Leadership Training

Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.

Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.

Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.

Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
 

Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.

Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
 

Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.

TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
 

Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.

Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
 

Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.

Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
 

George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.

Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.

Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
 

BUSINESS MOVES

U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).

USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
 

VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.

White Rock is a 218-bed, community hospital providing care to East Texas since 1959.

Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.

Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.

Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.

Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
 

Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.

Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
 

Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.

TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
 

Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.

Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
 

Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.

Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
 

George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.

Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.

Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
 

BUSINESS MOVES

U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).

USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
 

VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.

White Rock is a 218-bed, community hospital providing care to East Texas since 1959.

Modern Healthcare recently announced its list of the 50 Most Influential Physician Executives and Leaders, and hospital medicine was well represented among the honorees. The honored physicians were selected by a panel of experts and peers for their leadership and impact on the profession.

Topping the list was Scott Gottlieb, MD, the commissioner of the Food and Drug Administration. Dr. Gottlieb was confirmed to his position in May 2017 and, in his first year, has focused on price transparency and the approval of generic medications.

Dr. Gottlieb was deputy commissioner of the FDA from 2005-2007, and he has worked as an advisor and analyst for GlaxoSmithKline, the American Enterprise Institute, Vertex Pharmaceuticals, and Avilene Health.

Dr. Gottlieb earned his medical degree from the Icahn School of Medicine at Mount Sinai, New York, and completed his residency at Mount Sinai Hospital. He has worked as a hospitalist at New York University’s Tisch Hospital, the Hospital for Joint Diseases, and Stamford (Conn.) Hospital.
 

Patrick Conway, MD, was listed at number 23 on Modern Healthcare’s 50 Most Influential Physician Executives and Leaders. Formerly the deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services, Dr. Conway recently became president and chief executive officer of Blue Cross and Blue Shield of North Carolina.

Dr. Conway is known for his ability to develop and promote alternative payment models. He was elected to the National Academy of Medicine’s Institute of Medicine in 2014 and was selected as a Master of Hospital Medicine by the Society of Hospital Medicine.
 

Lynn Massingale, MD, the cofounder and chairman of TeamHealth, was named one of the 50 Most Influential Physician Executives and Leaders for a third year running, coming in at number 27 on the list. Dr. Massingale, who also recently was named to the Tennessee Healthcare Hall of Fame, founded TeamHealth in 1979 and was its chief executive officer for 30 years before assuming the role of chairman in 2008.

TeamHealth provides outsourced emergency medicine, hospitalist, critical care, anesthesiology, and acute care surgery services, among other specialties, at more than 3,200 facilities and physician groups across the United States.
 

Veeravat Taecharvongphairoj, MD, a veteran internist and hospitalist at Hemet Valley Medical Center in Hemet, Calif., has been honored by the International Association of Healthcare Professionals in its Leading Physicians of the World publication.

Dr. Taecharvongphairoj completed his residency at the University of Hawaii, Honolulu, before accepting a fellowship in hospital and palliative care at Cedars-Sinai Medical Center, Los Angeles. He is a member of the American Academy of Hospice and Palliative Medicine.
 

Sean Bain, MD, has been selected to the Glen Falls (N.Y.) Hospital Foundation Board of Trustees for 2018. Dr. Bain works as a hospitalist/internist at Glen Falls Hospital, where he is the president of medical staff. He manages the credentialing, continuing education, and policies and practices for the staff’s providers.

Dr. Bain received his medical degree at Albany (N.Y.) Medical College and served his residency at Wake Forest Baptist Medical Center, Winston-Salem, N.C.
 

George Harrison, MD, has been tabbed the new chief medical officer at Fairview Park Hospital in Dublin, Ga. Dr. Harrison will be charged with managing clinical quality and patient safety, staff relations, and clinical integration strategies at the hospital.

Prior to his appointment, Dr. Harrison was the codirector of the hospitalist program at Fairview Park. The Georgia native previously worked in management roles at urgent care centers, family practice centers, and hospitalist programs in North Carolina, South Carolina, and Georgia. He is a member of the American Academy of Family Physicians, the Society of Hospital Medicine, and the American Academy of Physician Leaders.

Dr. Harrison taught high school geometry and chemistry before earning his medical degree at the Morehouse School of Medicine, Atlanta. He did his residency at Duke University Medical Center, Durham, N.C.
 

BUSINESS MOVES

U.S. Acute Care Solutions (Canton, Ohio), a physician-owned, national provider of emergency medicine and hospitalist services, has extended its relationship with Central Health of Colorado and western Kansas. USACS has acquired the physicians of Front Range Emergency Specialists (Colorado Springs, Colo.), Southwest Emergency Physicians (Durango, Colo.), and Southern Colorado Emergency Specialists (Pueblo, Colo.).

USACS’s acquisition of these three physician groups adds care to more than 175,000 patients each year in central and southwest Colorado. USACS cares for more than 6 million patients per year at more than 200 locations across the United States.
 

VEP Healthcare (Concord, Calif.), an emergency medicine and hospitalist staffing company, has signed on to manage hospitalist and ED services at City Hospital at White Rock in Dallas. Its goals are to increase patient satisfaction, decrease wait times in seeing providers, raise recommendation rates, and lower malpractice claims.

White Rock is a 218-bed, community hospital providing care to East Texas since 1959.

Disruptive physician behavior can be more than a headache for the medical team, it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.

Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?

The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.

“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”

However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.

The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.

There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.

“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”

Disruptive physician behavior can be more than a headache for the medical team, it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.

Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?

The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.

“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”

However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.

The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.

There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.

“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”

Disruptive physician behavior can be more than a headache for the medical team, it can greatly lower staff morale and compromise patient care. Addressing this behavior head-on is imperative, experts said, but knowing which route to take is not always clear.

Physician leaders may wonder: When is this a human resources (HR) issue and when should the medical executive committee (MEC) step in?

The answer depends on the circumstances and the employment status of the physician in question, said Mark Peters, a labor and employment attorney based in Nashville, Tenn.

“There are a couple of different considerations when deciding how, or more accurately who, should address disruptive physician behavior in the workplace,” Mr. Peters said in an interview. “The first consideration is whether the physician is employed by the health care entity or is a contractor. Typically, absent an employment relationship with the physician, human resources is not involved directly with the physician and the issue is handled through the MEC.”

However, in some cases both HR and the MEC may become involved. For instance, if the complaint is made by an employee, HR would likely get involved – regardless of whether the disruptive physician is a contractor – because employers have a legal duty to ensure a “hostile-free environment,” Mr. Peters said.

The hospital may also ask that the MEC intervene to ensure the medical staff understands all of the facts and can weigh in on whether the doctor is being treated fairly by the hospital, he said.

There are a range of advantages and disadvantages to each resolution path, said Jeffrey Moseley, a health law attorney based in Franklin, Tenn. The HR route usually means dealing with a single point person and typically the issue is resolved more swiftly. Going through the MEC, on the other hand, often takes months. The MEC path also means more people will be involved, and it’s possible the case may become more political, depending on the culture of the MEC.

“If you have to end up taking an action, the employment setting may be a quicker way to address the issue than going through the medical staff side,” Mr. Moseley said in an interview. “Most medical staffs, if they were to try to restrict or revoke privileges, they are going to have to go through a fair hearing and appeals, [which] can take 6 months easily. The downside to the employment side is you don’t get all the immunities that you get on the medical staff side.”

Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.

One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.

At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.

Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.

Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.

But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.

The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.

“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
 

Goals, roles, and expectations

Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.

Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.

“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”

Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.

“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.

Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.

“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”

Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”

Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.

For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.

For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.

Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”

Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
 

Debunking myths

Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.

“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”

But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.

“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”

She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.

“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”

Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.

“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.

Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.

“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
 

Changing practice

Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.

“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.

As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.

But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.

“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”

Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.

“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”

PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.

“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”


 

Onboarding NPs and PAs

According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.

To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.

Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.

Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.

One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.

At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.

Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.

Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.

But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.

The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.

“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
 

Goals, roles, and expectations

Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.

Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.

“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”

Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.

“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.

Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.

“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”

Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”

Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.

For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.

For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.

Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”

Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
 

Debunking myths

Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.

“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”

But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.

“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”

She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.

“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”

Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.

“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.

Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.

“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
 

Changing practice

Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.

“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.

As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.

But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.

“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”

Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.

“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”

PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.

“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”


 

Onboarding NPs and PAs

According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.

To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.

Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.

Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.

One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.

At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.

Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.

Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.

But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.

The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.

“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
 

Goals, roles, and expectations

Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.

Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.

“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”

Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.

“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.

Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.

“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”

Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”

Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.

For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.

For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.

Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”

Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
 

Debunking myths

Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.

“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”

But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.

“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”

She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.

“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”

Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.

“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.

Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.

“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
 

Changing practice

Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.

“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.

As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.

But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.

“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”

Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.

“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”

PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.

“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”


 

Onboarding NPs and PAs

According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.

To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.

Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.

Unlike some children who wanted be firefighters or astronauts when they grew up, ever since Raj Sehgal, MD, FHM, was a boy, he dreamed of being a doctor.

Since earning his medical degree, Dr. Sehgal has kept himself involved in a wide variety of projects, driven by the desire to diversify his expertise.

Currently a clinical associate professor of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System, San Antonio, and University of Texas Health San Antonio, Dr. Sehgal has found his place as an educator as well as a clinician, earning the Division of Hospital Medicine Teaching Award in 2016.

As a member of the The Hospitalist’s volunteer editorial advisory board, Dr. Sehgal enjoys helping to educate and inform fellow hospitalists. He spoke with The Hospitalist to tell us more about himself.
 

How did you get into medicine?

I don’t know how old I was when I decided I was going to be a doctor, but it was at a very young age and I never really wavered in that desire. I guess I also would have wanted to be a baseball player or a musician, but I never had the talents for those, so it was doctor. That’s always what I was thinking of doing, straight through high school and college, and then after college I took a year off and joined AmeriCorps. I spent a year there and then went to medical school in Dallas at UT Southwestern. After medical school, I thought I should go somewhere as different from Dallas as possible, so I went to Portland, Ore., for my residency and then a fellowship in general internal medicine.

How did you end up in hospital medicine?

When I was doing my residency, I always enjoyed being a generalist. A lot of different areas of medicine interested me, but I like the breadth of things you encounter as a generalist, so I could never picture myself being a subspecialist, doing the same things every day, seeing the same things. I knew I wanted to keep practicing general internal medicine, so I took a fellowship where I was working both inpatient and outpatient, and when I was looking for a job, I sought out things that involved some inpatient and some outpatient work. It turned out hospital medicine was the best fit.

What would you say is your favorite part of hospital medicine?

My favorite part of the job is getting to teach, working with medical students and residents. I also like the variety of what I do as a hospitalist, so I’m about 50% clinical and the rest of the time I perform a variety of tasks, both administrative and educational.

What about your least favorite part of hospitalist work?

Sometimes, particularly if you’re doing clinical, educational, and administrative work, it can be a little overwhelming to try and do a little bit of everything. I think generally that’s a good thing, but sometimes it can feel like a little too much.

What is some of the best advice you have received regarding how to handle the stresses of hospital medicine?

Feel free to say no to things. When hospitalists are starting their careers, and particularly when they are new to a job and trying to express their desire to get involved, sometimes they can have too much thrown at them at once. People can get overloaded very quickly, so I think feeling like you’re able to say no to some requests, or to take some time to think before you accept an additional role. The other piece of advice I remember from my fellowship, is that, when you do something, make it count twice. For example, if you’re involved in a project, you get the practical clinical or educational benefits of whatever the project was. But also think about how you might write about your experience for research purposes, such as for a poster, article, or other presentation.

What is the worst advice you have been given?

I think it’s not necessarily bad advice, but I guess it’s advice that I haven’t really followed. Since I work in academic medicine, I’ve found that the people in academics fall into one of two categories: There are the people who find their niche and remain on that path, and they’re very clear about it and don’t really stray from it; and there are people who don’t find that niche right away. I think the advice I received when starting out was to try to find that niche, and if you’re building an academic career it is very helpful to have these things in which you have become the expert. But I’ve just tried to go where the job takes me. I don’t necessarily have a single academic niche or something that I spend all my time doing, but I do have my hand in a lot of different things. To me, that’s a lot more interesting because it adds to the variety of what you’re doing. Every day is a little different.

What else do you do professionally outside of hospital medicine?

I actually practice a little outpatient medicine. When I first started here, I wanted to keep some outpatient experience, and so I actually created my own clinic. It’s a procedure clinic where I do paracentesis on people who have cirrhosis. Then on the educational side, I sit on the admission committees for the medical school here, so I get to look through the applicants and choose who we interview, and then once we interview candidates, I help choose how we rank students for admission.

Where do you see yourself in the next 10 years?

I’ve never been one who looks at a particular job and says ‘Okay, I want to be the dean or have this position.’ I guess I just hope I’m better at the things I’m currently doing. I hope in 10 years that I’m a better teacher, that I’ll have learned more strategies to help more people, and that I have a better handle on the administrative side of the work. I hope I’ve progressed to a point in my career where I’m doing an even better job than I am now.

What are your goals as a member of the editorial board?

I have an interest not only in medicine but also in writing; I’ve gotten to do some writing both medical and nonmedical in the past. I’ve published a few articles in The Hospitalist, and hopefully, I can do more of that because writing is just another part of education.

Unlike some children who wanted be firefighters or astronauts when they grew up, ever since Raj Sehgal, MD, FHM, was a boy, he dreamed of being a doctor.

Since earning his medical degree, Dr. Sehgal has kept himself involved in a wide variety of projects, driven by the desire to diversify his expertise.

Currently a clinical associate professor of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System, San Antonio, and University of Texas Health San Antonio, Dr. Sehgal has found his place as an educator as well as a clinician, earning the Division of Hospital Medicine Teaching Award in 2016.

As a member of the The Hospitalist’s volunteer editorial advisory board, Dr. Sehgal enjoys helping to educate and inform fellow hospitalists. He spoke with The Hospitalist to tell us more about himself.
 

How did you get into medicine?

I don’t know how old I was when I decided I was going to be a doctor, but it was at a very young age and I never really wavered in that desire. I guess I also would have wanted to be a baseball player or a musician, but I never had the talents for those, so it was doctor. That’s always what I was thinking of doing, straight through high school and college, and then after college I took a year off and joined AmeriCorps. I spent a year there and then went to medical school in Dallas at UT Southwestern. After medical school, I thought I should go somewhere as different from Dallas as possible, so I went to Portland, Ore., for my residency and then a fellowship in general internal medicine.

How did you end up in hospital medicine?

When I was doing my residency, I always enjoyed being a generalist. A lot of different areas of medicine interested me, but I like the breadth of things you encounter as a generalist, so I could never picture myself being a subspecialist, doing the same things every day, seeing the same things. I knew I wanted to keep practicing general internal medicine, so I took a fellowship where I was working both inpatient and outpatient, and when I was looking for a job, I sought out things that involved some inpatient and some outpatient work. It turned out hospital medicine was the best fit.

What would you say is your favorite part of hospital medicine?

My favorite part of the job is getting to teach, working with medical students and residents. I also like the variety of what I do as a hospitalist, so I’m about 50% clinical and the rest of the time I perform a variety of tasks, both administrative and educational.

What about your least favorite part of hospitalist work?

Sometimes, particularly if you’re doing clinical, educational, and administrative work, it can be a little overwhelming to try and do a little bit of everything. I think generally that’s a good thing, but sometimes it can feel like a little too much.

What is some of the best advice you have received regarding how to handle the stresses of hospital medicine?

Feel free to say no to things. When hospitalists are starting their careers, and particularly when they are new to a job and trying to express their desire to get involved, sometimes they can have too much thrown at them at once. People can get overloaded very quickly, so I think feeling like you’re able to say no to some requests, or to take some time to think before you accept an additional role. The other piece of advice I remember from my fellowship, is that, when you do something, make it count twice. For example, if you’re involved in a project, you get the practical clinical or educational benefits of whatever the project was. But also think about how you might write about your experience for research purposes, such as for a poster, article, or other presentation.

What is the worst advice you have been given?

I think it’s not necessarily bad advice, but I guess it’s advice that I haven’t really followed. Since I work in academic medicine, I’ve found that the people in academics fall into one of two categories: There are the people who find their niche and remain on that path, and they’re very clear about it and don’t really stray from it; and there are people who don’t find that niche right away. I think the advice I received when starting out was to try to find that niche, and if you’re building an academic career it is very helpful to have these things in which you have become the expert. But I’ve just tried to go where the job takes me. I don’t necessarily have a single academic niche or something that I spend all my time doing, but I do have my hand in a lot of different things. To me, that’s a lot more interesting because it adds to the variety of what you’re doing. Every day is a little different.

What else do you do professionally outside of hospital medicine?

I actually practice a little outpatient medicine. When I first started here, I wanted to keep some outpatient experience, and so I actually created my own clinic. It’s a procedure clinic where I do paracentesis on people who have cirrhosis. Then on the educational side, I sit on the admission committees for the medical school here, so I get to look through the applicants and choose who we interview, and then once we interview candidates, I help choose how we rank students for admission.

Where do you see yourself in the next 10 years?

I’ve never been one who looks at a particular job and says ‘Okay, I want to be the dean or have this position.’ I guess I just hope I’m better at the things I’m currently doing. I hope in 10 years that I’m a better teacher, that I’ll have learned more strategies to help more people, and that I have a better handle on the administrative side of the work. I hope I’ve progressed to a point in my career where I’m doing an even better job than I am now.

What are your goals as a member of the editorial board?

I have an interest not only in medicine but also in writing; I’ve gotten to do some writing both medical and nonmedical in the past. I’ve published a few articles in The Hospitalist, and hopefully, I can do more of that because writing is just another part of education.

Unlike some children who wanted be firefighters or astronauts when they grew up, ever since Raj Sehgal, MD, FHM, was a boy, he dreamed of being a doctor.

Since earning his medical degree, Dr. Sehgal has kept himself involved in a wide variety of projects, driven by the desire to diversify his expertise.

Currently a clinical associate professor of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System, San Antonio, and University of Texas Health San Antonio, Dr. Sehgal has found his place as an educator as well as a clinician, earning the Division of Hospital Medicine Teaching Award in 2016.

As a member of the The Hospitalist’s volunteer editorial advisory board, Dr. Sehgal enjoys helping to educate and inform fellow hospitalists. He spoke with The Hospitalist to tell us more about himself.
 

How did you get into medicine?

I don’t know how old I was when I decided I was going to be a doctor, but it was at a very young age and I never really wavered in that desire. I guess I also would have wanted to be a baseball player or a musician, but I never had the talents for those, so it was doctor. That’s always what I was thinking of doing, straight through high school and college, and then after college I took a year off and joined AmeriCorps. I spent a year there and then went to medical school in Dallas at UT Southwestern. After medical school, I thought I should go somewhere as different from Dallas as possible, so I went to Portland, Ore., for my residency and then a fellowship in general internal medicine.

How did you end up in hospital medicine?

When I was doing my residency, I always enjoyed being a generalist. A lot of different areas of medicine interested me, but I like the breadth of things you encounter as a generalist, so I could never picture myself being a subspecialist, doing the same things every day, seeing the same things. I knew I wanted to keep practicing general internal medicine, so I took a fellowship where I was working both inpatient and outpatient, and when I was looking for a job, I sought out things that involved some inpatient and some outpatient work. It turned out hospital medicine was the best fit.

What would you say is your favorite part of hospital medicine?

My favorite part of the job is getting to teach, working with medical students and residents. I also like the variety of what I do as a hospitalist, so I’m about 50% clinical and the rest of the time I perform a variety of tasks, both administrative and educational.

What about your least favorite part of hospitalist work?

Sometimes, particularly if you’re doing clinical, educational, and administrative work, it can be a little overwhelming to try and do a little bit of everything. I think generally that’s a good thing, but sometimes it can feel like a little too much.

What is some of the best advice you have received regarding how to handle the stresses of hospital medicine?

Feel free to say no to things. When hospitalists are starting their careers, and particularly when they are new to a job and trying to express their desire to get involved, sometimes they can have too much thrown at them at once. People can get overloaded very quickly, so I think feeling like you’re able to say no to some requests, or to take some time to think before you accept an additional role. The other piece of advice I remember from my fellowship, is that, when you do something, make it count twice. For example, if you’re involved in a project, you get the practical clinical or educational benefits of whatever the project was. But also think about how you might write about your experience for research purposes, such as for a poster, article, or other presentation.

What is the worst advice you have been given?

I think it’s not necessarily bad advice, but I guess it’s advice that I haven’t really followed. Since I work in academic medicine, I’ve found that the people in academics fall into one of two categories: There are the people who find their niche and remain on that path, and they’re very clear about it and don’t really stray from it; and there are people who don’t find that niche right away. I think the advice I received when starting out was to try to find that niche, and if you’re building an academic career it is very helpful to have these things in which you have become the expert. But I’ve just tried to go where the job takes me. I don’t necessarily have a single academic niche or something that I spend all my time doing, but I do have my hand in a lot of different things. To me, that’s a lot more interesting because it adds to the variety of what you’re doing. Every day is a little different.

What else do you do professionally outside of hospital medicine?

I actually practice a little outpatient medicine. When I first started here, I wanted to keep some outpatient experience, and so I actually created my own clinic. It’s a procedure clinic where I do paracentesis on people who have cirrhosis. Then on the educational side, I sit on the admission committees for the medical school here, so I get to look through the applicants and choose who we interview, and then once we interview candidates, I help choose how we rank students for admission.

Where do you see yourself in the next 10 years?

I’ve never been one who looks at a particular job and says ‘Okay, I want to be the dean or have this position.’ I guess I just hope I’m better at the things I’m currently doing. I hope in 10 years that I’m a better teacher, that I’ll have learned more strategies to help more people, and that I have a better handle on the administrative side of the work. I hope I’ve progressed to a point in my career where I’m doing an even better job than I am now.

What are your goals as a member of the editorial board?

I have an interest not only in medicine but also in writing; I’ve gotten to do some writing both medical and nonmedical in the past. I’ve published a few articles in The Hospitalist, and hopefully, I can do more of that because writing is just another part of education.

The Society of Hospital Medicine has announced the appointment of Eric Howell, MD, MHM, to the position of chief operating officer (COO).

“Having been involved with SHM in many capacities since first joining, I am honored to now transition to chief operating officer,” Dr. Howell said. “I always tell everyone that my goal is to make the world a better place, and I know that SHM’s staff will be able to do just that through the development and deployment of a variety of products, tools, and services to help hospitalists improve patient care.”

In his new role as COO at SHM, Dr. Howell will lead senior management’s strategic planning as well as define organizational goals to drive extensive, sustainable growth. In addition to serving as SHM’s COO, Dr. Howell will continue his role as director of the hospital medicine division of Johns Hopkins Bayview Medical Center in Baltimore and professor of medicine in the department of medicine at Johns Hopkins University, also in Baltimore. Dr. Howell joined the Johns Hopkins Bayview hospitalist program in 2000, began the Howard County (Md.) General Hospital hospitalist program in 2010, and now oversees more than 200 physicians and clinical staff providing patient care in three hospitals.

“Eric has the perfect background to take SHM, its staff, and its membership to the next level,” said Laurence Wellikson, MD, MHM, chief executive officer of SHM. “His foundational leadership in the hospital medicine movement makes him the ideal person to lead SHM forward in its quest to provide hospitalists with the tools necessary to make a noteworthy difference in their institutions and in the lives of their patients.”

Dr. Howell is also a past president of SHM, the course director for the SHM Leadership Academies, and most recently, served as the senior physician advisor to SHM’s Center for Quality Improvement, which conducts quality improvement programs for hospitalist teams. He received his electrical engineering degree from the University of Maryland, which he said has served as an instrumental piece of his background for managing and implementing change in the hospital. His research has focused on the relationship between the emergency department and medicine floors, improving communication, throughput, and patient outcomes.




 

The Society of Hospital Medicine has announced the appointment of Eric Howell, MD, MHM, to the position of chief operating officer (COO).

“Having been involved with SHM in many capacities since first joining, I am honored to now transition to chief operating officer,” Dr. Howell said. “I always tell everyone that my goal is to make the world a better place, and I know that SHM’s staff will be able to do just that through the development and deployment of a variety of products, tools, and services to help hospitalists improve patient care.”

In his new role as COO at SHM, Dr. Howell will lead senior management’s strategic planning as well as define organizational goals to drive extensive, sustainable growth. In addition to serving as SHM’s COO, Dr. Howell will continue his role as director of the hospital medicine division of Johns Hopkins Bayview Medical Center in Baltimore and professor of medicine in the department of medicine at Johns Hopkins University, also in Baltimore. Dr. Howell joined the Johns Hopkins Bayview hospitalist program in 2000, began the Howard County (Md.) General Hospital hospitalist program in 2010, and now oversees more than 200 physicians and clinical staff providing patient care in three hospitals.

“Eric has the perfect background to take SHM, its staff, and its membership to the next level,” said Laurence Wellikson, MD, MHM, chief executive officer of SHM. “His foundational leadership in the hospital medicine movement makes him the ideal person to lead SHM forward in its quest to provide hospitalists with the tools necessary to make a noteworthy difference in their institutions and in the lives of their patients.”

Dr. Howell is also a past president of SHM, the course director for the SHM Leadership Academies, and most recently, served as the senior physician advisor to SHM’s Center for Quality Improvement, which conducts quality improvement programs for hospitalist teams. He received his electrical engineering degree from the University of Maryland, which he said has served as an instrumental piece of his background for managing and implementing change in the hospital. His research has focused on the relationship between the emergency department and medicine floors, improving communication, throughput, and patient outcomes.




 

The Society of Hospital Medicine has announced the appointment of Eric Howell, MD, MHM, to the position of chief operating officer (COO).

“Having been involved with SHM in many capacities since first joining, I am honored to now transition to chief operating officer,” Dr. Howell said. “I always tell everyone that my goal is to make the world a better place, and I know that SHM’s staff will be able to do just that through the development and deployment of a variety of products, tools, and services to help hospitalists improve patient care.”

In his new role as COO at SHM, Dr. Howell will lead senior management’s strategic planning as well as define organizational goals to drive extensive, sustainable growth. In addition to serving as SHM’s COO, Dr. Howell will continue his role as director of the hospital medicine division of Johns Hopkins Bayview Medical Center in Baltimore and professor of medicine in the department of medicine at Johns Hopkins University, also in Baltimore. Dr. Howell joined the Johns Hopkins Bayview hospitalist program in 2000, began the Howard County (Md.) General Hospital hospitalist program in 2010, and now oversees more than 200 physicians and clinical staff providing patient care in three hospitals.

“Eric has the perfect background to take SHM, its staff, and its membership to the next level,” said Laurence Wellikson, MD, MHM, chief executive officer of SHM. “His foundational leadership in the hospital medicine movement makes him the ideal person to lead SHM forward in its quest to provide hospitalists with the tools necessary to make a noteworthy difference in their institutions and in the lives of their patients.”

Dr. Howell is also a past president of SHM, the course director for the SHM Leadership Academies, and most recently, served as the senior physician advisor to SHM’s Center for Quality Improvement, which conducts quality improvement programs for hospitalist teams. He received his electrical engineering degree from the University of Maryland, which he said has served as an instrumental piece of his background for managing and implementing change in the hospital. His research has focused on the relationship between the emergency department and medicine floors, improving communication, throughput, and patient outcomes.




 

Society of Hospital Medicine committee participation is an exciting opportunity available to all medical students and resident physicians. Whether you are hoping to explore new facets of hospital medicine, or take the next step in shaping your career, committee involvement creates opportunities for individuals to share their insight and work collaboratively on key SHM priorities to shape the future of hospital medicine.

If you are interested, the application is short and straightforward. Requisite SHM membership is free for students and discounted for resident members. And the benefits of committee participation are far reaching.

SHM committee opportunities will cater to most interests and career paths. Our personal interest in academic hospital medicine and medical education led us to the Physicians-In-Training (PIT) committee, but seventeen committees are available (see the complete list below). Review the committee descriptions online and select the one that best aligns with your individual interests. A mentor’s insight may be valuable in determining which committee is the best opportunity.

SHM Committee Opportunities:

• Academic Hospitalist Committee
• Annual Meeting Committee
• Awards Committee
• Chapter Support Committee
• Communications Strategy Committee
• Digital Learning Committee
• Education Committee
• Hospital Quality and Patient Safety Committee
• Membership Committee
• Patient Experience Committee
• Performance Measurement & Reporting Committee
• Physicians in Training Committee
• Practice Analysis Committee
• Practice Management Committee
• Public Policy Committee
• Research Committee
• Special Interest Group Support Committee

Dr. Bartlett is a hospitalist at the University of New Mexico Hospital, Albuquerque. Mr. Namavar is a medical student at Stritch School of Medicine, Loyola University Chicago.

Society of Hospital Medicine committee participation is an exciting opportunity available to all medical students and resident physicians. Whether you are hoping to explore new facets of hospital medicine, or take the next step in shaping your career, committee involvement creates opportunities for individuals to share their insight and work collaboratively on key SHM priorities to shape the future of hospital medicine.

If you are interested, the application is short and straightforward. Requisite SHM membership is free for students and discounted for resident members. And the benefits of committee participation are far reaching.

SHM committee opportunities will cater to most interests and career paths. Our personal interest in academic hospital medicine and medical education led us to the Physicians-In-Training (PIT) committee, but seventeen committees are available (see the complete list below). Review the committee descriptions online and select the one that best aligns with your individual interests. A mentor’s insight may be valuable in determining which committee is the best opportunity.

SHM Committee Opportunities:

• Academic Hospitalist Committee
• Annual Meeting Committee
• Awards Committee
• Chapter Support Committee
• Communications Strategy Committee
• Digital Learning Committee
• Education Committee
• Hospital Quality and Patient Safety Committee
• Membership Committee
• Patient Experience Committee
• Performance Measurement & Reporting Committee
• Physicians in Training Committee
• Practice Analysis Committee
• Practice Management Committee
• Public Policy Committee
• Research Committee
• Special Interest Group Support Committee

Dr. Bartlett is a hospitalist at the University of New Mexico Hospital, Albuquerque. Mr. Namavar is a medical student at Stritch School of Medicine, Loyola University Chicago.

Society of Hospital Medicine committee participation is an exciting opportunity available to all medical students and resident physicians. Whether you are hoping to explore new facets of hospital medicine, or take the next step in shaping your career, committee involvement creates opportunities for individuals to share their insight and work collaboratively on key SHM priorities to shape the future of hospital medicine.

If you are interested, the application is short and straightforward. Requisite SHM membership is free for students and discounted for resident members. And the benefits of committee participation are far reaching.

SHM committee opportunities will cater to most interests and career paths. Our personal interest in academic hospital medicine and medical education led us to the Physicians-In-Training (PIT) committee, but seventeen committees are available (see the complete list below). Review the committee descriptions online and select the one that best aligns with your individual interests. A mentor’s insight may be valuable in determining which committee is the best opportunity.

SHM Committee Opportunities:

• Academic Hospitalist Committee
• Annual Meeting Committee
• Awards Committee
• Chapter Support Committee
• Communications Strategy Committee
• Digital Learning Committee
• Education Committee
• Hospital Quality and Patient Safety Committee
• Membership Committee
• Patient Experience Committee
• Performance Measurement & Reporting Committee
• Physicians in Training Committee
• Practice Analysis Committee
• Practice Management Committee
• Public Policy Committee
• Research Committee
• Special Interest Group Support Committee

Dr. Bartlett is a hospitalist at the University of New Mexico Hospital, Albuquerque. Mr. Namavar is a medical student at Stritch School of Medicine, Loyola University Chicago.

Editor’s note: SHM occasionally puts the spotlight on our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

This month, The Hospitalist spotlights Ramin Yazdanfar, MD, hospitalist and Harrisburg (Pa.) site medical director at UPMC Pinnacle. Dr. Ramin has been a member of SHM since 2016, has attended two annual conferences as well as Leadership Academy, and together with his team received SHM’s Award of Excellence in Teamwork.
 

How did you learn about SHM and why did you become a member?

I first heard about SHM during my initial job out of residency. At that time, our medical director encouraged engagement in the field of hospital medicine, and he was quite involved in local meetings and national conferences. I became a member because I felt it would be a good way to connect with other hospitalists who might have been going through similar experiences and struggles, and in the hopes of gaining something I could take back to use in my daily practice.

Which SHM conferences have you attended and why?

I have attended two national conferences thus far. The first was the 2016 SHM Annual Conference in San Diego, where our hospitalist team won the Excellence in Teamwork and Quality Improvement Award for our active bed management program under Mary Ellen Pfeiffer, MD, and William “Tex” Landis, MD, among others. I also attended the 2017 Leadership Academy in Scottsdale, Ariz. As a new site director for a new hospitalist group, I thought it would be a valuable learning experience, with the goal of improving my communication as a leader. I also will be attending the 2018 SHM Leadership Academy in Vancouver. I am excited to reconnect with peers I met last year and to advance my leadership skills further.

What were the main takeaways from Leadership: Mastering Teamwork, and how have you applied them in your practice?

My most vivid and actionable memory of Leadership: Mastering Teamwork was the initial session around the five dysfunctions of a team and how to build a cohesive leadership team. Allowing ourselves to be vulnerable and open creates the foundation of trust, on which we can build everything else, such as handling conflict and creating commitment, accountability, and results. I have tried to use these principles in our own practice, at UPMC Pinnacle Health in Harrisburg, Pa. We have an ever-growing health system with an expanding regional leadership team. We base our foundation on trust in one another, and in our vision, so the rest follows suit.

As a separate takeaway, I really enjoyed sessions with Leonard Marcus, PhD, on SWARM Intelligence and Meta-Leadership. He is a very engaging speaker whom I would recommend to anyone considering the Mastering Teamwork session.
 

What advice do you have for early-career hospitalists looking to advance their career in hospital medicine?

My advice to early-career hospitalists is to be open to opportunity. There is so much change and development in the field of hospital medicine. While the foundation of our job is in the patient care realm, many of us find a niche that interests us. My advice is pursue it and be open to what follows, without forgetting that we do this for our patients and community.

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: SHM occasionally puts the spotlight on our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

This month, The Hospitalist spotlights Ramin Yazdanfar, MD, hospitalist and Harrisburg (Pa.) site medical director at UPMC Pinnacle. Dr. Ramin has been a member of SHM since 2016, has attended two annual conferences as well as Leadership Academy, and together with his team received SHM’s Award of Excellence in Teamwork.
 

How did you learn about SHM and why did you become a member?

I first heard about SHM during my initial job out of residency. At that time, our medical director encouraged engagement in the field of hospital medicine, and he was quite involved in local meetings and national conferences. I became a member because I felt it would be a good way to connect with other hospitalists who might have been going through similar experiences and struggles, and in the hopes of gaining something I could take back to use in my daily practice.

Which SHM conferences have you attended and why?

I have attended two national conferences thus far. The first was the 2016 SHM Annual Conference in San Diego, where our hospitalist team won the Excellence in Teamwork and Quality Improvement Award for our active bed management program under Mary Ellen Pfeiffer, MD, and William “Tex” Landis, MD, among others. I also attended the 2017 Leadership Academy in Scottsdale, Ariz. As a new site director for a new hospitalist group, I thought it would be a valuable learning experience, with the goal of improving my communication as a leader. I also will be attending the 2018 SHM Leadership Academy in Vancouver. I am excited to reconnect with peers I met last year and to advance my leadership skills further.

What were the main takeaways from Leadership: Mastering Teamwork, and how have you applied them in your practice?

My most vivid and actionable memory of Leadership: Mastering Teamwork was the initial session around the five dysfunctions of a team and how to build a cohesive leadership team. Allowing ourselves to be vulnerable and open creates the foundation of trust, on which we can build everything else, such as handling conflict and creating commitment, accountability, and results. I have tried to use these principles in our own practice, at UPMC Pinnacle Health in Harrisburg, Pa. We have an ever-growing health system with an expanding regional leadership team. We base our foundation on trust in one another, and in our vision, so the rest follows suit.

As a separate takeaway, I really enjoyed sessions with Leonard Marcus, PhD, on SWARM Intelligence and Meta-Leadership. He is a very engaging speaker whom I would recommend to anyone considering the Mastering Teamwork session.
 

What advice do you have for early-career hospitalists looking to advance their career in hospital medicine?

My advice to early-career hospitalists is to be open to opportunity. There is so much change and development in the field of hospital medicine. While the foundation of our job is in the patient care realm, many of us find a niche that interests us. My advice is pursue it and be open to what follows, without forgetting that we do this for our patients and community.

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

Editor’s note: SHM occasionally puts the spotlight on our most active members who are making substantial contributions to hospital medicine. Visit www.hospitalmedicine.org for more information on how you can lend your expertise to help improve the care of hospitalized patients.

This month, The Hospitalist spotlights Ramin Yazdanfar, MD, hospitalist and Harrisburg (Pa.) site medical director at UPMC Pinnacle. Dr. Ramin has been a member of SHM since 2016, has attended two annual conferences as well as Leadership Academy, and together with his team received SHM’s Award of Excellence in Teamwork.
 

How did you learn about SHM and why did you become a member?

I first heard about SHM during my initial job out of residency. At that time, our medical director encouraged engagement in the field of hospital medicine, and he was quite involved in local meetings and national conferences. I became a member because I felt it would be a good way to connect with other hospitalists who might have been going through similar experiences and struggles, and in the hopes of gaining something I could take back to use in my daily practice.

Which SHM conferences have you attended and why?

I have attended two national conferences thus far. The first was the 2016 SHM Annual Conference in San Diego, where our hospitalist team won the Excellence in Teamwork and Quality Improvement Award for our active bed management program under Mary Ellen Pfeiffer, MD, and William “Tex” Landis, MD, among others. I also attended the 2017 Leadership Academy in Scottsdale, Ariz. As a new site director for a new hospitalist group, I thought it would be a valuable learning experience, with the goal of improving my communication as a leader. I also will be attending the 2018 SHM Leadership Academy in Vancouver. I am excited to reconnect with peers I met last year and to advance my leadership skills further.

What were the main takeaways from Leadership: Mastering Teamwork, and how have you applied them in your practice?

My most vivid and actionable memory of Leadership: Mastering Teamwork was the initial session around the five dysfunctions of a team and how to build a cohesive leadership team. Allowing ourselves to be vulnerable and open creates the foundation of trust, on which we can build everything else, such as handling conflict and creating commitment, accountability, and results. I have tried to use these principles in our own practice, at UPMC Pinnacle Health in Harrisburg, Pa. We have an ever-growing health system with an expanding regional leadership team. We base our foundation on trust in one another, and in our vision, so the rest follows suit.

As a separate takeaway, I really enjoyed sessions with Leonard Marcus, PhD, on SWARM Intelligence and Meta-Leadership. He is a very engaging speaker whom I would recommend to anyone considering the Mastering Teamwork session.
 

What advice do you have for early-career hospitalists looking to advance their career in hospital medicine?

My advice to early-career hospitalists is to be open to opportunity. There is so much change and development in the field of hospital medicine. While the foundation of our job is in the patient care realm, many of us find a niche that interests us. My advice is pursue it and be open to what follows, without forgetting that we do this for our patients and community.

Ms. Steele is a marketing communications specialist at the Society of Hospital Medicine.

At HM18 in Orlando, the Society of Hospital Medicine’s CEO Larry Wellikson, MD, MHM, challenged our thinking by sharing a slide with the attendees that effectively and accurately captured the current environment. Today’s largest retailer, Amazon, owns no inventory; today’s largest taxi company, Uber, owns no cars; and today’s largest provider of accommodations, Airbnb, owns no real estate.

The acute becomes more acute

When I started working as a hospitalist more than a decade ago, in a tertiary/quaternary academic medical center, the patients were severely ill with multiple comorbidities. Yet, in the span of 10 years, we care for many of those diagnoses in the ambulatory setting.

Reflecting on the severity of illness in my patients when I was recently on the medicine wards, I have to admit the patients now have a significantly higher burden of disease with twice as many comorbidities. As medicine has advanced and we have become more skilled at caring for patients, the acuity of patients has exponentially increased.

As this trend continues, hospitalists will need greater training in critical care components of hospital-based care. While we may comanage some of these patients with critical care, our skill sets need to intensify to address the growing needs of our patient population.
 

“Bread and butter” moves to lower-acuity settings and home

As our ability to manage patients advances, and the existing inpatient beds are occupied by sicker patients, the common hospital medicine diagnoses will move to skilled nursing facilities, long-term acute care settings, and ultimately home.

Delivery systems will have to create robust networks of home health and home services to actively manage patients with accountability. This provides an opportunity for hospitalists to manage acutely ill patients in less intense settings of care, and the emergence of telehealth will help facilitate this.

In a Feb. 6, 2018 article in JAMA – “Is it Time for a New Medical Specialty?” – Dr. Michael Nochomovitz and Dr. Rahul Sharma argue that, with rapid advances in technology and the establishment of telemedicine, a new specialty – the virtualist – will need to formally emerge (JAMA. 2018;319[5]:437-8. While telehealth has been successfully utilized for the delivery of acute care in remote regions, as well as the delivery of basic services for common diagnoses, it is not robustly and broadly integrated into all aspects of care delivery.

As we move from the hospital setting to less acute settings of care and home-based care, providers need specific training and skill sets in how to manage and deliver care without the patient in front of them. This includes knowledge of how to remotely manage acutely ill patients who are stable and do not require a hospitalization, as well as effectively managing day-to-day issues that arise with patients.
 

Translating our role in population health management

I have written previously about the expanding role of hospitalists in population health management. In addition to the transitions of care work that we are all involved in, hospitalists must actively partner with our ambulatory colleagues to identify and communicate key barriers to care.

Hospitalists are already instrumental in a number of institutions providing inpatient and ambulatory care for a select group of patients with high utilization. We have the ability to care for high utilizers and partner with ambulatory providers who can ensure we care for patients with high burdens of disease in the most appropriate settings of care. In the fall of 2018, SHM is convening a group of experts in population health to discuss the role of hospitalists in this area.

While I don’t have a crystal ball to predict the future, sadly, SHM is committed to proactively defining and advancing our specialty. I am confident that together we can find the solutions that will successfully advance us towards the future.
 

Dr. Afsar is president of the Society of Hospital Medicine, and chief ambulatory officer and chief medical officer for accountable care organizations at UC Irvine Health.

At HM18 in Orlando, the Society of Hospital Medicine’s CEO Larry Wellikson, MD, MHM, challenged our thinking by sharing a slide with the attendees that effectively and accurately captured the current environment. Today’s largest retailer, Amazon, owns no inventory; today’s largest taxi company, Uber, owns no cars; and today’s largest provider of accommodations, Airbnb, owns no real estate.

The acute becomes more acute

When I started working as a hospitalist more than a decade ago, in a tertiary/quaternary academic medical center, the patients were severely ill with multiple comorbidities. Yet, in the span of 10 years, we care for many of those diagnoses in the ambulatory setting.

Reflecting on the severity of illness in my patients when I was recently on the medicine wards, I have to admit the patients now have a significantly higher burden of disease with twice as many comorbidities. As medicine has advanced and we have become more skilled at caring for patients, the acuity of patients has exponentially increased.

As this trend continues, hospitalists will need greater training in critical care components of hospital-based care. While we may comanage some of these patients with critical care, our skill sets need to intensify to address the growing needs of our patient population.
 

“Bread and butter” moves to lower-acuity settings and home

As our ability to manage patients advances, and the existing inpatient beds are occupied by sicker patients, the common hospital medicine diagnoses will move to skilled nursing facilities, long-term acute care settings, and ultimately home.

Delivery systems will have to create robust networks of home health and home services to actively manage patients with accountability. This provides an opportunity for hospitalists to manage acutely ill patients in less intense settings of care, and the emergence of telehealth will help facilitate this.

In a Feb. 6, 2018 article in JAMA – “Is it Time for a New Medical Specialty?” – Dr. Michael Nochomovitz and Dr. Rahul Sharma argue that, with rapid advances in technology and the establishment of telemedicine, a new specialty – the virtualist – will need to formally emerge (JAMA. 2018;319[5]:437-8. While telehealth has been successfully utilized for the delivery of acute care in remote regions, as well as the delivery of basic services for common diagnoses, it is not robustly and broadly integrated into all aspects of care delivery.

As we move from the hospital setting to less acute settings of care and home-based care, providers need specific training and skill sets in how to manage and deliver care without the patient in front of them. This includes knowledge of how to remotely manage acutely ill patients who are stable and do not require a hospitalization, as well as effectively managing day-to-day issues that arise with patients.
 

Translating our role in population health management

I have written previously about the expanding role of hospitalists in population health management. In addition to the transitions of care work that we are all involved in, hospitalists must actively partner with our ambulatory colleagues to identify and communicate key barriers to care.

Hospitalists are already instrumental in a number of institutions providing inpatient and ambulatory care for a select group of patients with high utilization. We have the ability to care for high utilizers and partner with ambulatory providers who can ensure we care for patients with high burdens of disease in the most appropriate settings of care. In the fall of 2018, SHM is convening a group of experts in population health to discuss the role of hospitalists in this area.

While I don’t have a crystal ball to predict the future, sadly, SHM is committed to proactively defining and advancing our specialty. I am confident that together we can find the solutions that will successfully advance us towards the future.
 

Dr. Afsar is president of the Society of Hospital Medicine, and chief ambulatory officer and chief medical officer for accountable care organizations at UC Irvine Health.

At HM18 in Orlando, the Society of Hospital Medicine’s CEO Larry Wellikson, MD, MHM, challenged our thinking by sharing a slide with the attendees that effectively and accurately captured the current environment. Today’s largest retailer, Amazon, owns no inventory; today’s largest taxi company, Uber, owns no cars; and today’s largest provider of accommodations, Airbnb, owns no real estate.

The acute becomes more acute

When I started working as a hospitalist more than a decade ago, in a tertiary/quaternary academic medical center, the patients were severely ill with multiple comorbidities. Yet, in the span of 10 years, we care for many of those diagnoses in the ambulatory setting.

Reflecting on the severity of illness in my patients when I was recently on the medicine wards, I have to admit the patients now have a significantly higher burden of disease with twice as many comorbidities. As medicine has advanced and we have become more skilled at caring for patients, the acuity of patients has exponentially increased.

As this trend continues, hospitalists will need greater training in critical care components of hospital-based care. While we may comanage some of these patients with critical care, our skill sets need to intensify to address the growing needs of our patient population.
 

“Bread and butter” moves to lower-acuity settings and home

As our ability to manage patients advances, and the existing inpatient beds are occupied by sicker patients, the common hospital medicine diagnoses will move to skilled nursing facilities, long-term acute care settings, and ultimately home.

Delivery systems will have to create robust networks of home health and home services to actively manage patients with accountability. This provides an opportunity for hospitalists to manage acutely ill patients in less intense settings of care, and the emergence of telehealth will help facilitate this.

In a Feb. 6, 2018 article in JAMA – “Is it Time for a New Medical Specialty?” – Dr. Michael Nochomovitz and Dr. Rahul Sharma argue that, with rapid advances in technology and the establishment of telemedicine, a new specialty – the virtualist – will need to formally emerge (JAMA. 2018;319[5]:437-8. While telehealth has been successfully utilized for the delivery of acute care in remote regions, as well as the delivery of basic services for common diagnoses, it is not robustly and broadly integrated into all aspects of care delivery.

As we move from the hospital setting to less acute settings of care and home-based care, providers need specific training and skill sets in how to manage and deliver care without the patient in front of them. This includes knowledge of how to remotely manage acutely ill patients who are stable and do not require a hospitalization, as well as effectively managing day-to-day issues that arise with patients.
 

Translating our role in population health management

I have written previously about the expanding role of hospitalists in population health management. In addition to the transitions of care work that we are all involved in, hospitalists must actively partner with our ambulatory colleagues to identify and communicate key barriers to care.

Hospitalists are already instrumental in a number of institutions providing inpatient and ambulatory care for a select group of patients with high utilization. We have the ability to care for high utilizers and partner with ambulatory providers who can ensure we care for patients with high burdens of disease in the most appropriate settings of care. In the fall of 2018, SHM is convening a group of experts in population health to discuss the role of hospitalists in this area.

While I don’t have a crystal ball to predict the future, sadly, SHM is committed to proactively defining and advancing our specialty. I am confident that together we can find the solutions that will successfully advance us towards the future.
 

Dr. Afsar is president of the Society of Hospital Medicine, and chief ambulatory officer and chief medical officer for accountable care organizations at UC Irvine Health.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

If you are in the business of health care – whether as a direct care provider who is doing their best in an increasingly complex system with an increasingly complex panel of patients; a hospital medicine group leader who is trying to keep a group afloat and lead people through this rocky terrain; or a hospital system leader or chief medical officer dealing with the arcane and ever-changing landscape – there is one universal truth: This business is hard.

You can call it “challenging.” You can say there are “opportunities for improvement.” You can put all kinds of sugar on top, but at times, it is a bitter drink to swallow.

So why, as hospitalists, do we keep doing this?

I always joke that I’m going to open a “fro-yo” stand on the beach, but of course, I never do. And that constancy is one huge reason why I love hospitalists. We are always trying to decode, unlock, and solve some of these seemingly unsolvable problems. But at the same time, this plethora of constant change and instability at all kinds of levels can be a bit, well, impossible.

How do we do it every day? You can change jobs, change patient panels, and change medical systems, but no matter what, you will be confronted on some level with a gap of clearly defined solutions to your “challenges.”

One thing in my arsenal of coping, beyond my fro-yo fantasy, is simply this: compassion. When one of your providers comes to you and is complaining about their workload, don’t tell them about how you used to see three times as many patients at your last job. Instead, put your hand on their shoulder, look them in the eye, and say “It is hard. It is.”

When the CEO of your hospital tells you that the already tiny margin of the hospital is shrinking, and she has to cut a service you feel is indispensable, reflect her pain. Believe me – she feels it.

To practice compassion in hospital medicine is to accept that medicine is hard on everyone. It’s not “us” versus “them.” It’s not just “us” that hurts and “them” that are immune. We all struggle.

We need – I need – to acknowledge the pain this profession often elicits. It can be burnout, resentment, overarching grief, or incredible frustration with broken systems and sometimes broken people. When we deny it, when we try to shove those feelings deep down, then people – good people who feel these things – perceive they are flawed or somehow not cut out for this profession. So they end up leaving. Or imploding.

Instead, if we practice compassion for ourselves and each other, we may find strength and restoration in these relationships with others. We will normalize these very normal responses to the challenges we face every day. And we may then survive all these “opportunities for improvement.”

I challenge everyone to practice this simple compassionate meditation. It will take less than five minutes. As you lay in bed at night, your mind racing, concentrate on feeling compassion for four different people. Start with the person you don’t know well, such as the person who works at the dry cleaner. Breathe deeply. Pick a sentence – a gift to give. I always think, “I wish you happy and healthy, wealthy and wise.” Do this for three or four deep breaths.

Next, using this same technique, choose someone that is hard to feel compassion for – perhaps that difficult family member, or the co-worker that gets under your skin.

Then feel that compassion. Breathe deeply – for yourself, with all your human frailties. You don’t have to be perfect to be loved or lovable. Feel that.

Finally, take a deep breath, feel your chest opening, expanding. Feel that compassion for the whole world – the whole crummy mixed-up world that’s just doing its best. The world needs our compassion, too.

While you were at HM18, I hope you were able to look into the eyes of the others you see. These are your fellow hospitalists. People who feel your joys, your frustrations. Some of those eyes will be bright and excited; others will be worn and tired. But revel in this shared and universal knowledge.

It is hard. But with compassion and understanding, we can make it a bit better. For all of us.

Read the full post at hospitalleader.org.

Ms. Cardin, ACNP-BC, SFHM is vice president, Advanced Practice Providers, at Sound Physicians, and also serves on SHM’s Board of Directors.

Also in The Hospital Leader

• How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
• “Harper’s Index” of Hospital Medicine 2018 by Jordan Messler, MD, SFHM
• What’s a Cost, Charge, and Price? by Brad Flansbaum, DO, MPH, MHM

If you are in the business of health care – whether as a direct care provider who is doing their best in an increasingly complex system with an increasingly complex panel of patients; a hospital medicine group leader who is trying to keep a group afloat and lead people through this rocky terrain; or a hospital system leader or chief medical officer dealing with the arcane and ever-changing landscape – there is one universal truth: This business is hard.

You can call it “challenging.” You can say there are “opportunities for improvement.” You can put all kinds of sugar on top, but at times, it is a bitter drink to swallow.

So why, as hospitalists, do we keep doing this?

I always joke that I’m going to open a “fro-yo” stand on the beach, but of course, I never do. And that constancy is one huge reason why I love hospitalists. We are always trying to decode, unlock, and solve some of these seemingly unsolvable problems. But at the same time, this plethora of constant change and instability at all kinds of levels can be a bit, well, impossible.

How do we do it every day? You can change jobs, change patient panels, and change medical systems, but no matter what, you will be confronted on some level with a gap of clearly defined solutions to your “challenges.”

One thing in my arsenal of coping, beyond my fro-yo fantasy, is simply this: compassion. When one of your providers comes to you and is complaining about their workload, don’t tell them about how you used to see three times as many patients at your last job. Instead, put your hand on their shoulder, look them in the eye, and say “It is hard. It is.”

When the CEO of your hospital tells you that the already tiny margin of the hospital is shrinking, and she has to cut a service you feel is indispensable, reflect her pain. Believe me – she feels it.

To practice compassion in hospital medicine is to accept that medicine is hard on everyone. It’s not “us” versus “them.” It’s not just “us” that hurts and “them” that are immune. We all struggle.

We need – I need – to acknowledge the pain this profession often elicits. It can be burnout, resentment, overarching grief, or incredible frustration with broken systems and sometimes broken people. When we deny it, when we try to shove those feelings deep down, then people – good people who feel these things – perceive they are flawed or somehow not cut out for this profession. So they end up leaving. Or imploding.

Instead, if we practice compassion for ourselves and each other, we may find strength and restoration in these relationships with others. We will normalize these very normal responses to the challenges we face every day. And we may then survive all these “opportunities for improvement.”

I challenge everyone to practice this simple compassionate meditation. It will take less than five minutes. As you lay in bed at night, your mind racing, concentrate on feeling compassion for four different people. Start with the person you don’t know well, such as the person who works at the dry cleaner. Breathe deeply. Pick a sentence – a gift to give. I always think, “I wish you happy and healthy, wealthy and wise.” Do this for three or four deep breaths.

Next, using this same technique, choose someone that is hard to feel compassion for – perhaps that difficult family member, or the co-worker that gets under your skin.

Then feel that compassion. Breathe deeply – for yourself, with all your human frailties. You don’t have to be perfect to be loved or lovable. Feel that.

Finally, take a deep breath, feel your chest opening, expanding. Feel that compassion for the whole world – the whole crummy mixed-up world that’s just doing its best. The world needs our compassion, too.

While you were at HM18, I hope you were able to look into the eyes of the others you see. These are your fellow hospitalists. People who feel your joys, your frustrations. Some of those eyes will be bright and excited; others will be worn and tired. But revel in this shared and universal knowledge.

It is hard. But with compassion and understanding, we can make it a bit better. For all of us.

Read the full post at hospitalleader.org.

Ms. Cardin, ACNP-BC, SFHM is vice president, Advanced Practice Providers, at Sound Physicians, and also serves on SHM’s Board of Directors.

Also in The Hospital Leader

• How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
• “Harper’s Index” of Hospital Medicine 2018 by Jordan Messler, MD, SFHM
• What’s a Cost, Charge, and Price? by Brad Flansbaum, DO, MPH, MHM

If you are in the business of health care – whether as a direct care provider who is doing their best in an increasingly complex system with an increasingly complex panel of patients; a hospital medicine group leader who is trying to keep a group afloat and lead people through this rocky terrain; or a hospital system leader or chief medical officer dealing with the arcane and ever-changing landscape – there is one universal truth: This business is hard.

You can call it “challenging.” You can say there are “opportunities for improvement.” You can put all kinds of sugar on top, but at times, it is a bitter drink to swallow.

So why, as hospitalists, do we keep doing this?

I always joke that I’m going to open a “fro-yo” stand on the beach, but of course, I never do. And that constancy is one huge reason why I love hospitalists. We are always trying to decode, unlock, and solve some of these seemingly unsolvable problems. But at the same time, this plethora of constant change and instability at all kinds of levels can be a bit, well, impossible.

How do we do it every day? You can change jobs, change patient panels, and change medical systems, but no matter what, you will be confronted on some level with a gap of clearly defined solutions to your “challenges.”

One thing in my arsenal of coping, beyond my fro-yo fantasy, is simply this: compassion. When one of your providers comes to you and is complaining about their workload, don’t tell them about how you used to see three times as many patients at your last job. Instead, put your hand on their shoulder, look them in the eye, and say “It is hard. It is.”

When the CEO of your hospital tells you that the already tiny margin of the hospital is shrinking, and she has to cut a service you feel is indispensable, reflect her pain. Believe me – she feels it.

To practice compassion in hospital medicine is to accept that medicine is hard on everyone. It’s not “us” versus “them.” It’s not just “us” that hurts and “them” that are immune. We all struggle.

We need – I need – to acknowledge the pain this profession often elicits. It can be burnout, resentment, overarching grief, or incredible frustration with broken systems and sometimes broken people. When we deny it, when we try to shove those feelings deep down, then people – good people who feel these things – perceive they are flawed or somehow not cut out for this profession. So they end up leaving. Or imploding.

Instead, if we practice compassion for ourselves and each other, we may find strength and restoration in these relationships with others. We will normalize these very normal responses to the challenges we face every day. And we may then survive all these “opportunities for improvement.”

I challenge everyone to practice this simple compassionate meditation. It will take less than five minutes. As you lay in bed at night, your mind racing, concentrate on feeling compassion for four different people. Start with the person you don’t know well, such as the person who works at the dry cleaner. Breathe deeply. Pick a sentence – a gift to give. I always think, “I wish you happy and healthy, wealthy and wise.” Do this for three or four deep breaths.

Next, using this same technique, choose someone that is hard to feel compassion for – perhaps that difficult family member, or the co-worker that gets under your skin.

Then feel that compassion. Breathe deeply – for yourself, with all your human frailties. You don’t have to be perfect to be loved or lovable. Feel that.

Finally, take a deep breath, feel your chest opening, expanding. Feel that compassion for the whole world – the whole crummy mixed-up world that’s just doing its best. The world needs our compassion, too.

While you were at HM18, I hope you were able to look into the eyes of the others you see. These are your fellow hospitalists. People who feel your joys, your frustrations. Some of those eyes will be bright and excited; others will be worn and tired. But revel in this shared and universal knowledge.

It is hard. But with compassion and understanding, we can make it a bit better. For all of us.

Read the full post at hospitalleader.org.

Ms. Cardin, ACNP-BC, SFHM is vice president, Advanced Practice Providers, at Sound Physicians, and also serves on SHM’s Board of Directors.

Also in The Hospital Leader

• How Can Hospitalists Improve Their HCAHPS Scores? by Leslie Flores, MHA, SFHM
• “Harper’s Index” of Hospital Medicine 2018 by Jordan Messler, MD, SFHM
• What’s a Cost, Charge, and Price? by Brad Flansbaum, DO, MPH, MHM