? So asked Gregory Misky, MD, assistant professor of medicine at the University of Colorado Denver, and his colleagues in a survey-based study. The results agree with other recent assessments that mentors are in short supply. “Academic hospital medicine groups have an acute need for mentoring and career development programs,” one study concludes.

The research of Dr. Misky and his collaborators found that only 42% of academic hospitalists could identify a mentor, while only 31% reported that they were mentoring another academic hospitalist.1 Based on sheer numbers and experience, the pool of mentors may significantly expand as the field matures. But Dr. Misky also urges some flexibility, noting that his own mentor is a non-hospitalist.

In his own research, Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., found that residents considering a career in HM placed less emphasis on the specialty or subspecialty of their mentor.5 Why? Very likely, he says, there just weren’t enough hospitalist mentors around to get a sense of what the career was all about.

Dr. West hopes the numbers suggest otherwise in the near future. “You want to recruit bright people into your specialty, but at the same time, you also want to recruit the right people,” he says. “And that means that you need to be able to expose people to a full breadth of what a decision to pursue a certain specialty really means.”

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8) 782-785.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers [published online ahead of print July 20, 2011]. J Gen Intern Med. doi:10.1007/s116060-011-1780-z.
4. Yoon J, Miller A, Rasinski K, Curlin F. Burnout, sense of calling, and career resilience among hospitalists and primary care physicians: a national survey. J Hosp Med. 2011;6(4):S90-S91.
5. West CP, Drefahl MM, Popkave C, Kolars JC. Internal medicine resident self-report of factors associated with career decisions. J Gen Intern Med. 2009;24(8):946-949.
6. Funk C, Anderson BL, Schulkin J, Weinstein L. Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e1-177.e4.
7. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91.
8. Sehgal NL, Sharpe BA, Auerbach AA, Wachter RM. Investing in the future: Building an academic hospitalist faculty development program. J Hosp Med. 2011;6(3):161-166.

Gregory Misky, MD, describes it as a “deer in the headlights” moment. About four years ago, Dr. Misky, assistant professor of medicine at the University of Colorado Denver, and Mark Reid, MD, assistant professor at Denver Health Medical Center, were trying to figure out what being an academic hospitalist was all about. What were the expectations of them, and how could they combine their clinical duties with scholarly work, especially given the significant lack of mentorship?

The duo wondered if other young hospitalists were feeling the same uncertainty about their chosen career, and whether there were any variables that might help predict success or burnout among their fellow doctors.

They haven’t been alone. Regardless of the practice model and location, physicians within the fastest-spreading medical specialty in the U.S. have noted both the promise and unsettled nature of HM. “We are still a relatively young profession, and I think over the past five to 10 years, we’ve been seeing the growing pains of the profession,” says Tosha Wetterneck, MD, MS, FACP, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison.

In response to mounting concerns over multiple career-satisfaction-related issues, SHM assembled a Career Satisfaction Task Force that produced a detailed white paper at the end of 2006 (available from the “White Papers” tab under the “Publications” heading at www.hospitalmedicine.org).

One tangible outcome of the paper was the establishment of “Four Pillars of Career Satisfaction” for hospitalists:

• Reward and recognition;
• Workload and schedule;
• Autonomy and control; and
• Community and environment.

The paper included definitions for each pillar, and assembled scorecards, action steps, tools, and recommendations for both HM leaders and individual hospitalists to help shore up perceived weak spots.

So how strong are those pillars in practice? If hospitalists are the future of healthcare, as SHM and other medical groups assert, what do current studies suggest about the prospects of HM solidifying into a satisfying and sustainable career choice?

The Evidence

One outgrowth of Dr. Misky and Dr. Reid’s frustration was a study in which they and their collaborators emailed a 61-question survey to hospitalists at 20 academic medical centers. Among the results, the researchers found that 75% of respondents reported either “high” or “somewhat high” satisfaction with their current job. At the same time, though, 67% felt “high” or “somewhat high” stress levels at work, and nearly 1 in 4 (24%) reported some degree of burnout, based on their own definition of the word.¹

As one of the first hospitalists in his group, Dr. Misky recalls the stress he felt over whether the hospital, division, and department would all buy into the idea of an academic hospitalist, and what his role would be. “I think we spent a lot of our early years trying to carve out our niche and proving ourselves and trying to balance the clinical needs that people had for us with other expectations of being an academic,” he says. Dr. Misky likens the experience to the adrenaline rush of mountain-biking straight down a hill. The feeling that too many things are going on at once, though, might also partially explain the apparent dichotomy of high overall satisfaction but a worrisome degree of burnout.

The profession hasn’t been around long enough for good longitudinal studies, and surveys have worded questions on satisfaction and burnout in different ways, complicating attempts at direct comparisons over time. A 2001 study, for example, reported that 12.9% of community and academic hospitalists were burned out, with another 25% at risk, but the survey was limited to dues-paying members of the National Association of Inpatient Physicians, the precursor to SHM.²

Nor has it been easy to compare hospitalist satisfaction and burnout levels to those of other specialists. “We haven’t really defined what a sustained, long-term career in hospital medicine is going to be,” Dr. Wetterneck says. “And in that way, it’s hard to say, ‘Compared to other professions, are we happier or not?’”

Listen to Greg Misky, MD

One of her recent studies, however, generally agrees with the handful of surveys addressing satisfaction and burnout among hospitalists. Overall, 63% of respondents reported high satisfaction with their job, while 69% were highly satisfied with their specialty. Roughly 30%, however, also reported feeling symptom of job burnout.³

Kelki Hinami, MD, MS, assistant of professor of medicine at Northwestern University Feinberg School of Medicine in Chicago and a coauthor of the study, says one take-home message is that hospitalists do fairly well in finding jobs that match their individual needs. “To further illustrate this, we found that hospitalists working in various practice models have different ideas about what is most important to their job,” he says.

Autonomy, for example, is considered most important by more local group hospitalists than by those of any other model, while recognition by leaders and having a variety of tasks at work are particularly important to academic hospitalists. Unlike other hospitalists, however, fewer academics consider pay to be the most important job characteristic.

A third study, led by John Yoon, MD, assistant professor in the section of hospital medicine at the University of Chicago, has examined career satisfaction, burnout, and morale among primary-care physicians (PCPs) and hospitalists. So far, the results he reported at HM11 largely agree with the other recent surveys: Combined, 85% of hospitalists report being either somewhat or very satisfied with their overall career. Conversely, 24% of hospitalists regretted choosing medicine as a career and 38% say they would have chosen a different medical specialty if they had to do it over again.⁴

Dr. Yoon says his data, compiled from two survey samples of about 1,000 generalists each, have revealed few differences between hospitalists and PCPs. “I thought hospitalists would be more satisfied than primary-care physicians, given the declining satisfaction rates of PCPs that we know about, and that students and trainees are less likely to go into primary care,” he says. Even burnout rates are similar, however; Dr. Yoon says he’s noticed a trend toward hospitalists reporting less burnout than PCPs, but the difference is not yet statistically significant.

Choice of a New Generation?

HM’s attractiveness to medical residents offers other clues about its ability to provide a sustainable and satisfying career choice. Salary, part of the “reward and recognition” pillar, has long been one perceived weakness. Anecdotally, however, Dr. Yoon says many general medicine residents see HM as a better financial option than primary care. “Some of the residents I work with, when I asked them, ‘Will you be a primary-care physician or a hospitalist?’ a lot of them say, ‘Probably hospitalist,’” he says. “And generally the reason is because they have to pay off their debt.”

It’s true that hospitalists’ salaries lag behind that of most of other specialists. Nevertheless, researchers like Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., say many medical residents are prioritizing financial considerations as relatively low on the scale of general preferences.

One loss I’m starting to feel keenly as an academic hospitalist … really is the loss of having long-term relationships with patients. My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.

—John Yoon, MD, assistant professor, section of hospital medicine, University of Chicago

Dr. West, an associate program director for the internal-medicine residency program at Mayo, sees a generational sea change in the career considerations deemed most important. Based on a career decision survey filled out by nearly 15,000 internal-medical residents, he found that roughly 70% of respondents said time with family was of “high” or “very high” importance to their career decisions.⁵ The category, which relates to SHM’s “workload and schedule” pillar, beat out eight others as the most important factor overall, while global financial considerations scored relatively low.

Residents who placed high value on time with family were more likely to choose careers in more predictable, outpatient-based specialties, such as endocrinology or rheumatology. HM also fared well in this category. Dr. West says the results suggest that residents considering a hospitalist career are attracted to the specialty’s flexibility and predictability of the largely shift-based scheduling.

William Cors, MD, chief medical quality officer at Pocono Health System in East Stroudsburg, Pa., says more physicians are looking for job security, predictable shifts, and a better work-life balance. As HM matures and demonstrates that it can address those needs, Dr. Cors sees it becoming more attractive for medical students and residents.

In practice, though, other research suggests a career in HM doesn’t always meet expectations. Dr. Wetterneck and Dr. Hinami, for example, highlighted both compensation and work-life balance as points of concern in their study: For both factors, only about 30% of hospitalists were optimally satisfied.

Separately, Dr. Misky and his colleagues reported that roughly half of academic hospitalists were satisfied with the ability to control their schedule, and with their amount of personal and family time. Those who were unsatisfied with either of these categories, the survey found, were at higher risk for burnout. Similarly, Dr. Yoon found that physicians who reported having no control over their work hours or their call schedule, part of SHM’s “autonomy and control” pillar, were more likely to report burnout.

So why is HM stumbling on perceived selling points like family friendliness and autonomy? Dr. Wetterneck believes too many unfilled jobs and rapid turnover could be putting more pressure on existing hospitalists and interfering with their ability to balance home and work life. “There’s a huge need for hospitalists everywhere,” she says, and reliance on them has been especially acute at academic centers and large community hospitals contending with the recently imposed limits on residents’ work hours.

Listen to Greg Misky, MD

The Hospitalist: A People Person

Another shift may be occurring in the types of relationships necessary for a satisfying work environment, a big part of the “community and environment” pillar. Although Dr. Yoon says long-term connections with students and trainees have added meaning to his job, he is mourning the absence of other bonds. “One loss I’m starting to feel keenly as an academic hospitalist, having spent my early training years as a primary-care doc, really is the loss of having long-term relationships with patients,” he says. “My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.”

Dr. Yoon has pondered whether the HM field can rearrange practice settings to promote more satisfying relationships. Such a change, he says, might occur through innovative models that aid coordination with medical homes, or provide more chronic care for high-risk patients. “In my view, the trajectory of hospital medicine is pretty wide open for creativity and new models of care,” he says. “I think it will be partly driven by the need to want to have more meaningful interactions with patients.”

Those relationships need not be long-term, however. One recent study found high satisfaction among hospitalists and laborists working within the fast-growing OBGYN hospitalist field.⁶

Dr. Hinami says collaborative care that involves close working relationships with specialists and other care providers might help propel the hospitalist movement forward. In his survey with Dr. Wetterneck, hospitalists ranked relationships with staff and colleagues among the most satisfying of any of the domains; hospitalists also indicated high levels of satisfaction with their patient relationships. “Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships,” Dr. Hinami says.

Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships.

—Keiki Hinami, MD, assistant professor of medicine, Northwestern University Feinberg School of Medicine, Chicago

A 2002 survey-based study reinforces the importance of such bonds. Job burnout and intent to remain in the hospitalist career, its authors concluded, were more highly influenced by “favorable social relations” involving colleagues, coworkers, and patients than by such factors as reduced autonomy and the use of financial incentives.⁷

The focus on maintaining multiple relationships fits well with the collaborative approach to care that many hospitalists say they value highly. One big satisfier for hospitalists, Dr. Cors says, will be “a sense that they’re really part of a healthcare team and not just punching the clock and doing their shifts.”

The Verdict

Despite the difficulty in discerning long-term trends, studies suggest that overall satisfaction with the specialty of hospital medicine remains high, a promising sign for the maturing field. Career hospitalists also seem adept at relationships with peers and other providers, a skill that will serve them well as collaborative-care models gain steam.

Nonetheless, surveys also suggest a worrisome rate of burnout and less-than-optimal satisfaction with elements that should be the strong suits of HM, such as work-life balance and autonomy. Academics are searching for their own clinical-research balance. And Dr. West says the jury’s still out on the future pitfalls that might get in the way of a sustainable career path for older practitioners, such as overnight shifts.

Hospitalist-led efforts, however, may be starting to pay dividends. At the University of California at San Francisco, a faculty development program for first-year hospitalists has included a coaching relationship with a senior faculty member, a teaching course, newly established divisional grand rounds, and a framework for meeting scholarly expectations. Upon its implementation, the program has led to higher job satisfaction, skill-set comfort, and academic production among participants.⁸

Given the expanding range of HM duties and practice models, hospitals, division chiefs, and team leaders cannot rely on a single recipe for happy and productive hospitalists. “I don’t know if there is a cookbook; I think it’s highly variable depending on your institution and the needs of the academic facility where you are,” Dr. Misky says.

SHM’s 2006 white paper stated that the best career satisfaction strategy is to find a job that fits an individual’s preferences and attitudes. “People who are unhappy with their job don’t tend to stay in it, and from what we know about hospital medicine right now, you can find pretty much any type of job anywhere you want, so the job market is very open,” Dr. Wetterneck says.

Ensuring the right fit for doctors within HM, though, will require institutional support. “It’s going to be up to hospitals and hospitalist programs to create jobs that are sustainable that people like,” she says, “so that hospitalists will stay long in their job and in the profession.”

Bryn Nelson is a freelance medical writer based in Seattle.

More Mentorship in Hospital Medicine? It’s Academic

Within the 2011 State of Hospital Medicine report, one statistic in particular points to the youth of the medical specialty: Just over 10% of surveyed hospitalists had reached the rank of associate professor or higher.

How might the potential lack of mentorship within this immature field affect the ability of hospitalists to successfully navigate academia? So asked Gregory Misky, MD, assistant professor of medicine at the University of Colorado Denver, and his colleagues in a survey-based study. The results agree with other recent assessments that mentors are in short supply. “Academic hospital medicine groups have an acute need for mentoring and career development programs,” one study concludes.

The research of Dr. Misky and his collaborators found that only 42% of academic hospitalists could identify a mentor, while only 31% reported that they were mentoring another academic hospitalist.1 Based on sheer numbers and experience, the pool of mentors may significantly expand as the field matures. But Dr. Misky also urges some flexibility, noting that his own mentor is a non-hospitalist.

In his own research, Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., found that residents considering a career in HM placed less emphasis on the specialty or subspecialty of their mentor.5 Why? Very likely, he says, there just weren’t enough hospitalist mentors around to get a sense of what the career was all about.

Dr. West hopes the numbers suggest otherwise in the near future. “You want to recruit bright people into your specialty, but at the same time, you also want to recruit the right people,” he says. “And that means that you need to be able to expose people to a full breadth of what a decision to pursue a certain specialty really means.”

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8) 782-785.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers [published online ahead of print July 20, 2011]. J Gen Intern Med. doi:10.1007/s116060-011-1780-z.
4. Yoon J, Miller A, Rasinski K, Curlin F. Burnout, sense of calling, and career resilience among hospitalists and primary care physicians: a national survey. J Hosp Med. 2011;6(4):S90-S91.
5. West CP, Drefahl MM, Popkave C, Kolars JC. Internal medicine resident self-report of factors associated with career decisions. J Gen Intern Med. 2009;24(8):946-949.
6. Funk C, Anderson BL, Schulkin J, Weinstein L. Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e1-177.e4.
7. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91.
8. Sehgal NL, Sharpe BA, Auerbach AA, Wachter RM. Investing in the future: Building an academic hospitalist faculty development program. J Hosp Med. 2011;6(3):161-166.

Gregory Misky, MD, describes it as a “deer in the headlights” moment. About four years ago, Dr. Misky, assistant professor of medicine at the University of Colorado Denver, and Mark Reid, MD, assistant professor at Denver Health Medical Center, were trying to figure out what being an academic hospitalist was all about. What were the expectations of them, and how could they combine their clinical duties with scholarly work, especially given the significant lack of mentorship?

The duo wondered if other young hospitalists were feeling the same uncertainty about their chosen career, and whether there were any variables that might help predict success or burnout among their fellow doctors.

They haven’t been alone. Regardless of the practice model and location, physicians within the fastest-spreading medical specialty in the U.S. have noted both the promise and unsettled nature of HM. “We are still a relatively young profession, and I think over the past five to 10 years, we’ve been seeing the growing pains of the profession,” says Tosha Wetterneck, MD, MS, FACP, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison.

In response to mounting concerns over multiple career-satisfaction-related issues, SHM assembled a Career Satisfaction Task Force that produced a detailed white paper at the end of 2006 (available from the “White Papers” tab under the “Publications” heading at www.hospitalmedicine.org).

One tangible outcome of the paper was the establishment of “Four Pillars of Career Satisfaction” for hospitalists:

• Reward and recognition;
• Workload and schedule;
• Autonomy and control; and
• Community and environment.

The paper included definitions for each pillar, and assembled scorecards, action steps, tools, and recommendations for both HM leaders and individual hospitalists to help shore up perceived weak spots.

So how strong are those pillars in practice? If hospitalists are the future of healthcare, as SHM and other medical groups assert, what do current studies suggest about the prospects of HM solidifying into a satisfying and sustainable career choice?

The Evidence

One outgrowth of Dr. Misky and Dr. Reid’s frustration was a study in which they and their collaborators emailed a 61-question survey to hospitalists at 20 academic medical centers. Among the results, the researchers found that 75% of respondents reported either “high” or “somewhat high” satisfaction with their current job. At the same time, though, 67% felt “high” or “somewhat high” stress levels at work, and nearly 1 in 4 (24%) reported some degree of burnout, based on their own definition of the word.¹

As one of the first hospitalists in his group, Dr. Misky recalls the stress he felt over whether the hospital, division, and department would all buy into the idea of an academic hospitalist, and what his role would be. “I think we spent a lot of our early years trying to carve out our niche and proving ourselves and trying to balance the clinical needs that people had for us with other expectations of being an academic,” he says. Dr. Misky likens the experience to the adrenaline rush of mountain-biking straight down a hill. The feeling that too many things are going on at once, though, might also partially explain the apparent dichotomy of high overall satisfaction but a worrisome degree of burnout.

The profession hasn’t been around long enough for good longitudinal studies, and surveys have worded questions on satisfaction and burnout in different ways, complicating attempts at direct comparisons over time. A 2001 study, for example, reported that 12.9% of community and academic hospitalists were burned out, with another 25% at risk, but the survey was limited to dues-paying members of the National Association of Inpatient Physicians, the precursor to SHM.²

Nor has it been easy to compare hospitalist satisfaction and burnout levels to those of other specialists. “We haven’t really defined what a sustained, long-term career in hospital medicine is going to be,” Dr. Wetterneck says. “And in that way, it’s hard to say, ‘Compared to other professions, are we happier or not?’”

Listen to Greg Misky, MD

One of her recent studies, however, generally agrees with the handful of surveys addressing satisfaction and burnout among hospitalists. Overall, 63% of respondents reported high satisfaction with their job, while 69% were highly satisfied with their specialty. Roughly 30%, however, also reported feeling symptom of job burnout.³

Kelki Hinami, MD, MS, assistant of professor of medicine at Northwestern University Feinberg School of Medicine in Chicago and a coauthor of the study, says one take-home message is that hospitalists do fairly well in finding jobs that match their individual needs. “To further illustrate this, we found that hospitalists working in various practice models have different ideas about what is most important to their job,” he says.

Autonomy, for example, is considered most important by more local group hospitalists than by those of any other model, while recognition by leaders and having a variety of tasks at work are particularly important to academic hospitalists. Unlike other hospitalists, however, fewer academics consider pay to be the most important job characteristic.

A third study, led by John Yoon, MD, assistant professor in the section of hospital medicine at the University of Chicago, has examined career satisfaction, burnout, and morale among primary-care physicians (PCPs) and hospitalists. So far, the results he reported at HM11 largely agree with the other recent surveys: Combined, 85% of hospitalists report being either somewhat or very satisfied with their overall career. Conversely, 24% of hospitalists regretted choosing medicine as a career and 38% say they would have chosen a different medical specialty if they had to do it over again.⁴

Dr. Yoon says his data, compiled from two survey samples of about 1,000 generalists each, have revealed few differences between hospitalists and PCPs. “I thought hospitalists would be more satisfied than primary-care physicians, given the declining satisfaction rates of PCPs that we know about, and that students and trainees are less likely to go into primary care,” he says. Even burnout rates are similar, however; Dr. Yoon says he’s noticed a trend toward hospitalists reporting less burnout than PCPs, but the difference is not yet statistically significant.

Choice of a New Generation?

HM’s attractiveness to medical residents offers other clues about its ability to provide a sustainable and satisfying career choice. Salary, part of the “reward and recognition” pillar, has long been one perceived weakness. Anecdotally, however, Dr. Yoon says many general medicine residents see HM as a better financial option than primary care. “Some of the residents I work with, when I asked them, ‘Will you be a primary-care physician or a hospitalist?’ a lot of them say, ‘Probably hospitalist,’” he says. “And generally the reason is because they have to pay off their debt.”

It’s true that hospitalists’ salaries lag behind that of most of other specialists. Nevertheless, researchers like Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., say many medical residents are prioritizing financial considerations as relatively low on the scale of general preferences.

One loss I’m starting to feel keenly as an academic hospitalist … really is the loss of having long-term relationships with patients. My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.

—John Yoon, MD, assistant professor, section of hospital medicine, University of Chicago

Dr. West, an associate program director for the internal-medicine residency program at Mayo, sees a generational sea change in the career considerations deemed most important. Based on a career decision survey filled out by nearly 15,000 internal-medical residents, he found that roughly 70% of respondents said time with family was of “high” or “very high” importance to their career decisions.⁵ The category, which relates to SHM’s “workload and schedule” pillar, beat out eight others as the most important factor overall, while global financial considerations scored relatively low.

Residents who placed high value on time with family were more likely to choose careers in more predictable, outpatient-based specialties, such as endocrinology or rheumatology. HM also fared well in this category. Dr. West says the results suggest that residents considering a hospitalist career are attracted to the specialty’s flexibility and predictability of the largely shift-based scheduling.

William Cors, MD, chief medical quality officer at Pocono Health System in East Stroudsburg, Pa., says more physicians are looking for job security, predictable shifts, and a better work-life balance. As HM matures and demonstrates that it can address those needs, Dr. Cors sees it becoming more attractive for medical students and residents.

In practice, though, other research suggests a career in HM doesn’t always meet expectations. Dr. Wetterneck and Dr. Hinami, for example, highlighted both compensation and work-life balance as points of concern in their study: For both factors, only about 30% of hospitalists were optimally satisfied.

Separately, Dr. Misky and his colleagues reported that roughly half of academic hospitalists were satisfied with the ability to control their schedule, and with their amount of personal and family time. Those who were unsatisfied with either of these categories, the survey found, were at higher risk for burnout. Similarly, Dr. Yoon found that physicians who reported having no control over their work hours or their call schedule, part of SHM’s “autonomy and control” pillar, were more likely to report burnout.

So why is HM stumbling on perceived selling points like family friendliness and autonomy? Dr. Wetterneck believes too many unfilled jobs and rapid turnover could be putting more pressure on existing hospitalists and interfering with their ability to balance home and work life. “There’s a huge need for hospitalists everywhere,” she says, and reliance on them has been especially acute at academic centers and large community hospitals contending with the recently imposed limits on residents’ work hours.

Listen to Greg Misky, MD

The Hospitalist: A People Person

Another shift may be occurring in the types of relationships necessary for a satisfying work environment, a big part of the “community and environment” pillar. Although Dr. Yoon says long-term connections with students and trainees have added meaning to his job, he is mourning the absence of other bonds. “One loss I’m starting to feel keenly as an academic hospitalist, having spent my early training years as a primary-care doc, really is the loss of having long-term relationships with patients,” he says. “My clinical encounters with patients these days as a hospitalist are very intense, but also very brief.”

Dr. Yoon has pondered whether the HM field can rearrange practice settings to promote more satisfying relationships. Such a change, he says, might occur through innovative models that aid coordination with medical homes, or provide more chronic care for high-risk patients. “In my view, the trajectory of hospital medicine is pretty wide open for creativity and new models of care,” he says. “I think it will be partly driven by the need to want to have more meaningful interactions with patients.”

Those relationships need not be long-term, however. One recent study found high satisfaction among hospitalists and laborists working within the fast-growing OBGYN hospitalist field.⁶

Dr. Hinami says collaborative care that involves close working relationships with specialists and other care providers might help propel the hospitalist movement forward. In his survey with Dr. Wetterneck, hospitalists ranked relationships with staff and colleagues among the most satisfying of any of the domains; hospitalists also indicated high levels of satisfaction with their patient relationships. “Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships,” Dr. Hinami says.

Clearly, relationships are critical to overall job satisfaction, and hospitalists, I think, are doing a fairly good job at maintaining those relationships.

—Keiki Hinami, MD, assistant professor of medicine, Northwestern University Feinberg School of Medicine, Chicago

A 2002 survey-based study reinforces the importance of such bonds. Job burnout and intent to remain in the hospitalist career, its authors concluded, were more highly influenced by “favorable social relations” involving colleagues, coworkers, and patients than by such factors as reduced autonomy and the use of financial incentives.⁷

The focus on maintaining multiple relationships fits well with the collaborative approach to care that many hospitalists say they value highly. One big satisfier for hospitalists, Dr. Cors says, will be “a sense that they’re really part of a healthcare team and not just punching the clock and doing their shifts.”

The Verdict

Despite the difficulty in discerning long-term trends, studies suggest that overall satisfaction with the specialty of hospital medicine remains high, a promising sign for the maturing field. Career hospitalists also seem adept at relationships with peers and other providers, a skill that will serve them well as collaborative-care models gain steam.

Nonetheless, surveys also suggest a worrisome rate of burnout and less-than-optimal satisfaction with elements that should be the strong suits of HM, such as work-life balance and autonomy. Academics are searching for their own clinical-research balance. And Dr. West says the jury’s still out on the future pitfalls that might get in the way of a sustainable career path for older practitioners, such as overnight shifts.

Hospitalist-led efforts, however, may be starting to pay dividends. At the University of California at San Francisco, a faculty development program for first-year hospitalists has included a coaching relationship with a senior faculty member, a teaching course, newly established divisional grand rounds, and a framework for meeting scholarly expectations. Upon its implementation, the program has led to higher job satisfaction, skill-set comfort, and academic production among participants.⁸

Given the expanding range of HM duties and practice models, hospitals, division chiefs, and team leaders cannot rely on a single recipe for happy and productive hospitalists. “I don’t know if there is a cookbook; I think it’s highly variable depending on your institution and the needs of the academic facility where you are,” Dr. Misky says.

SHM’s 2006 white paper stated that the best career satisfaction strategy is to find a job that fits an individual’s preferences and attitudes. “People who are unhappy with their job don’t tend to stay in it, and from what we know about hospital medicine right now, you can find pretty much any type of job anywhere you want, so the job market is very open,” Dr. Wetterneck says.

Ensuring the right fit for doctors within HM, though, will require institutional support. “It’s going to be up to hospitals and hospitalist programs to create jobs that are sustainable that people like,” she says, “so that hospitalists will stay long in their job and in the profession.”

Bryn Nelson is a freelance medical writer based in Seattle.

More Mentorship in Hospital Medicine? It’s Academic

Within the 2011 State of Hospital Medicine report, one statistic in particular points to the youth of the medical specialty: Just over 10% of surveyed hospitalists had reached the rank of associate professor or higher.

How might the potential lack of mentorship within this immature field affect the ability of hospitalists to successfully navigate academia? So asked Gregory Misky, MD, assistant professor of medicine at the University of Colorado Denver, and his colleagues in a survey-based study. The results agree with other recent assessments that mentors are in short supply. “Academic hospital medicine groups have an acute need for mentoring and career development programs,” one study concludes.

The research of Dr. Misky and his collaborators found that only 42% of academic hospitalists could identify a mentor, while only 31% reported that they were mentoring another academic hospitalist.1 Based on sheer numbers and experience, the pool of mentors may significantly expand as the field matures. But Dr. Misky also urges some flexibility, noting that his own mentor is a non-hospitalist.

In his own research, Colin West, MD, PhD, associate professor of medicine and biostatistics at the Mayo Clinic in Rochester, Minn., found that residents considering a career in HM placed less emphasis on the specialty or subspecialty of their mentor.5 Why? Very likely, he says, there just weren’t enough hospitalist mentors around to get a sense of what the career was all about.

Dr. West hopes the numbers suggest otherwise in the near future. “You want to recruit bright people into your specialty, but at the same time, you also want to recruit the right people,” he says. “And that means that you need to be able to expose people to a full breadth of what a decision to pursue a certain specialty really means.”

References

1. Glasheen JJ, Misky GJ, Reid MB, Harrison RA, Sharpe B, Auerbach A. Career satisfaction and burnout in academic hospital medicine. Arch Intern Med. 2011;171(8) 782-785.
2. Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161(6):851-858.
3. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers [published online ahead of print July 20, 2011]. J Gen Intern Med. doi:10.1007/s116060-011-1780-z.
4. Yoon J, Miller A, Rasinski K, Curlin F. Burnout, sense of calling, and career resilience among hospitalists and primary care physicians: a national survey. J Hosp Med. 2011;6(4):S90-S91.
5. West CP, Drefahl MM, Popkave C, Kolars JC. Internal medicine resident self-report of factors associated with career decisions. J Gen Intern Med. 2009;24(8):946-949.
6. Funk C, Anderson BL, Schulkin J, Weinstein L. Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol. 2010;203(2):177.e1-177.e4.
7. Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. J Health Soc Behav. 2002;43(1):72-91.
8. Sehgal NL, Sharpe BA, Auerbach AA, Wachter RM. Investing in the future: Building an academic hospitalist faculty development program. J Hosp Med. 2011;6(3):161-166.

Hospital medicine is fortunate to have many very dedicated and professionally centered doctors who work enthusiastically to both provide excellent care to their patients and work to make their own practice and their hospital a better place. I am lucky to practice with many of them in our practice in Bellevue, Wash.

Yet a significant portion of hospitalists have chosen this work because they’re looking for relatively-low-commitment work. In essence, they see themselves as dating their practice rather than marrying it. Some of them might even say, “I thought I wanted a career. It turns out all I wanted was a paycheck.”

Most are skilled clinicians who find the energy to do a good job for the patients under their care but don’t have a mindset of owning their practice and investing time in making it perform better.

This gives rise to a dilemma: How can a practice turn these perfectly capable physicians into meaningfully engaged participants in the hospitalist practice itself and the hospital as a whole? What about a salary bonus based on good citizenship? Would that cause them to become more engaged and committed?

There is voluminous research and a whole row of books at your local Barnes & Noble that address these questions more completely that I can, so I’ll just share some real-world experience and insights from one book.

What Might a Citizenship Bonus Look Like?

There are a number of ways to consider designing a citizenship bonus. At a previous SHM practice-management course, Win Whitcomb, MD, MHM, presented one example from Mercy Medical Center in Springfield, Mass. (see Figure 1).

The following kinds of activities might be appropriate for a hospitalist to earn a citizenship bonus:

• Active participation on approved hospital committees (e.g. the pharmacy and therapeutic committees) and regular input from and feedback to the hospitalist group (e.g. via e-mail) about relevant activities of the committee;
• A project to improve clinical care (e.g. improved glycemic control, fall prevention, med reconciliation, discharge processes, readmission rates, ensuring follow-up of tests resulted after discharge, etc.);
• A project to improve business operations—for example, improve our billing/coding accuracy. Such a project could be to develop a new progress note template and collect data regarding its use and effectiveness;
• Work to improve communication and interaction with other hospital staff—for example, joint rounding with nurses, improve throughput, etc.; and
• Project(s) to increase the group’s social cohesion and engagement with hospital initiatives and goals.

Does a Citizenship Bonus Help or Hinder a Practice?

From the experience Mercy Hospital had with the citizenship bonus, Win concluded that many, but not all, hospitalists who don’t seem interested in quality improvement (QI) will become engaged if there is a reward/recognition structure. A relatively small dollar bonus is OK, as long as non-monetary rewards exist (e.g. improvement demonstrable, sense of teamwork, recognition). And hospitalists who were engaged prior to establishing the salary incentive are not likely to change their behavior, but their effort is now recognized—allowing for sustained engagement.

I’m sure many institutions would find a similar desirable outcome from putting into place a citizenship bonus. But it isn’t a guarantee. All performance bonus programs, whether based on “hard” outcomes like patient satisfaction scores or “soft” things like citizenship, are tricky to set up and operate effectively.

I have seen well-intentioned efforts to create a citizenship bonus lead to an increase in hospitalists working on projects outside of direct patient care, but at a cost of leading them to focus more intently on just how much they’re being paid for any work outside of direct patient care. It seems that the bonus might have ignited more frustration and concern about compensation, and any benefit to the practice might have been offset by harm to group culture. And if the bonus goes away, some doctors might be even less engaged than they were before it was turned on.

In “Drive: The Surprising Truth About What Motivates Us,” Daniel Pink makes a pretty convincing case that “the more prominent salary, perks, and benefits are in someone’s work life, the more they can inhibit creativity and unravel performance.” He makes the case that organizations are most demotivating “when they use rewards like money to motivate staff.”

“Effective organizations compensate people in amounts and ways that allow individuals to mostly forget about compensation and instead focus on the work itself,” Pink writes.

How do you allow individuals to forget about compensation? He says ensure internal and external fairness in compensation; pay more than average; and if you use performance metrics, make them wide-ranging, relevant, and hard to game.

So maybe financial compensation for citizenship, whether paid through a bonus, hourly, or some other separate salary element, isn’t such a good idea for a hospitalist practice (or any physician practice?). I don’t have a definitive answer, so you’ll have to decide this for yourself. But my hunch is that groups with a thriving culture might in some cases benefit from a well-designed citizenship bonus. That said, those groups also could be the ones less in need of it.

Groups that already have a weak or unhealthy culture, or are frustrated by what they see is inadequate compensation for clinical work, might find such a bonus leads to problems that offset its benefit.

Training in leadership, quality improvement, and other non-clinical areas that are critical for the success of a hospitalist practice is always worthwhile and might capture many of the benefits of a citizenship bonus without its drawbacks.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Hospital medicine is fortunate to have many very dedicated and professionally centered doctors who work enthusiastically to both provide excellent care to their patients and work to make their own practice and their hospital a better place. I am lucky to practice with many of them in our practice in Bellevue, Wash.

Yet a significant portion of hospitalists have chosen this work because they’re looking for relatively-low-commitment work. In essence, they see themselves as dating their practice rather than marrying it. Some of them might even say, “I thought I wanted a career. It turns out all I wanted was a paycheck.”

Most are skilled clinicians who find the energy to do a good job for the patients under their care but don’t have a mindset of owning their practice and investing time in making it perform better.

This gives rise to a dilemma: How can a practice turn these perfectly capable physicians into meaningfully engaged participants in the hospitalist practice itself and the hospital as a whole? What about a salary bonus based on good citizenship? Would that cause them to become more engaged and committed?

There is voluminous research and a whole row of books at your local Barnes & Noble that address these questions more completely that I can, so I’ll just share some real-world experience and insights from one book.

What Might a Citizenship Bonus Look Like?

There are a number of ways to consider designing a citizenship bonus. At a previous SHM practice-management course, Win Whitcomb, MD, MHM, presented one example from Mercy Medical Center in Springfield, Mass. (see Figure 1).

The following kinds of activities might be appropriate for a hospitalist to earn a citizenship bonus:

• Active participation on approved hospital committees (e.g. the pharmacy and therapeutic committees) and regular input from and feedback to the hospitalist group (e.g. via e-mail) about relevant activities of the committee;
• A project to improve clinical care (e.g. improved glycemic control, fall prevention, med reconciliation, discharge processes, readmission rates, ensuring follow-up of tests resulted after discharge, etc.);
• A project to improve business operations—for example, improve our billing/coding accuracy. Such a project could be to develop a new progress note template and collect data regarding its use and effectiveness;
• Work to improve communication and interaction with other hospital staff—for example, joint rounding with nurses, improve throughput, etc.; and
• Project(s) to increase the group’s social cohesion and engagement with hospital initiatives and goals.

Does a Citizenship Bonus Help or Hinder a Practice?

From the experience Mercy Hospital had with the citizenship bonus, Win concluded that many, but not all, hospitalists who don’t seem interested in quality improvement (QI) will become engaged if there is a reward/recognition structure. A relatively small dollar bonus is OK, as long as non-monetary rewards exist (e.g. improvement demonstrable, sense of teamwork, recognition). And hospitalists who were engaged prior to establishing the salary incentive are not likely to change their behavior, but their effort is now recognized—allowing for sustained engagement.

I’m sure many institutions would find a similar desirable outcome from putting into place a citizenship bonus. But it isn’t a guarantee. All performance bonus programs, whether based on “hard” outcomes like patient satisfaction scores or “soft” things like citizenship, are tricky to set up and operate effectively.

I have seen well-intentioned efforts to create a citizenship bonus lead to an increase in hospitalists working on projects outside of direct patient care, but at a cost of leading them to focus more intently on just how much they’re being paid for any work outside of direct patient care. It seems that the bonus might have ignited more frustration and concern about compensation, and any benefit to the practice might have been offset by harm to group culture. And if the bonus goes away, some doctors might be even less engaged than they were before it was turned on.

In “Drive: The Surprising Truth About What Motivates Us,” Daniel Pink makes a pretty convincing case that “the more prominent salary, perks, and benefits are in someone’s work life, the more they can inhibit creativity and unravel performance.” He makes the case that organizations are most demotivating “when they use rewards like money to motivate staff.”

“Effective organizations compensate people in amounts and ways that allow individuals to mostly forget about compensation and instead focus on the work itself,” Pink writes.

How do you allow individuals to forget about compensation? He says ensure internal and external fairness in compensation; pay more than average; and if you use performance metrics, make them wide-ranging, relevant, and hard to game.

So maybe financial compensation for citizenship, whether paid through a bonus, hourly, or some other separate salary element, isn’t such a good idea for a hospitalist practice (or any physician practice?). I don’t have a definitive answer, so you’ll have to decide this for yourself. But my hunch is that groups with a thriving culture might in some cases benefit from a well-designed citizenship bonus. That said, those groups also could be the ones less in need of it.

Groups that already have a weak or unhealthy culture, or are frustrated by what they see is inadequate compensation for clinical work, might find such a bonus leads to problems that offset its benefit.

Training in leadership, quality improvement, and other non-clinical areas that are critical for the success of a hospitalist practice is always worthwhile and might capture many of the benefits of a citizenship bonus without its drawbacks.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Hospital medicine is fortunate to have many very dedicated and professionally centered doctors who work enthusiastically to both provide excellent care to their patients and work to make their own practice and their hospital a better place. I am lucky to practice with many of them in our practice in Bellevue, Wash.

Yet a significant portion of hospitalists have chosen this work because they’re looking for relatively-low-commitment work. In essence, they see themselves as dating their practice rather than marrying it. Some of them might even say, “I thought I wanted a career. It turns out all I wanted was a paycheck.”

Most are skilled clinicians who find the energy to do a good job for the patients under their care but don’t have a mindset of owning their practice and investing time in making it perform better.

This gives rise to a dilemma: How can a practice turn these perfectly capable physicians into meaningfully engaged participants in the hospitalist practice itself and the hospital as a whole? What about a salary bonus based on good citizenship? Would that cause them to become more engaged and committed?

There is voluminous research and a whole row of books at your local Barnes & Noble that address these questions more completely that I can, so I’ll just share some real-world experience and insights from one book.

What Might a Citizenship Bonus Look Like?

There are a number of ways to consider designing a citizenship bonus. At a previous SHM practice-management course, Win Whitcomb, MD, MHM, presented one example from Mercy Medical Center in Springfield, Mass. (see Figure 1).

The following kinds of activities might be appropriate for a hospitalist to earn a citizenship bonus:

• Active participation on approved hospital committees (e.g. the pharmacy and therapeutic committees) and regular input from and feedback to the hospitalist group (e.g. via e-mail) about relevant activities of the committee;
• A project to improve clinical care (e.g. improved glycemic control, fall prevention, med reconciliation, discharge processes, readmission rates, ensuring follow-up of tests resulted after discharge, etc.);
• A project to improve business operations—for example, improve our billing/coding accuracy. Such a project could be to develop a new progress note template and collect data regarding its use and effectiveness;
• Work to improve communication and interaction with other hospital staff—for example, joint rounding with nurses, improve throughput, etc.; and
• Project(s) to increase the group’s social cohesion and engagement with hospital initiatives and goals.

Does a Citizenship Bonus Help or Hinder a Practice?

From the experience Mercy Hospital had with the citizenship bonus, Win concluded that many, but not all, hospitalists who don’t seem interested in quality improvement (QI) will become engaged if there is a reward/recognition structure. A relatively small dollar bonus is OK, as long as non-monetary rewards exist (e.g. improvement demonstrable, sense of teamwork, recognition). And hospitalists who were engaged prior to establishing the salary incentive are not likely to change their behavior, but their effort is now recognized—allowing for sustained engagement.

I’m sure many institutions would find a similar desirable outcome from putting into place a citizenship bonus. But it isn’t a guarantee. All performance bonus programs, whether based on “hard” outcomes like patient satisfaction scores or “soft” things like citizenship, are tricky to set up and operate effectively.

I have seen well-intentioned efforts to create a citizenship bonus lead to an increase in hospitalists working on projects outside of direct patient care, but at a cost of leading them to focus more intently on just how much they’re being paid for any work outside of direct patient care. It seems that the bonus might have ignited more frustration and concern about compensation, and any benefit to the practice might have been offset by harm to group culture. And if the bonus goes away, some doctors might be even less engaged than they were before it was turned on.

In “Drive: The Surprising Truth About What Motivates Us,” Daniel Pink makes a pretty convincing case that “the more prominent salary, perks, and benefits are in someone’s work life, the more they can inhibit creativity and unravel performance.” He makes the case that organizations are most demotivating “when they use rewards like money to motivate staff.”

“Effective organizations compensate people in amounts and ways that allow individuals to mostly forget about compensation and instead focus on the work itself,” Pink writes.

How do you allow individuals to forget about compensation? He says ensure internal and external fairness in compensation; pay more than average; and if you use performance metrics, make them wide-ranging, relevant, and hard to game.

So maybe financial compensation for citizenship, whether paid through a bonus, hourly, or some other separate salary element, isn’t such a good idea for a hospitalist practice (or any physician practice?). I don’t have a definitive answer, so you’ll have to decide this for yourself. But my hunch is that groups with a thriving culture might in some cases benefit from a well-designed citizenship bonus. That said, those groups also could be the ones less in need of it.

Groups that already have a weak or unhealthy culture, or are frustrated by what they see is inadequate compensation for clinical work, might find such a bonus leads to problems that offset its benefit.

Training in leadership, quality improvement, and other non-clinical areas that are critical for the success of a hospitalist practice is always worthwhile and might capture many of the benefits of a citizenship bonus without its drawbacks.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

MIAMI BEACH, Fla.—Muralidharan Reddy, MD, had just finished a five-hour class on the business concepts behind running a hospital and how a hospital CEO thinks—part of the entry-level curriculum at SHM’s Leadership Academy. As he stood up from the round table in a room still buzzing with conversation, he was glad he had signed up—in fact, he had been one of the first to arrive for the 7:30 a.m. session at the Fontainebleau resort.

“It improves my CV, number one,” says Dr. Reddy, a hospitalist at New England Baptist Hospital in Boston. “And it’s not just the CV, but I need the experience to guide me to work as a leader in a hospital group, or even plan on starting a group, or things like that. If I’m going to be a hospitalist, I have to work on trying to get those skills.”

A big plus, he adds, is “you get to learn from experts.”

The four-day academy provides hospitalists an intense learning experience. “Some of these skills, people learn it on the job or you get it through Academy,” Dr. Reddy says. “So I do both.”

Hospitalists who participate in the session repeatedly express concerns that if they don’t hone their understanding of the business aspects of the hospital and refine their skills in interacting with colleagues, they could be left behind in a fast-moving environment.

“I think it’s important,” said Mana Goshtasbi, MD, a hospitalist with Cogent HMG who has worked for two years at St. Joseph’s Hospital in Tampa, Fla. “I think that’s the direction. I think you have to know this stuff because of all the changes.”

Leadership Academy courses come in three levels, which build on one another: Foundations for Effective Leadership, Personal Leadership Excellence, and Strengthening Your Organization. Those who have completed the three levels can apply for certification, which requires completion of a pre-approved leadership project.

Know Your Value, Know Your Customers

Dr. Michael Guthrie, MD, MBA

In his first-level session, instructor Michael Guthrie, MD, MBA, executive in residence and adjunct professor at the University of Colorado Denver School of Business’ program in health administration, spent most of his presentation on his feet, wending his way among the tables, challenging the physician-students to think differently from the ways they’ve been trained to think about healthcare. That starts with stepping outside of themselves and taking a look at how they are viewed in terms of the hospital they’re working with as hospitalists, says Dr. Guthrie, former CEO of the Good Samaritan Health System in San Jose, Calif., and former COO for the Penrose-St. Francis Healthcare System in Colorado.

“What’s affecting the organization that you operate in, and what does that mean about the kinds of demands that are being made of you and requests that are being made of you?” he asks the attendees. “What does it mean about the value that’s received from the work that you do in that organization?”

A hospitalists’ value is a common theme. “What is it that you offer as hospitalists that has created a group of enthusiasts?” he asks. “What is it that you offer to any customer that’s of value to them that they would give up their hard-earned money in exchange for it? Who are your customers?”

A key “customer” group is primary-care physicians (PCPs) whose patients end up under a hospitalist’s care, he explains. They get value from the hospitalist in a variety of ways.

“That’s a more effective way for them to spend their life [at their own clinic],” he says. “They get to manage their schedule differently, they don’t have to drive. They are all exchange values. … There’s a very definite exchange going on here. If you fail in that exchange, we all know what would happen, right? They’d stop sending you patients.”

A physician chimes in: “If you’re the only hospitalist there, they don’t have a choice.”

Dr. Guthrie, quick to seize upon what he sees as a teaching moment, tells the group to “be careful.”

“In the short term, that’s absolutely true,” he says. “In the long term, there are a lot of other alternatives. And if there aren’t, someone will invent one. You see that’s the thing about our society—if there’s an opportunity with a whole, big, dissatisfied customer segment, somebody will notice and invent the way to satisfy their needs. That’s called capitalism.”

It’s what happened with the late Steve Jobs and the iPod, when he realized customers needed a way to easily access their music collections, Dr. Guthrie points out.

“He understood the dissatisfactions of the market,” he continues. “Before that, they didn’t have any choices.

“Healthcare is the same. But it’s a little more difficult to develop those choices. It’s hard to build a new hospital right in the middle of someplace where there’s only one hospital. So they invent other ways to do it, ways to get their patients taken care of: They travel.”

About 700,000 people flew to Southeast Asia last year for medical procedures, he says, making the point that American patients have options.

“Somewhat difficult, but they do have alternatives,” he says. “Customers will, when pushed hard enough, if dissatisfied enough, leave you, even when you think you have them trapped.”

Dr. Michael Guthrie, MD, MBA

Think Tanks

A key part of the session is time set aside for group work, in which Dr. Guthrie gives the class an assignment and attendees tackle it at their tables as a unit. The first task is to identify business drivers at hospitals, what the objectives of the hospital should be in response to those things, and how those objectives affect the work of hospitalists.

Then the groups go to work. A few minutes later, though, Dr. Guthrie speaks up through the chatter.

“Let’s stop for a minute. I want to tell you that most of you are on completely the wrong track,” he says, drawing chuckles. “But this is part of the reason we do it this way. The idea here is to get outside of your head.”

One group lists “profit” as a business driver.

“Profit is not a business driver,” he says. “I know you’re sort of raised to think that way. It isn’t. It’s a measurement. It’s like blood pressure. So it is not a business driver. We use it as a measurement of the success with which we’re synthesizing the business drivers and the environment and meeting the objectives of those drivers, or those trends.”

Business drivers are more along the lines of government mandates and an aging population, which some of the groups had mentioned. “That’s the level of abstraction I want you get to,” he says. “Think out in the marketplace.”

When it comes down to it, Dr. Guthrie explains, the hospitalist plays a role in just about every measurement used to determine excellence at a hospital—from quality to customer loyalty, from retention of patients to productivity.

He also emphasizes the difference between how a doctor has been trained essentially to be an individual expert—patient presents a problem, doctor presents a solution—and how those trained to be managers and leaders operate through other people.

Leaders of the Future

Daniel Duzan, MD, a hospitalist for TeamHealth at Fort Loudoun Medical Center in Lenoir City, Tenn., southwest of Knoxville, says doctors he knows recommended the academy. He says it made sense to him because he’s “migrating toward a leadership role in my own hospital.”

“My goal for coming was to kind of lay some foundation for skills and requirements that it takes to kind of migrate from just being a regular hospitalist to being one that’s got some extra responsibility,” Dr. Duzan says.

He was happy to learn more about “some of the jargon, lingo, that’s getting pushed our direction in terms of business drivers and the objectives” as well as “what would it be like to be the CEO, etc., and kind of putting us in their shoes, hearing things, seeing things and how they think about things, then developing plans.”

Jeet Gujral, MD, a hospitalist at Southside Hospital on Long Island, N.Y., says her motivation to learn about practice management is due in part to the new demands she is feeling because of the business considerations of the hospital. Talking with other hospitalists about their experiences was a big help, she says. In fact, she adds, that was probably even more helpful than the actual content of the session.

“I think what I’m getting more out of it [is that] there are several who are feeling the same heat,” she says. “It’s nice not feeling alone.”

Tom Collins is a freelance writer based in Florida.

MIAMI BEACH, Fla.—Muralidharan Reddy, MD, had just finished a five-hour class on the business concepts behind running a hospital and how a hospital CEO thinks—part of the entry-level curriculum at SHM’s Leadership Academy. As he stood up from the round table in a room still buzzing with conversation, he was glad he had signed up—in fact, he had been one of the first to arrive for the 7:30 a.m. session at the Fontainebleau resort.

“It improves my CV, number one,” says Dr. Reddy, a hospitalist at New England Baptist Hospital in Boston. “And it’s not just the CV, but I need the experience to guide me to work as a leader in a hospital group, or even plan on starting a group, or things like that. If I’m going to be a hospitalist, I have to work on trying to get those skills.”

A big plus, he adds, is “you get to learn from experts.”

The four-day academy provides hospitalists an intense learning experience. “Some of these skills, people learn it on the job or you get it through Academy,” Dr. Reddy says. “So I do both.”

Hospitalists who participate in the session repeatedly express concerns that if they don’t hone their understanding of the business aspects of the hospital and refine their skills in interacting with colleagues, they could be left behind in a fast-moving environment.

“I think it’s important,” said Mana Goshtasbi, MD, a hospitalist with Cogent HMG who has worked for two years at St. Joseph’s Hospital in Tampa, Fla. “I think that’s the direction. I think you have to know this stuff because of all the changes.”

Leadership Academy courses come in three levels, which build on one another: Foundations for Effective Leadership, Personal Leadership Excellence, and Strengthening Your Organization. Those who have completed the three levels can apply for certification, which requires completion of a pre-approved leadership project.

Know Your Value, Know Your Customers

Dr. Michael Guthrie, MD, MBA

In his first-level session, instructor Michael Guthrie, MD, MBA, executive in residence and adjunct professor at the University of Colorado Denver School of Business’ program in health administration, spent most of his presentation on his feet, wending his way among the tables, challenging the physician-students to think differently from the ways they’ve been trained to think about healthcare. That starts with stepping outside of themselves and taking a look at how they are viewed in terms of the hospital they’re working with as hospitalists, says Dr. Guthrie, former CEO of the Good Samaritan Health System in San Jose, Calif., and former COO for the Penrose-St. Francis Healthcare System in Colorado.

“What’s affecting the organization that you operate in, and what does that mean about the kinds of demands that are being made of you and requests that are being made of you?” he asks the attendees. “What does it mean about the value that’s received from the work that you do in that organization?”

A hospitalists’ value is a common theme. “What is it that you offer as hospitalists that has created a group of enthusiasts?” he asks. “What is it that you offer to any customer that’s of value to them that they would give up their hard-earned money in exchange for it? Who are your customers?”

A key “customer” group is primary-care physicians (PCPs) whose patients end up under a hospitalist’s care, he explains. They get value from the hospitalist in a variety of ways.

“That’s a more effective way for them to spend their life [at their own clinic],” he says. “They get to manage their schedule differently, they don’t have to drive. They are all exchange values. … There’s a very definite exchange going on here. If you fail in that exchange, we all know what would happen, right? They’d stop sending you patients.”

A physician chimes in: “If you’re the only hospitalist there, they don’t have a choice.”

Dr. Guthrie, quick to seize upon what he sees as a teaching moment, tells the group to “be careful.”

“In the short term, that’s absolutely true,” he says. “In the long term, there are a lot of other alternatives. And if there aren’t, someone will invent one. You see that’s the thing about our society—if there’s an opportunity with a whole, big, dissatisfied customer segment, somebody will notice and invent the way to satisfy their needs. That’s called capitalism.”

It’s what happened with the late Steve Jobs and the iPod, when he realized customers needed a way to easily access their music collections, Dr. Guthrie points out.

“He understood the dissatisfactions of the market,” he continues. “Before that, they didn’t have any choices.

“Healthcare is the same. But it’s a little more difficult to develop those choices. It’s hard to build a new hospital right in the middle of someplace where there’s only one hospital. So they invent other ways to do it, ways to get their patients taken care of: They travel.”

About 700,000 people flew to Southeast Asia last year for medical procedures, he says, making the point that American patients have options.

“Somewhat difficult, but they do have alternatives,” he says. “Customers will, when pushed hard enough, if dissatisfied enough, leave you, even when you think you have them trapped.”

Dr. Michael Guthrie, MD, MBA

Think Tanks

A key part of the session is time set aside for group work, in which Dr. Guthrie gives the class an assignment and attendees tackle it at their tables as a unit. The first task is to identify business drivers at hospitals, what the objectives of the hospital should be in response to those things, and how those objectives affect the work of hospitalists.

Then the groups go to work. A few minutes later, though, Dr. Guthrie speaks up through the chatter.

“Let’s stop for a minute. I want to tell you that most of you are on completely the wrong track,” he says, drawing chuckles. “But this is part of the reason we do it this way. The idea here is to get outside of your head.”

One group lists “profit” as a business driver.

“Profit is not a business driver,” he says. “I know you’re sort of raised to think that way. It isn’t. It’s a measurement. It’s like blood pressure. So it is not a business driver. We use it as a measurement of the success with which we’re synthesizing the business drivers and the environment and meeting the objectives of those drivers, or those trends.”

Business drivers are more along the lines of government mandates and an aging population, which some of the groups had mentioned. “That’s the level of abstraction I want you get to,” he says. “Think out in the marketplace.”

When it comes down to it, Dr. Guthrie explains, the hospitalist plays a role in just about every measurement used to determine excellence at a hospital—from quality to customer loyalty, from retention of patients to productivity.

He also emphasizes the difference between how a doctor has been trained essentially to be an individual expert—patient presents a problem, doctor presents a solution—and how those trained to be managers and leaders operate through other people.

Leaders of the Future

Daniel Duzan, MD, a hospitalist for TeamHealth at Fort Loudoun Medical Center in Lenoir City, Tenn., southwest of Knoxville, says doctors he knows recommended the academy. He says it made sense to him because he’s “migrating toward a leadership role in my own hospital.”

“My goal for coming was to kind of lay some foundation for skills and requirements that it takes to kind of migrate from just being a regular hospitalist to being one that’s got some extra responsibility,” Dr. Duzan says.

He was happy to learn more about “some of the jargon, lingo, that’s getting pushed our direction in terms of business drivers and the objectives” as well as “what would it be like to be the CEO, etc., and kind of putting us in their shoes, hearing things, seeing things and how they think about things, then developing plans.”

Jeet Gujral, MD, a hospitalist at Southside Hospital on Long Island, N.Y., says her motivation to learn about practice management is due in part to the new demands she is feeling because of the business considerations of the hospital. Talking with other hospitalists about their experiences was a big help, she says. In fact, she adds, that was probably even more helpful than the actual content of the session.

“I think what I’m getting more out of it [is that] there are several who are feeling the same heat,” she says. “It’s nice not feeling alone.”

Tom Collins is a freelance writer based in Florida.

MIAMI BEACH, Fla.—Muralidharan Reddy, MD, had just finished a five-hour class on the business concepts behind running a hospital and how a hospital CEO thinks—part of the entry-level curriculum at SHM’s Leadership Academy. As he stood up from the round table in a room still buzzing with conversation, he was glad he had signed up—in fact, he had been one of the first to arrive for the 7:30 a.m. session at the Fontainebleau resort.

“It improves my CV, number one,” says Dr. Reddy, a hospitalist at New England Baptist Hospital in Boston. “And it’s not just the CV, but I need the experience to guide me to work as a leader in a hospital group, or even plan on starting a group, or things like that. If I’m going to be a hospitalist, I have to work on trying to get those skills.”

A big plus, he adds, is “you get to learn from experts.”

The four-day academy provides hospitalists an intense learning experience. “Some of these skills, people learn it on the job or you get it through Academy,” Dr. Reddy says. “So I do both.”

Hospitalists who participate in the session repeatedly express concerns that if they don’t hone their understanding of the business aspects of the hospital and refine their skills in interacting with colleagues, they could be left behind in a fast-moving environment.

“I think it’s important,” said Mana Goshtasbi, MD, a hospitalist with Cogent HMG who has worked for two years at St. Joseph’s Hospital in Tampa, Fla. “I think that’s the direction. I think you have to know this stuff because of all the changes.”

Leadership Academy courses come in three levels, which build on one another: Foundations for Effective Leadership, Personal Leadership Excellence, and Strengthening Your Organization. Those who have completed the three levels can apply for certification, which requires completion of a pre-approved leadership project.

Know Your Value, Know Your Customers

Dr. Michael Guthrie, MD, MBA

In his first-level session, instructor Michael Guthrie, MD, MBA, executive in residence and adjunct professor at the University of Colorado Denver School of Business’ program in health administration, spent most of his presentation on his feet, wending his way among the tables, challenging the physician-students to think differently from the ways they’ve been trained to think about healthcare. That starts with stepping outside of themselves and taking a look at how they are viewed in terms of the hospital they’re working with as hospitalists, says Dr. Guthrie, former CEO of the Good Samaritan Health System in San Jose, Calif., and former COO for the Penrose-St. Francis Healthcare System in Colorado.

“What’s affecting the organization that you operate in, and what does that mean about the kinds of demands that are being made of you and requests that are being made of you?” he asks the attendees. “What does it mean about the value that’s received from the work that you do in that organization?”

A hospitalists’ value is a common theme. “What is it that you offer as hospitalists that has created a group of enthusiasts?” he asks. “What is it that you offer to any customer that’s of value to them that they would give up their hard-earned money in exchange for it? Who are your customers?”

A key “customer” group is primary-care physicians (PCPs) whose patients end up under a hospitalist’s care, he explains. They get value from the hospitalist in a variety of ways.

“That’s a more effective way for them to spend their life [at their own clinic],” he says. “They get to manage their schedule differently, they don’t have to drive. They are all exchange values. … There’s a very definite exchange going on here. If you fail in that exchange, we all know what would happen, right? They’d stop sending you patients.”

A physician chimes in: “If you’re the only hospitalist there, they don’t have a choice.”

Dr. Guthrie, quick to seize upon what he sees as a teaching moment, tells the group to “be careful.”

“In the short term, that’s absolutely true,” he says. “In the long term, there are a lot of other alternatives. And if there aren’t, someone will invent one. You see that’s the thing about our society—if there’s an opportunity with a whole, big, dissatisfied customer segment, somebody will notice and invent the way to satisfy their needs. That’s called capitalism.”

It’s what happened with the late Steve Jobs and the iPod, when he realized customers needed a way to easily access their music collections, Dr. Guthrie points out.

“He understood the dissatisfactions of the market,” he continues. “Before that, they didn’t have any choices.

“Healthcare is the same. But it’s a little more difficult to develop those choices. It’s hard to build a new hospital right in the middle of someplace where there’s only one hospital. So they invent other ways to do it, ways to get their patients taken care of: They travel.”

About 700,000 people flew to Southeast Asia last year for medical procedures, he says, making the point that American patients have options.

“Somewhat difficult, but they do have alternatives,” he says. “Customers will, when pushed hard enough, if dissatisfied enough, leave you, even when you think you have them trapped.”

Dr. Michael Guthrie, MD, MBA

Think Tanks

A key part of the session is time set aside for group work, in which Dr. Guthrie gives the class an assignment and attendees tackle it at their tables as a unit. The first task is to identify business drivers at hospitals, what the objectives of the hospital should be in response to those things, and how those objectives affect the work of hospitalists.

Then the groups go to work. A few minutes later, though, Dr. Guthrie speaks up through the chatter.

“Let’s stop for a minute. I want to tell you that most of you are on completely the wrong track,” he says, drawing chuckles. “But this is part of the reason we do it this way. The idea here is to get outside of your head.”

One group lists “profit” as a business driver.

“Profit is not a business driver,” he says. “I know you’re sort of raised to think that way. It isn’t. It’s a measurement. It’s like blood pressure. So it is not a business driver. We use it as a measurement of the success with which we’re synthesizing the business drivers and the environment and meeting the objectives of those drivers, or those trends.”

Business drivers are more along the lines of government mandates and an aging population, which some of the groups had mentioned. “That’s the level of abstraction I want you get to,” he says. “Think out in the marketplace.”

When it comes down to it, Dr. Guthrie explains, the hospitalist plays a role in just about every measurement used to determine excellence at a hospital—from quality to customer loyalty, from retention of patients to productivity.

He also emphasizes the difference between how a doctor has been trained essentially to be an individual expert—patient presents a problem, doctor presents a solution—and how those trained to be managers and leaders operate through other people.

Leaders of the Future

Daniel Duzan, MD, a hospitalist for TeamHealth at Fort Loudoun Medical Center in Lenoir City, Tenn., southwest of Knoxville, says doctors he knows recommended the academy. He says it made sense to him because he’s “migrating toward a leadership role in my own hospital.”

“My goal for coming was to kind of lay some foundation for skills and requirements that it takes to kind of migrate from just being a regular hospitalist to being one that’s got some extra responsibility,” Dr. Duzan says.

He was happy to learn more about “some of the jargon, lingo, that’s getting pushed our direction in terms of business drivers and the objectives” as well as “what would it be like to be the CEO, etc., and kind of putting us in their shoes, hearing things, seeing things and how they think about things, then developing plans.”

Jeet Gujral, MD, a hospitalist at Southside Hospital on Long Island, N.Y., says her motivation to learn about practice management is due in part to the new demands she is feeling because of the business considerations of the hospital. Talking with other hospitalists about their experiences was a big help, she says. In fact, she adds, that was probably even more helpful than the actual content of the session.

“I think what I’m getting more out of it [is that] there are several who are feeling the same heat,” she says. “It’s nice not feeling alone.”

Tom Collins is a freelance writer based in Florida.

SHM and the Medical Group Management Association (MGMA) have enjoyed a successful survey collaboration for the past two years. Working together under a survey collaboration agreement to jointly conduct comprehensive annual surveys of HM groups, the two entities have been able to provide an unprecedented amount of high-quality information for members—not only data about hospitalist compensation and productivity, but also about many other aspects of the ways hospitalists and HM groups function.

And while SHM’s relationship with MGMA remains strong, all good things must come to an end—or at least change considerably.

MGMA is headed in new strategic directions that require a reallocation of its existing survey operations department resources. As a result, SHM and MGMA have agreed to change the way they work together, and this will have some important implications for the types of compensation and productivity data that will be available to hospitalists in the future.

MGMA will continue to conduct its regular surveys, including capturing compensation and productivity data for hospitalists. But instead of incorporating a hospital medicine supplement as it has for the last two years, SHM will instead conduct a separate survey each year to collect additional information about the characteristics of HM practices.

The SHM survey will be launched in January to coincide with the launch of MGMA’s Physician Compensation and Production Survey; in fact, academic groups that participated in MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management this fall might already have noticed that the survey no longer included a hospital medicine supplement. SHM is encouraging hospitalists to participate in both the applicable MGMA survey and the companion SHM survey.

SHM will then license MGMA’s compensation and productivity data for both academic and nonacademic hospitalists, then will combine it with the results of its separate SHM survey to create the 2012 State of Hospital Medicine report.

The good news is that this approach will enable SHM to have greater flexibility to design surveys and analyze results in ways that best meet the needs of its constituents, and SHM will also be able to continue to provide survey information annually, rather than going back to the old biannual format.

However, some of the more detailed looks at compensation and productivity data will be lost; those data glimpses only were possible when the supplemental survey was integrated with MGMA’s survey instruments. Such data for 2012 will only be available for national, hospital-employed vs. not-hospital-employed, and geographic region cohorts.

Like the hospitalists it surveys, this report has changed every time it has been conducted. And SHM depends on its members to make sure it is delivering the kind of information that effectively, efficiently, and profitably guides hospitalists’ decisions.

Together, SHM and MGMA have been working to find the right balance that enables MGMA to pursue new strategies and still gives hospitalists the data they need. Ultimately, hospitalists will be the judges of whether the right balance has been struck.

Please send your thoughts and feedback to [email protected].

SHM and the Medical Group Management Association (MGMA) have enjoyed a successful survey collaboration for the past two years. Working together under a survey collaboration agreement to jointly conduct comprehensive annual surveys of HM groups, the two entities have been able to provide an unprecedented amount of high-quality information for members—not only data about hospitalist compensation and productivity, but also about many other aspects of the ways hospitalists and HM groups function.

And while SHM’s relationship with MGMA remains strong, all good things must come to an end—or at least change considerably.

MGMA is headed in new strategic directions that require a reallocation of its existing survey operations department resources. As a result, SHM and MGMA have agreed to change the way they work together, and this will have some important implications for the types of compensation and productivity data that will be available to hospitalists in the future.

MGMA will continue to conduct its regular surveys, including capturing compensation and productivity data for hospitalists. But instead of incorporating a hospital medicine supplement as it has for the last two years, SHM will instead conduct a separate survey each year to collect additional information about the characteristics of HM practices.

The SHM survey will be launched in January to coincide with the launch of MGMA’s Physician Compensation and Production Survey; in fact, academic groups that participated in MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management this fall might already have noticed that the survey no longer included a hospital medicine supplement. SHM is encouraging hospitalists to participate in both the applicable MGMA survey and the companion SHM survey.

SHM will then license MGMA’s compensation and productivity data for both academic and nonacademic hospitalists, then will combine it with the results of its separate SHM survey to create the 2012 State of Hospital Medicine report.

The good news is that this approach will enable SHM to have greater flexibility to design surveys and analyze results in ways that best meet the needs of its constituents, and SHM will also be able to continue to provide survey information annually, rather than going back to the old biannual format.

However, some of the more detailed looks at compensation and productivity data will be lost; those data glimpses only were possible when the supplemental survey was integrated with MGMA’s survey instruments. Such data for 2012 will only be available for national, hospital-employed vs. not-hospital-employed, and geographic region cohorts.

Like the hospitalists it surveys, this report has changed every time it has been conducted. And SHM depends on its members to make sure it is delivering the kind of information that effectively, efficiently, and profitably guides hospitalists’ decisions.

Together, SHM and MGMA have been working to find the right balance that enables MGMA to pursue new strategies and still gives hospitalists the data they need. Ultimately, hospitalists will be the judges of whether the right balance has been struck.

Please send your thoughts and feedback to [email protected].

SHM and the Medical Group Management Association (MGMA) have enjoyed a successful survey collaboration for the past two years. Working together under a survey collaboration agreement to jointly conduct comprehensive annual surveys of HM groups, the two entities have been able to provide an unprecedented amount of high-quality information for members—not only data about hospitalist compensation and productivity, but also about many other aspects of the ways hospitalists and HM groups function.

And while SHM’s relationship with MGMA remains strong, all good things must come to an end—or at least change considerably.

MGMA is headed in new strategic directions that require a reallocation of its existing survey operations department resources. As a result, SHM and MGMA have agreed to change the way they work together, and this will have some important implications for the types of compensation and productivity data that will be available to hospitalists in the future.

MGMA will continue to conduct its regular surveys, including capturing compensation and productivity data for hospitalists. But instead of incorporating a hospital medicine supplement as it has for the last two years, SHM will instead conduct a separate survey each year to collect additional information about the characteristics of HM practices.

The SHM survey will be launched in January to coincide with the launch of MGMA’s Physician Compensation and Production Survey; in fact, academic groups that participated in MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management this fall might already have noticed that the survey no longer included a hospital medicine supplement. SHM is encouraging hospitalists to participate in both the applicable MGMA survey and the companion SHM survey.

SHM will then license MGMA’s compensation and productivity data for both academic and nonacademic hospitalists, then will combine it with the results of its separate SHM survey to create the 2012 State of Hospital Medicine report.

The good news is that this approach will enable SHM to have greater flexibility to design surveys and analyze results in ways that best meet the needs of its constituents, and SHM will also be able to continue to provide survey information annually, rather than going back to the old biannual format.

However, some of the more detailed looks at compensation and productivity data will be lost; those data glimpses only were possible when the supplemental survey was integrated with MGMA’s survey instruments. Such data for 2012 will only be available for national, hospital-employed vs. not-hospital-employed, and geographic region cohorts.

Like the hospitalists it surveys, this report has changed every time it has been conducted. And SHM depends on its members to make sure it is delivering the kind of information that effectively, efficiently, and profitably guides hospitalists’ decisions.

Together, SHM and MGMA have been working to find the right balance that enables MGMA to pursue new strategies and still gives hospitalists the data they need. Ultimately, hospitalists will be the judges of whether the right balance has been struck.

Please send your thoughts and feedback to [email protected].