Leadership Training

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.

I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.

I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.

Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?

After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.

Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.

I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.

Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.

I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.

I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.

Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?

After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.

Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.

I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.

Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

When I decided to leave the business world to pursue a career in medicine, I envisioned myself in a clinic or an operating room helping the people in my community with the knowledge and skills acquired in my medical training. The thought of becoming a researcher had never even crossed my mind.

I grew up in Scottsdale, Arizona, a city which has no major academic medical centers. Prior to entering medical school, I was enrolled in a postbaccalaureate program at Johns Hopkins University, where I took the basic science classes necessary to apply. I was quite surprised to learn that, even at this level of education, I was required to participate in a research project. This experience changed the way I envisioned my entire career as a physician.

I am now a fourth year medical student and a pioneer of the “new curriculum” at Weill Cornell Medical College. In contrast to the traditional medical school curriculum, Cornell carved out 6 months of protected research time for all medical students by condensing the preclinical curriculum from 2 years to 1.5 years. I learned how much I enjoyed research at Johns Hopkins, which is one of the main reasons I applied here.

Despite my interest in research, I still struggled with the ultimate career question: What kind of doctor do I want to be?

After completing my medicine clerkship, I remember feeling intellectually stimulated in a way I hadn’t experienced in the previous years. While this may have had to do with the subject matter, I attribute much of this feeling to my clerkship director whose passion for medicine and teaching was contagious. I ultimately chose Ernie Esquivel, MD, to be my research mentor because of how much he impacted my education.

Together we came up with a project to study the utility of bone biopsies in the management of osteomyelitis. We are doing this by analyzing changes from empiric to final antibiotics after bone biopsy results become available to determine how clinicians use this information to guide their management of the disease. We were also interested in analyzing predictors of positive bone cultures in this population. The success of this project will mostly be based on our ability to perform these analyses, regardless of what the results may be. We hypothesize that, in fact, bone biopsy results are not likely to have a significant impact on antibiotic management of osteomyelitis in nonvertebral bones.

I was one of the lucky few to be awarded a grant from the Society of Hospital Medicine, which will be instrumental in the success of the project. This grant will not only support my ongoing research efforts but will also afford me the opportunity to attend the annual SHM conference and become integrated into the medical community in a way that would otherwise never be possible.

Cole Hirschfeld is originally from Phoenix, Ariz. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a fourth year medical student at Weill Cornell Medical College and plans to apply for residency in internal medicine.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?

Having volunteered at various hospitals since middle school, I became profoundly aware from a young age of the level of clinical knowledge that physicians must possess in order to safely treat their patients. When taking English and psychology classes in college, I became fascinated with the process of communication and common misunderstandings that take place due to different frames of mind.

Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.

At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.

With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.

We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.

I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.

Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?

Having volunteered at various hospitals since middle school, I became profoundly aware from a young age of the level of clinical knowledge that physicians must possess in order to safely treat their patients. When taking English and psychology classes in college, I became fascinated with the process of communication and common misunderstandings that take place due to different frames of mind.

Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.

At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.

With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.

We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.

I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.

Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

Quality improvement in clinical practice has recently become very important to me. What use is clinical knowledge if it cannot be appropriately used to benefit patients in a clinical setting?

Having volunteered at various hospitals since middle school, I became profoundly aware from a young age of the level of clinical knowledge that physicians must possess in order to safely treat their patients. When taking English and psychology classes in college, I became fascinated with the process of communication and common misunderstandings that take place due to different frames of mind.

Throughout my 1st year at medical school, my interest in communication continued to grow. In one of my classes, Essentials of Clinical Reasoning, we were taught to continually consider how to effectively translate our thought processes and potential diagnoses to our patients. To begin crafting effective HPIs, we created complete, whole histories from visit to visit.

At this time, I discovered the subfield of research concerning strategies surrounding handoffs as transition of care changes, with patients often suffering due to breakdowns in communication.

With my interest in handoffs, and with direction from the Society of Hospital Medicine, I reached out to Dr. Vineet Arora, a leading academic hospitalist at the University of Chicago with a highly impressive history of research concerning quality of care toward hospitalized adults. Under the supervision of Dr. Arora and Dr. Juan Rojas, a pulmonary critical care fellow, I will help investigate whether receiving floor physicians and intensive care unit physicians possess similar shared mental models in regards to the most pertinent point of care – when patients are transferred out of the ICU.

We seek to identify if there are any associations present between readmission from the general floor, the providers’ rated likelihood of the patient returning to the ICU, and whether floor and ICU physicians are on the same page concerning condition management while on the floor.

I believe the experience I gain at the University of Chicago Medical Center will be invaluable to my future as a physician. I am very excited to get to know the various clinicians at UChicago, to gain clinical experience by observing the management of the general ward, and to identify how effective physicians communicate.

Above all, I hope to use any knowledge I gain this summer to become an efficient, knowledgeable, and compassionate physician capable of providing the highest quality of care to my future patients.

Anton Garazha is a medical student at Chicago Medical School at Rosalind Franklin University in North Chicago, Ill. He received his B.S. in Biology from Loyola University in Chicago in 2015 and his Master of Biomedical Science from Rosalind Franklin University in 2016. Anton is very interested in community outreach and quality improvement, and in his spare time tutors students in science-based subjects.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.

I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.

We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.

Our objectives are twofold: describe the incidence of the transfers, as well as the clinical characteristics mentioned above, and conduct a case-control study comparing outcomes of the emergency transfer cases with matched controls.

So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.

I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.

I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.

After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.

I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.

Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.

I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.

We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.

Our objectives are twofold: describe the incidence of the transfers, as well as the clinical characteristics mentioned above, and conduct a case-control study comparing outcomes of the emergency transfer cases with matched controls.

So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.

I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.

I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.

After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.

I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.

Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.

 

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the program, recipients are required to write about their experiences on a biweekly basis.

I’m a rising second year medical student working this summer on a project to determine predictors for pediatric clinical deterioration and unplanned transfers to the pediatric ICU.

We’re hoping to identify characteristics of the pediatric population that is more prone to these unplanned transfers, as well as determine what clinical signs serve as reliable warnings so that an intervention can be designed to prevent these emergency transfers.

Our objectives are twofold: describe the incidence of the transfers, as well as the clinical characteristics mentioned above, and conduct a case-control study comparing outcomes of the emergency transfer cases with matched controls.

So far, I have been searching the literature for what current interventions exist to prevent pediatric clinical deterioration. I have been reading about rapid response teams and their effectiveness in preventing codes, as well as what measures are used to evaluate the condition of a pediatric patient who is at risk for clinical deterioration. It is clear that more investigation is needed to identify reliable predictors that indicate a possible ICU transfer for the child patient.

I was interested in this project, and in quality improvement, because of its power to directly improve patient care and safety. It is vital to identify and fix problems that are preventable. It is directly related to the work of the physician, and the interprofessional collaboration aspect is key to improve communication that directly affects the patients’ outcomes.

I was introduced to the field during the past year in medical school, and this prompted me to start looking for research projects in the hospital medicine department at Cincinnati Children’s Hospital. I was connected with Patrick Brady, MD, an attending physician in the division of hospital medicine at Cincinnati Children’s, whose work involves studying patient safety. His goals of investigating how to prevent clinical deterioration in pediatric patients aligned with what I wanted to learn during my research experience.

After partnering with my primary mentor, Dr. Brady, we discussed how the Student Hospitalist Scholar Grant would be a good fit for me, so I decided to apply.

I am excited to continue this experience this summer, as I believe it would not only educate me about applying interventions to better patient care but also about medicine in general. I plan to carry on and apply these lessons learned during my third year of medical school for rotations.

Farah Hussain is a second year medical student at the University of Cincinnati and student researcher at Cincinnati Children’s Hospital Medical Center. Her research interests involve bettering patient care in vulnerable populations.

 

Background and growth

Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.

The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.

A quick review of older articles and publications gives a very interesting and wry snapshot of the utilization of NP/PA providers in hospital medicine in past years. The titles alone provide for a chuckle or two:

• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”¹

• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”²

These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.

Program models

Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.

The first model is the classic paired rounding or “dyad” model. This is where a physician and an APP split a panel of patients. The APP then cares for his/her panel of patients, including daily visits, progress notes, calling consults, discharges, discharge summaries, procedures, billing, etc. The physician does the same for his/her panel of patients. The physician and the APP may then “run the list together” and the physician may then see most or all of the APP’s patients and bill for them when medical complexity demands. This allows for a higher volume of patients to be seen and billed, at a lower overall cost; it also provides for backup/support/redundancy for both team members when the patient acuity gets high.

Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.

The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).

Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.

APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.

On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.³

Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.

 

Ongoing barriers

There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”

On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.

If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.

Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.

Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.

Summary and future

In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.

References

1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.

2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.

3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.

 

Background and growth

Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.

The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.

A quick review of older articles and publications gives a very interesting and wry snapshot of the utilization of NP/PA providers in hospital medicine in past years. The titles alone provide for a chuckle or two:

• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”¹

• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”²

These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.

Program models

Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.

The first model is the classic paired rounding or “dyad” model. This is where a physician and an APP split a panel of patients. The APP then cares for his/her panel of patients, including daily visits, progress notes, calling consults, discharges, discharge summaries, procedures, billing, etc. The physician does the same for his/her panel of patients. The physician and the APP may then “run the list together” and the physician may then see most or all of the APP’s patients and bill for them when medical complexity demands. This allows for a higher volume of patients to be seen and billed, at a lower overall cost; it also provides for backup/support/redundancy for both team members when the patient acuity gets high.

Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.

The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).

Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.

APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.

On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.³

Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.

 

Ongoing barriers

There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”

On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.

If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.

Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.

Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.

Summary and future

In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.

References

1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.

2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.

3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.

 

Background and growth

Hospitalist nurse practitioner (NP) and physician assistant (PA) providers have been a growing and evolving part of the inpatient medical workforce, seemingly since the inception of hospital medicine. Given the growth of these disciplines within hospital medicine, at this juncture it is helpful to look at this journey, to see what roles these providers have been serving, and to consider newer and novel trends in how NPs and PAs are being weaved into hospital medicine programs.

The drivers for growth in this provider population are not unlike those of physician hospitalists. The same milieu that provided inroads for physicians in hospital-based care have led the way for increased use of NP/PA providers. An aging physician workforce, residency work hour reforms, increasing complexity of patients and systems on the inpatient side, and the recognition that caring for inpatients is a specialty vastly different from the role of internist in primary care have all impacted the numbers of NPs and PAs in this arena.

A quick review of older articles and publications gives a very interesting and wry snapshot of the utilization of NP/PA providers in hospital medicine in past years. The titles alone provide for a chuckle or two:

• 2007 Today’s Hospitalist article: “Midlevels make a rocky entrance into hospital medicine”¹

• 2009 ACP Hospitalist article: “When hiring midlevels, proceed with caution”²

These titles reflect the uncertainty at the time in how best to utilize NP/PA providers in hospital medicine (as well as an unfashionable vocabulary). The numbers at the time tell a similar story. In the Society of Hospital Medicine survey in 2007-2008, about 29% and 21% of hospital medicine practices utilized NPs and PAs, respectively. However, by 2014 about 50% of Veterans Affairs inpatient medical services deployed NP/PA providers, and most recent data from the Society of Hospital Medicine reveal that about 63% of groups use these advanced practice providers (APPs), with higher numbers in pediatric programs. Clearly there is evolving growth and enthusiasm for NP/PAs in hospital medicine.

Program models

Determining how best to use NP/PAs in hospital medicine programs has had a similar evolution. Reviewing past articles addressing these issues, one can see that there has been clear migration; initially NP/PAs were primarily hired to assist with late-afternoon admission surges, with about 60% of the APP workload being utilized to admit in 2007. Their role has continued to grow and change, much as hospitalist practices have; current program models consist of a few major types, with some novel models coming to the fore.

The first model is the classic paired rounding or “dyad” model. This is where a physician and an APP split a panel of patients. The APP then cares for his/her panel of patients, including daily visits, progress notes, calling consults, discharges, discharge summaries, procedures, billing, etc. The physician does the same for his/her panel of patients. The physician and the APP may then “run the list together” and the physician may then see most or all of the APP’s patients and bill for them when medical complexity demands. This allows for a higher volume of patients to be seen and billed, at a lower overall cost; it also provides for backup/support/redundancy for both team members when the patient acuity gets high.

Another model is use of an NP/PA in an observation unit or with lower acuity observation patients. The majority of the management of the patients is completed and billed by the APP, with the physician available for backup. This hits the “sweet spot,” utilizing the right provider with the right skill set for the right patient. The program has to account for some reimbursement or compensation for the physician oversight time, but it is a very efficient use of APPs.

The third major deployment of APPs is with admissions. Many groups use APPs to admit into the late afternoon and evening, getting patients “tucked in,” including starting diagnostic work-ups and treatment plans. The physician hospitalist then evaluates the patient the next day and often bills for the admission. This model works in situations where the patient work-up is dependent on lab testing, imaging, or other diagnostic testing to understand and plan for the “arc” of the hospitalization; or in situations where the diagnosis is clear, but the patient needs time with treatment to determine response. The downside of this model is long-term job satisfaction for the APP (although some programs have them rotate through such a model at intervals).

Another area where APPs have made strong inroads is that of comanagement services. The NP or PA develops a long-term relationship with a surgical comanagement team, and is often highly engaged and extremely appreciated for managing chronic conditions such as hypertension and diabetes. This can be a very satisfying model for both teams. The NP/PA usually bills independently for these encounters.

APPS are also used in cross coverage and triage roles, allowing the day teams to focus on their primary patients. In a triage role, they can interface with the emergency department, providing a semi-neutral “mediator” for patient disposition.

On the more novel end of the spectrum, there is growth in more independent roles for APP hospitalists. Some groups are having success at using the paired rounding or dyad model, but having the physician see the patient every third day. This is most successful where there is strong onboarding and deep clarity for when to contact the backup physician. There are some data to support the effectiveness of this model, most recently in the Journal of Clinical Outcomes Management.³

Critical access hospitals are also having success in deploying APPs in a very independent role, staffing these hospitals at night. Smaller, rural hospitals with aging medical staff have learned to maximize the scope of practice of their APPs to remain viable and provide care for inpatients. This can be a very successful model for APPs working at the maximum scope of their practice. In addition, the use of telemedicine has been implemented to allow for remote physician backup. This may be a rapidly growing arm to hospital medicine practices in the future.

 

Ongoing barriers

There are many barriers to maximizing the scope of practice and efficiency of APPs in hospital medicine. They range from the “macro” to the “micro.”

On the larger stage, Medicare requires that home care orders be signed by an attending physician, which can be inefficient and difficult to accomplish. Other payers may have somewhat arcane statutes that limit billing practices, and state practice limitations vary widely. Although 22 states now allow for independent practice for NPs, other states may have a very restrictive practice environment that can impede creative care delivery models. But regardless of how liberal a practice the state allows, a hospital’s medical bylaws can still restrict the day-to-day practice of APPs. And those restrictive bylaws are emblematic of a more constant and corporeal barrier to APP practice, that of medical staff culture.

If there are physicians on the staff who fear that utilization of NP/PA providers will lead to a decay in the quality of care, or who feel threatened by the use of APPs, that can create a local stopgap to maximizing utilization of APPs. In addition, hospitalist physicians and leaders may lack knowledge or experience in APP practice. APPs take more time to successfully onboard than physicians; without clear expectations or road maps to accomplish this onboarding, leaders may feel that APP integration doesn’t work. And one bad experience can create long-term barriers for future practices.

Other barriers are the lack of standardized rigor and vigor in graduate education programs (in both educational and clinical experiences). This results in variation in the quality of NP/PA providers at graduation. Knowledge gaps may be perceived as incompetence, rather than just a lack of experience. There is a certificate for added qualification in hospital medicine for PA providers (which includes a specialty exam), and there is an acute care focus for NPs in training; however, there is no standardized licensure to ensure hospital medicine competency, creating a quagmire for hospitalist leaders who desire demonstrable competence of these providers.

Another barrier for some programs is financial; physicians may not want to give up their RVUs to an NP/PA provider. This can really inhibit a more independent role for the APP. It is important that financial incentives align with all members of the practice working at maximum scope.

Summary and future

In summary, the role of PA/NP in hospital medicine has continued to grow and evolve, to meet the needs of the industry. This includes an increase in the scope and independence of APPs, including the use of telehealth for required oversight. As a specialty, it is imperative that we continue to research APP model effectiveness, embrace innovative delivery models, and support effective onboarding and career development opportunities for our NP/PA providers.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Ms. Cardin is vice president, Advanced Practice Providers, at Sound Physicians, and is a member of SHM’s Board of Directors.

References

1. “Midlevels make a rocky entrance into hospital medicine,” by Bonnie Darves, Today’s Hospitalist, January 2007.

2. “When hiring midlevels, proceed with caution,” by Jessica Berthold, ACP Hospitalist, April 2009.

3. “A Comparison of Conventional and Expanded Physician Assistant Hospitalist Staffing Models at a Community Hospital,” J Clin Outcomes Manag. 2016 Oct 1;23[10]:455-61.

 

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. For more information on how you can lend your expertise to help SHM improve the care of hospitalized patients, log on to www.hospitalmedicine.org/getinvolved.

This month, The Hospitalist spotlights Sandra Gage, MD, PhD, SFHM, associate professor of pediatrics in the section of hospital medicine at the Medical College of Wisconsin, newly appointed chair of SHM’s Pediatrics Committee, and SHM member of almost 20 years.

Why did you choose a career in pediatric hospital medicine, and how did you become an SHM member?

I would say that pediatric hospital medicine chose me. After obtaining a degree in physical therapy and spending five years treating children with a variety of neurological and neurodevelopmental disorders, I went back to school to get my MD and a PhD in neurobiology, thinking that I would specialize in either pediatric neurology or pediatric physical medicine and rehabilitation.

I always had an interest in treating children but never considered general pediatrics because spending my time in the outpatient clinic setting had little appeal for me. This was before the concept of being a “hospitalist” was widespread – and even before the phrase was coined – but there were a few providers in my academic pediatric group who focused on inpatient care. The pace, variety and challenge of treating hospitalized children was exactly what I was looking for, and, following completion of my pediatric residency, I slowly became a full-time hospitalist.

I joined SHM (then NAIP) on completion of my residency in 1998, shortly after the organization was founded, and was thrilled to find a national group of like-minded physicians. Because of the constraints of a large family and rapidly growing clinical responsibilities, my initial involvement with SHM was mostly as an avid reader of the Journal of Hospital Medicine from afar. Over the last ten years, I have been able to attend the annual meetings and get involved on the national level, which has exponentially increased the value of my membership.
 

What is the Pediatrics Committee currently working on, and what do you hope to accomplish during your term as Committee Chair?

With subspecialty status coming soon, rapidly expanding interest in the profession and the introduction of hospitalists into more areas of care, the landscape of pediatric hospital medicine is ever-changing. This amplifies the importance of the Pediatrics Committee’s role. The overall goals of the committee are to promote the growth and development of pediatric hospital medicine as a field and to provide educational and practical resources for individual practitioners.

The 2017-2018 committee comprises enthusiastic members from a wide variety of practice settings. At our first meeting in May, we formulated many exciting and innovative ideas to achieve our goals. As we continue to narrow down our approach and finalize our tasks for the year, we are also beginning to determine the content for the pediatric track at HM18. An example of a project the committee has executed in the past is the development of hospitalist-specific American Board of Pediatrics Maintenance of Certification modules for the SHM Learning Portal. In addition, the 2017 Pediatric Hospital Medicine (PHM) meeting is hosted by SHM this July in Nashville, and many Pediatrics Committee members are hard at work on finalizing those plans.
 

How has the PHM meeting evolved since its inception, and what value do you find in attending?

I have been an attendee of PHM many times over the years. The meeting has grown from a small group of no more than 100 individuals in a few hotel meeting rooms to more than 1,000 attendees and a wide variety of tracks and offerings. The growth of this meeting is truly reflective of the growth of our subspecialty, and the meeting brings together practitioners, both old and new, in an atmosphere full of innovations and ideas. Like SHM’s annual meeting, the PHM meeting is a great place for learning, sharing, and networking.

What advice do you have for fellow pediatric hospitalists during this transformational time in health care?

The direction of health care has provided fodder for lively discussion since I started my career 20 years ago. The nature of the practice of medicine is evolving, and, as physicians, we must be adept at navigating the changing climate while maintaining our goal of providing excellent care for our patients. As hospitalists, we have the opportunity to be in the forefront of the changes that will impact hospital care and utilization.

 

Whether our work is done at a local or a national level, as a group or as individuals, I believe that hospitalists will have an active role in directing the course of the future of medicine. We spend much of our clinical time advocating for our patients, but your experience is important and your voice can make an important contribution to the direction of health care for one child or for all children. Whether it is in the hospital hallway or on the Hill, continue to strive to do what you already do best.

Felicia Steele is SHM’s communications coordinator.

 

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. For more information on how you can lend your expertise to help SHM improve the care of hospitalized patients, log on to www.hospitalmedicine.org/getinvolved.

This month, The Hospitalist spotlights Sandra Gage, MD, PhD, SFHM, associate professor of pediatrics in the section of hospital medicine at the Medical College of Wisconsin, newly appointed chair of SHM’s Pediatrics Committee, and SHM member of almost 20 years.

Why did you choose a career in pediatric hospital medicine, and how did you become an SHM member?

I would say that pediatric hospital medicine chose me. After obtaining a degree in physical therapy and spending five years treating children with a variety of neurological and neurodevelopmental disorders, I went back to school to get my MD and a PhD in neurobiology, thinking that I would specialize in either pediatric neurology or pediatric physical medicine and rehabilitation.

I always had an interest in treating children but never considered general pediatrics because spending my time in the outpatient clinic setting had little appeal for me. This was before the concept of being a “hospitalist” was widespread – and even before the phrase was coined – but there were a few providers in my academic pediatric group who focused on inpatient care. The pace, variety and challenge of treating hospitalized children was exactly what I was looking for, and, following completion of my pediatric residency, I slowly became a full-time hospitalist.

I joined SHM (then NAIP) on completion of my residency in 1998, shortly after the organization was founded, and was thrilled to find a national group of like-minded physicians. Because of the constraints of a large family and rapidly growing clinical responsibilities, my initial involvement with SHM was mostly as an avid reader of the Journal of Hospital Medicine from afar. Over the last ten years, I have been able to attend the annual meetings and get involved on the national level, which has exponentially increased the value of my membership.
 

What is the Pediatrics Committee currently working on, and what do you hope to accomplish during your term as Committee Chair?

With subspecialty status coming soon, rapidly expanding interest in the profession and the introduction of hospitalists into more areas of care, the landscape of pediatric hospital medicine is ever-changing. This amplifies the importance of the Pediatrics Committee’s role. The overall goals of the committee are to promote the growth and development of pediatric hospital medicine as a field and to provide educational and practical resources for individual practitioners.

The 2017-2018 committee comprises enthusiastic members from a wide variety of practice settings. At our first meeting in May, we formulated many exciting and innovative ideas to achieve our goals. As we continue to narrow down our approach and finalize our tasks for the year, we are also beginning to determine the content for the pediatric track at HM18. An example of a project the committee has executed in the past is the development of hospitalist-specific American Board of Pediatrics Maintenance of Certification modules for the SHM Learning Portal. In addition, the 2017 Pediatric Hospital Medicine (PHM) meeting is hosted by SHM this July in Nashville, and many Pediatrics Committee members are hard at work on finalizing those plans.
 

How has the PHM meeting evolved since its inception, and what value do you find in attending?

I have been an attendee of PHM many times over the years. The meeting has grown from a small group of no more than 100 individuals in a few hotel meeting rooms to more than 1,000 attendees and a wide variety of tracks and offerings. The growth of this meeting is truly reflective of the growth of our subspecialty, and the meeting brings together practitioners, both old and new, in an atmosphere full of innovations and ideas. Like SHM’s annual meeting, the PHM meeting is a great place for learning, sharing, and networking.

What advice do you have for fellow pediatric hospitalists during this transformational time in health care?

The direction of health care has provided fodder for lively discussion since I started my career 20 years ago. The nature of the practice of medicine is evolving, and, as physicians, we must be adept at navigating the changing climate while maintaining our goal of providing excellent care for our patients. As hospitalists, we have the opportunity to be in the forefront of the changes that will impact hospital care and utilization.

 

Whether our work is done at a local or a national level, as a group or as individuals, I believe that hospitalists will have an active role in directing the course of the future of medicine. We spend much of our clinical time advocating for our patients, but your experience is important and your voice can make an important contribution to the direction of health care for one child or for all children. Whether it is in the hospital hallway or on the Hill, continue to strive to do what you already do best.

Felicia Steele is SHM’s communications coordinator.

 

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. For more information on how you can lend your expertise to help SHM improve the care of hospitalized patients, log on to www.hospitalmedicine.org/getinvolved.

This month, The Hospitalist spotlights Sandra Gage, MD, PhD, SFHM, associate professor of pediatrics in the section of hospital medicine at the Medical College of Wisconsin, newly appointed chair of SHM’s Pediatrics Committee, and SHM member of almost 20 years.

Why did you choose a career in pediatric hospital medicine, and how did you become an SHM member?

I would say that pediatric hospital medicine chose me. After obtaining a degree in physical therapy and spending five years treating children with a variety of neurological and neurodevelopmental disorders, I went back to school to get my MD and a PhD in neurobiology, thinking that I would specialize in either pediatric neurology or pediatric physical medicine and rehabilitation.

I always had an interest in treating children but never considered general pediatrics because spending my time in the outpatient clinic setting had little appeal for me. This was before the concept of being a “hospitalist” was widespread – and even before the phrase was coined – but there were a few providers in my academic pediatric group who focused on inpatient care. The pace, variety and challenge of treating hospitalized children was exactly what I was looking for, and, following completion of my pediatric residency, I slowly became a full-time hospitalist.

I joined SHM (then NAIP) on completion of my residency in 1998, shortly after the organization was founded, and was thrilled to find a national group of like-minded physicians. Because of the constraints of a large family and rapidly growing clinical responsibilities, my initial involvement with SHM was mostly as an avid reader of the Journal of Hospital Medicine from afar. Over the last ten years, I have been able to attend the annual meetings and get involved on the national level, which has exponentially increased the value of my membership.
 

What is the Pediatrics Committee currently working on, and what do you hope to accomplish during your term as Committee Chair?

With subspecialty status coming soon, rapidly expanding interest in the profession and the introduction of hospitalists into more areas of care, the landscape of pediatric hospital medicine is ever-changing. This amplifies the importance of the Pediatrics Committee’s role. The overall goals of the committee are to promote the growth and development of pediatric hospital medicine as a field and to provide educational and practical resources for individual practitioners.

The 2017-2018 committee comprises enthusiastic members from a wide variety of practice settings. At our first meeting in May, we formulated many exciting and innovative ideas to achieve our goals. As we continue to narrow down our approach and finalize our tasks for the year, we are also beginning to determine the content for the pediatric track at HM18. An example of a project the committee has executed in the past is the development of hospitalist-specific American Board of Pediatrics Maintenance of Certification modules for the SHM Learning Portal. In addition, the 2017 Pediatric Hospital Medicine (PHM) meeting is hosted by SHM this July in Nashville, and many Pediatrics Committee members are hard at work on finalizing those plans.
 

How has the PHM meeting evolved since its inception, and what value do you find in attending?

I have been an attendee of PHM many times over the years. The meeting has grown from a small group of no more than 100 individuals in a few hotel meeting rooms to more than 1,000 attendees and a wide variety of tracks and offerings. The growth of this meeting is truly reflective of the growth of our subspecialty, and the meeting brings together practitioners, both old and new, in an atmosphere full of innovations and ideas. Like SHM’s annual meeting, the PHM meeting is a great place for learning, sharing, and networking.

What advice do you have for fellow pediatric hospitalists during this transformational time in health care?

The direction of health care has provided fodder for lively discussion since I started my career 20 years ago. The nature of the practice of medicine is evolving, and, as physicians, we must be adept at navigating the changing climate while maintaining our goal of providing excellent care for our patients. As hospitalists, we have the opportunity to be in the forefront of the changes that will impact hospital care and utilization.

 

Whether our work is done at a local or a national level, as a group or as individuals, I believe that hospitalists will have an active role in directing the course of the future of medicine. We spend much of our clinical time advocating for our patients, but your experience is important and your voice can make an important contribution to the direction of health care for one child or for all children. Whether it is in the hospital hallway or on the Hill, continue to strive to do what you already do best.

Felicia Steele is SHM’s communications coordinator.

 

Editor’s Note: This SHM series highlights the professional pathways of quality improvement leaders. This month features the story of John Bulger, DO, chief medical officer for Geisinger Health Plan.

As chief medical officer for Geisinger Health Plan, John Bulger, DO, MBA, is intimately acquainted with the daily challenges that intersect with the delivery of safe, quality-driven care in the hospital system.

He’s also very familiar with the intricacies of carving out a professional road map. When Dr. Bulger began practicing as an internist at Geisinger Health System in the late 1990s, there wasn’t a formal hospitalist designation. He created one and became director of the hospital medicine program. Years later, when the opportunity arose to become chief quality officer, Dr. Bulger was a natural fit for the position, having led many improvement-centered committees and projects while running the hospital medicine group.

But the quality know-how did not come without additional training. “While competencies like problem solving and being a good listener and team player are part of the job of being a hospitalist, they don’t make you an expert in QI,” Dr. Bulger said. “There are learned skills that you need to spend time developing.”

Early in his QI immersion, Dr. Bulger sought training where available from sources such as ACP and SHM, while familiarizing himself with methodologies such as PDSA and Lean. There are far more QI training opportunities available to hospitalists today than when Dr. Bulger began his journey, but the fundamentals of success come back to finding the right mentors, team building, and implementing projects built around SMART goals.

Getting started, Dr. Bulger suggests to “pick something within your scope, like medical reconciliation for every patient, or ensuring that every patient who leaves the hospital gets an appointment with their primary physician within 7 days. Early on, we were working on issues like pneumonia core measures and providing discharge instructions.”

He cautions those starting out in QI against viewing unintended outcomes or project setbacks as failure. “If your goal is to take a (scenario) from bad to perfect, you’ll end up getting discouraged. Any effort toward making things better is helpful. If it doesn’t work you try something else.”

While Dr. Bulger is fully supportive of the impact that quality improvement projects make at the institutional level, he encourages clinicians and researchers to always keep the Institute for Healthcare Improvement Triple Aim in sight.

“We need better measures and more discussion about what is best for patients,” Dr. Bulger said. “The things we talk about in (health care) – readmission rates, glycemic control – have a minimal impact on people’s health, but the social determinants of health – the patient’s housing and economic situation – play a bigger role than anything else. As we move from provider- to patient-centric communities by fixing the Triple Aim, the experience will be better for both providers and patients.”
 

Claudia Stahl is content manager for the Society of Hospital Medicine.

 

Editor’s Note: This SHM series highlights the professional pathways of quality improvement leaders. This month features the story of John Bulger, DO, chief medical officer for Geisinger Health Plan.

As chief medical officer for Geisinger Health Plan, John Bulger, DO, MBA, is intimately acquainted with the daily challenges that intersect with the delivery of safe, quality-driven care in the hospital system.

He’s also very familiar with the intricacies of carving out a professional road map. When Dr. Bulger began practicing as an internist at Geisinger Health System in the late 1990s, there wasn’t a formal hospitalist designation. He created one and became director of the hospital medicine program. Years later, when the opportunity arose to become chief quality officer, Dr. Bulger was a natural fit for the position, having led many improvement-centered committees and projects while running the hospital medicine group.

But the quality know-how did not come without additional training. “While competencies like problem solving and being a good listener and team player are part of the job of being a hospitalist, they don’t make you an expert in QI,” Dr. Bulger said. “There are learned skills that you need to spend time developing.”

Early in his QI immersion, Dr. Bulger sought training where available from sources such as ACP and SHM, while familiarizing himself with methodologies such as PDSA and Lean. There are far more QI training opportunities available to hospitalists today than when Dr. Bulger began his journey, but the fundamentals of success come back to finding the right mentors, team building, and implementing projects built around SMART goals.

Getting started, Dr. Bulger suggests to “pick something within your scope, like medical reconciliation for every patient, or ensuring that every patient who leaves the hospital gets an appointment with their primary physician within 7 days. Early on, we were working on issues like pneumonia core measures and providing discharge instructions.”

He cautions those starting out in QI against viewing unintended outcomes or project setbacks as failure. “If your goal is to take a (scenario) from bad to perfect, you’ll end up getting discouraged. Any effort toward making things better is helpful. If it doesn’t work you try something else.”

While Dr. Bulger is fully supportive of the impact that quality improvement projects make at the institutional level, he encourages clinicians and researchers to always keep the Institute for Healthcare Improvement Triple Aim in sight.

“We need better measures and more discussion about what is best for patients,” Dr. Bulger said. “The things we talk about in (health care) – readmission rates, glycemic control – have a minimal impact on people’s health, but the social determinants of health – the patient’s housing and economic situation – play a bigger role than anything else. As we move from provider- to patient-centric communities by fixing the Triple Aim, the experience will be better for both providers and patients.”
 

Claudia Stahl is content manager for the Society of Hospital Medicine.

 

Editor’s Note: This SHM series highlights the professional pathways of quality improvement leaders. This month features the story of John Bulger, DO, chief medical officer for Geisinger Health Plan.

As chief medical officer for Geisinger Health Plan, John Bulger, DO, MBA, is intimately acquainted with the daily challenges that intersect with the delivery of safe, quality-driven care in the hospital system.

He’s also very familiar with the intricacies of carving out a professional road map. When Dr. Bulger began practicing as an internist at Geisinger Health System in the late 1990s, there wasn’t a formal hospitalist designation. He created one and became director of the hospital medicine program. Years later, when the opportunity arose to become chief quality officer, Dr. Bulger was a natural fit for the position, having led many improvement-centered committees and projects while running the hospital medicine group.

But the quality know-how did not come without additional training. “While competencies like problem solving and being a good listener and team player are part of the job of being a hospitalist, they don’t make you an expert in QI,” Dr. Bulger said. “There are learned skills that you need to spend time developing.”

Early in his QI immersion, Dr. Bulger sought training where available from sources such as ACP and SHM, while familiarizing himself with methodologies such as PDSA and Lean. There are far more QI training opportunities available to hospitalists today than when Dr. Bulger began his journey, but the fundamentals of success come back to finding the right mentors, team building, and implementing projects built around SMART goals.

Getting started, Dr. Bulger suggests to “pick something within your scope, like medical reconciliation for every patient, or ensuring that every patient who leaves the hospital gets an appointment with their primary physician within 7 days. Early on, we were working on issues like pneumonia core measures and providing discharge instructions.”

He cautions those starting out in QI against viewing unintended outcomes or project setbacks as failure. “If your goal is to take a (scenario) from bad to perfect, you’ll end up getting discouraged. Any effort toward making things better is helpful. If it doesn’t work you try something else.”

While Dr. Bulger is fully supportive of the impact that quality improvement projects make at the institutional level, he encourages clinicians and researchers to always keep the Institute for Healthcare Improvement Triple Aim in sight.

“We need better measures and more discussion about what is best for patients,” Dr. Bulger said. “The things we talk about in (health care) – readmission rates, glycemic control – have a minimal impact on people’s health, but the social determinants of health – the patient’s housing and economic situation – play a bigger role than anything else. As we move from provider- to patient-centric communities by fixing the Triple Aim, the experience will be better for both providers and patients.”
 

Claudia Stahl is content manager for the Society of Hospital Medicine.

 

“We Are Not Done Changing”

Recently, the online version of JAMA published an original investigation titled, “Patient Mortality During Unannounced Accreditation Surveys at US Hospitals.” The purpose of this investigation was to determine the effect of heightened vigilance during unannounced accreditation surveys on safety and quality of inpatient care.

The authors found that there was a significant reduction in mortality in patients admitted during the week of surveys by The Joint Commission. The change was more significant in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks, a 5.9% relative decrease. The positive effects of being monitored have been well documented in all kinds of arenas, such as hand washing and antibiotic stewardship. But mortality?

This is an interesting outcome, especially considering a recent ordeal I went through with my dear sister-in-law. She was on vacation in a somewhat remote location and suffers from a chronic illness that requires her to have a tunneled line through which she receives nocturnal TPN. She presented with high fever and rigors, septic, with a Klebsiella bacteremia. Though I was reassured somewhat by the words “sepsis protocol” used by the hospital staff, I was utterly dismayed when the hospitalist continued to use her line, even though the culture from the line was positive and she continued to spike fevers and develop rigors whenever the line was accessed.

Overall, I feel like I’m a reasonable person, but the clear lack of interest – or willingness to consider that this might not be a good idea on the part of the hospitalist in charge – incited a certain amount of anger and disbelief in me. She also received an antibiotic that she had a documented allergy to – a clear medical error. I instructed my sis-in-law to refuse access to the line; it was removed, and she ultimately recovered to discharge.

This brings me back to the JAMA study. It’s easy to perceive unannounced inspections as merely an inconvenience, where things are locked up that normally aren’t, or where that coveted cup of coffee you normally bring on rounds to get you through your day is summarily yanked out of your hand.

Read the full text of this blog post at hospitalleader.org.
 

Also on The Hospital Leader…

• How Often Do You Ask This (Ineffective) Question? by Brad Flansbaum, DO, MPH, MHM• Building a Practice that People Want to Be a Part Of by Leslie Flores, MHA• A Need for Medicare Appeals Process Reform in Hospital Observation Care by Anne Sheehy, MD, MS, FHM

 

“We Are Not Done Changing”

Recently, the online version of JAMA published an original investigation titled, “Patient Mortality During Unannounced Accreditation Surveys at US Hospitals.” The purpose of this investigation was to determine the effect of heightened vigilance during unannounced accreditation surveys on safety and quality of inpatient care.

The authors found that there was a significant reduction in mortality in patients admitted during the week of surveys by The Joint Commission. The change was more significant in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks, a 5.9% relative decrease. The positive effects of being monitored have been well documented in all kinds of arenas, such as hand washing and antibiotic stewardship. But mortality?

This is an interesting outcome, especially considering a recent ordeal I went through with my dear sister-in-law. She was on vacation in a somewhat remote location and suffers from a chronic illness that requires her to have a tunneled line through which she receives nocturnal TPN. She presented with high fever and rigors, septic, with a Klebsiella bacteremia. Though I was reassured somewhat by the words “sepsis protocol” used by the hospital staff, I was utterly dismayed when the hospitalist continued to use her line, even though the culture from the line was positive and she continued to spike fevers and develop rigors whenever the line was accessed.

Overall, I feel like I’m a reasonable person, but the clear lack of interest – or willingness to consider that this might not be a good idea on the part of the hospitalist in charge – incited a certain amount of anger and disbelief in me. She also received an antibiotic that she had a documented allergy to – a clear medical error. I instructed my sis-in-law to refuse access to the line; it was removed, and she ultimately recovered to discharge.

This brings me back to the JAMA study. It’s easy to perceive unannounced inspections as merely an inconvenience, where things are locked up that normally aren’t, or where that coveted cup of coffee you normally bring on rounds to get you through your day is summarily yanked out of your hand.

Read the full text of this blog post at hospitalleader.org.
 

Also on The Hospital Leader…

• How Often Do You Ask This (Ineffective) Question? by Brad Flansbaum, DO, MPH, MHM• Building a Practice that People Want to Be a Part Of by Leslie Flores, MHA• A Need for Medicare Appeals Process Reform in Hospital Observation Care by Anne Sheehy, MD, MS, FHM

 

“We Are Not Done Changing”

Recently, the online version of JAMA published an original investigation titled, “Patient Mortality During Unannounced Accreditation Surveys at US Hospitals.” The purpose of this investigation was to determine the effect of heightened vigilance during unannounced accreditation surveys on safety and quality of inpatient care.

The authors found that there was a significant reduction in mortality in patients admitted during the week of surveys by The Joint Commission. The change was more significant in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks, a 5.9% relative decrease. The positive effects of being monitored have been well documented in all kinds of arenas, such as hand washing and antibiotic stewardship. But mortality?

This is an interesting outcome, especially considering a recent ordeal I went through with my dear sister-in-law. She was on vacation in a somewhat remote location and suffers from a chronic illness that requires her to have a tunneled line through which she receives nocturnal TPN. She presented with high fever and rigors, septic, with a Klebsiella bacteremia. Though I was reassured somewhat by the words “sepsis protocol” used by the hospital staff, I was utterly dismayed when the hospitalist continued to use her line, even though the culture from the line was positive and she continued to spike fevers and develop rigors whenever the line was accessed.

Overall, I feel like I’m a reasonable person, but the clear lack of interest – or willingness to consider that this might not be a good idea on the part of the hospitalist in charge – incited a certain amount of anger and disbelief in me. She also received an antibiotic that she had a documented allergy to – a clear medical error. I instructed my sis-in-law to refuse access to the line; it was removed, and she ultimately recovered to discharge.

This brings me back to the JAMA study. It’s easy to perceive unannounced inspections as merely an inconvenience, where things are locked up that normally aren’t, or where that coveted cup of coffee you normally bring on rounds to get you through your day is summarily yanked out of your hand.

Read the full text of this blog post at hospitalleader.org.
 

Also on The Hospital Leader…

• How Often Do You Ask This (Ineffective) Question? by Brad Flansbaum, DO, MPH, MHM• Building a Practice that People Want to Be a Part Of by Leslie Flores, MHA• A Need for Medicare Appeals Process Reform in Hospital Observation Care by Anne Sheehy, MD, MS, FHM

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

What I say and do

I say “thank you” to each patient at the close of the clinical encounter and ask if there is something I can do for him or her before leaving the room.

Why I do it

The beginning and the end of a medical visit each have a significant impact on how patients view their overall experience with the physician. Devoting energy and thought to these critical moments during the patient-physician interaction is simple and rewarding, and helps leave patients with a good impression.

Closing the visit in a deliberate manner, by thanking the patient and asking if there is some way I can assist before departing, ensures that I remain attentive and engaged until the encounter concludes, shows compassion, and helps patients feel appreciated and understood.
 

How I do it

At the close of each patient visit, whether in the emergency department with a new admission or during daily rounds, I incorporate a “thank you” prior to leaving the room.

For example, I thank the patient for going over the details of her history with me; I know she has repeated the same information several times already. I thank the patient who brought in a detailed home medication list that made medication reconciliation a breeze for this organization. If I discussed a sensitive or difficult topic with the patient, such as substance use, I thank the patient for being honest. Another option is to thank the patient for trusting me with his care during the hospitalization. My favorite “thank you,” and one that will work in any situation, is to thank a patient for his or her patience. Whether it is waiting for a procedure, waiting to eat, or waiting for the green light to go home, our patients’ patience is tremendous and absolutely deserves to be recognized.

After saying “thank you,” I close with a simple but powerful question: “Is there something I can do for you before I leave? I have time.” Perhaps I can assist with a refill of ice chips, help find the call button, or relay a message to the bedside nurse. Whatever the task may be, offering to help before departing humanizes the interaction between physician and patient and is sure to be appreciated and remembered. Furthermore, taking a pause in the hectic pace of the day to show patients that we care can give busy hospitalists a moment to recharge before moving on to the next item on the to-do list. Any way you look at it, thanking our patients and offering to help is time well spent.
 

Dr. Sebasky is assistant clinical professor at the University of California, San Diego.

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

What I say and do

I say “thank you” to each patient at the close of the clinical encounter and ask if there is something I can do for him or her before leaving the room.

Why I do it

The beginning and the end of a medical visit each have a significant impact on how patients view their overall experience with the physician. Devoting energy and thought to these critical moments during the patient-physician interaction is simple and rewarding, and helps leave patients with a good impression.

Closing the visit in a deliberate manner, by thanking the patient and asking if there is some way I can assist before departing, ensures that I remain attentive and engaged until the encounter concludes, shows compassion, and helps patients feel appreciated and understood.
 

How I do it

At the close of each patient visit, whether in the emergency department with a new admission or during daily rounds, I incorporate a “thank you” prior to leaving the room.

For example, I thank the patient for going over the details of her history with me; I know she has repeated the same information several times already. I thank the patient who brought in a detailed home medication list that made medication reconciliation a breeze for this organization. If I discussed a sensitive or difficult topic with the patient, such as substance use, I thank the patient for being honest. Another option is to thank the patient for trusting me with his care during the hospitalization. My favorite “thank you,” and one that will work in any situation, is to thank a patient for his or her patience. Whether it is waiting for a procedure, waiting to eat, or waiting for the green light to go home, our patients’ patience is tremendous and absolutely deserves to be recognized.

After saying “thank you,” I close with a simple but powerful question: “Is there something I can do for you before I leave? I have time.” Perhaps I can assist with a refill of ice chips, help find the call button, or relay a message to the bedside nurse. Whatever the task may be, offering to help before departing humanizes the interaction between physician and patient and is sure to be appreciated and remembered. Furthermore, taking a pause in the hectic pace of the day to show patients that we care can give busy hospitalists a moment to recharge before moving on to the next item on the to-do list. Any way you look at it, thanking our patients and offering to help is time well spent.
 

Dr. Sebasky is assistant clinical professor at the University of California, San Diego.

 

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experience of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”

What I say and do

I say “thank you” to each patient at the close of the clinical encounter and ask if there is something I can do for him or her before leaving the room.

Why I do it

The beginning and the end of a medical visit each have a significant impact on how patients view their overall experience with the physician. Devoting energy and thought to these critical moments during the patient-physician interaction is simple and rewarding, and helps leave patients with a good impression.

Closing the visit in a deliberate manner, by thanking the patient and asking if there is some way I can assist before departing, ensures that I remain attentive and engaged until the encounter concludes, shows compassion, and helps patients feel appreciated and understood.
 

How I do it

At the close of each patient visit, whether in the emergency department with a new admission or during daily rounds, I incorporate a “thank you” prior to leaving the room.

For example, I thank the patient for going over the details of her history with me; I know she has repeated the same information several times already. I thank the patient who brought in a detailed home medication list that made medication reconciliation a breeze for this organization. If I discussed a sensitive or difficult topic with the patient, such as substance use, I thank the patient for being honest. Another option is to thank the patient for trusting me with his care during the hospitalization. My favorite “thank you,” and one that will work in any situation, is to thank a patient for his or her patience. Whether it is waiting for a procedure, waiting to eat, or waiting for the green light to go home, our patients’ patience is tremendous and absolutely deserves to be recognized.

After saying “thank you,” I close with a simple but powerful question: “Is there something I can do for you before I leave? I have time.” Perhaps I can assist with a refill of ice chips, help find the call button, or relay a message to the bedside nurse. Whatever the task may be, offering to help before departing humanizes the interaction between physician and patient and is sure to be appreciated and remembered. Furthermore, taking a pause in the hectic pace of the day to show patients that we care can give busy hospitalists a moment to recharge before moving on to the next item on the to-do list. Any way you look at it, thanking our patients and offering to help is time well spent.
 

Dr. Sebasky is assistant clinical professor at the University of California, San Diego.

 

SHM’s two newest board members – pediatric hospitalist Kris Rehm, MD, SFHM, and perioperative specialist Rachel Thompson, MD, MPH, SFHM – will bring their expertise to bear on the society’s top panel.

However, neither woman sees her role as shaping the board. In fact, they see themselves as lucky to be joining the team.

“It’s a true honor to be able to sit on the board and serve the community of hospitalists,” said Dr. Thompson, outgoing chair of SHM’s chapter support committee and head of the section of hospital medicine at the University of Nebraska in Omaha.

“I really want to hear everyone’s voice, and I hope to see how we can all move to better places together,” added Dr. Rehm, associate professor of clinical pediatrics and director of the division of hospital medicine at Vanderbilt University in Nashville.

Both board members were officially seated for three-year terms at HM17 in Las Vegas. They replace former SHM president Robert Harrington, MD, SFHM, and veteran pediatric hospitalist Erin Stucky Fisher, MD, MHM.

Each of the new board members brings a strong perspective to the panel.

For Dr. Thompson, that viewpoint is based in engagement. She is the former chair of SHM’s Pacific Northwest chapter and has spent the past few years leading the perioperative issues for the society’s work group.

“We get to a certain point of our career as hospitalists, and if we’re just plugging in and working, doing our shifts, somewhere in that 8- to 10-year range, we might get a little bored, tired, worn out,” Dr. Thompson said. “I believe, if we have the community and professional home to keep us engaged, that helps us see the value in what we’re doing every day. It helps us continue to grow, so we don’t hit that wall.”

Given Dr. Thompson’s involvement both with her chapter and the society’s chapter support committee, she will likely continue that effort to make sure SHM’s board sees the value of encouraging and partnering with local chapters. She will also work with SHM president Ron Greeno, MD, FCCP, MHM, on policy issues, as her background in public health has aligned her interests on health care reform and other headwinds facing the specialty.

“I went in to do my masters in public health with the idea that I wanted to build the skill set so that I could be more analytical in how I approach our problem solving, our discovery in the hospital setting,” she said. “It really speaks to a part of me that has always been interested in finding ways to prevent illness and moving beyond that reactivity that we have in medicine into a prevention-based [approach].”

Dr. Thompson noted that her background in perioperative medicine helps her work as part of a team because it “entirely relies on collaboration and coordination of care, which is pretty much the basis of what we do in the hospital any day.”

Dr. Rehm, who serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, said she will also bring a teamwork-focused perspective to the SHM board.

She could be expected to view everything through the lens of inpatient pediatrics, but that’s not her style.

“I think we have so many similarities and so many things that [pediatric and adult hospitalists] can partner to do together,” she said. “We all are involved in, for example, medication reconciliation or discharge-management planning or postacute care follow-up. There’s a lot of synergy, and I think we can learn so much from each other.”

Dr. Rehm, who chairs SHM’s Pediatrics Committee and the 2017 Pediatric Hospital Medicine meeting, pointed out that working well with others is a natural skill set for hospitalists.

“Collaboration is probably my biggest skill set and that of many hospital medicine providers,” she said. “I think I do that in my job here at Vanderbilt in thinking about complicated patients that requirement multiple subspecialists and in bringing together people to figure out the question at hand. That is definitely my leadership style.”

If Dr. Rehm has one goal on the board, it is to become a little bit more like Dr. Thompson and focus on chapter development for pediatric hospitalists.

“I’m really interested in engaging with members to better understand the struggles on the front line so that we can make sure that, as an organization, we’re offering a brand of things that our membership needs,” she said. “So, I’m really looking forward to becoming more involved in the chapter engagement and development. The Nashville chapter is getting re-engaged now and I’m excited to be involved.”

To prepare for her debut board meeting in Las Vegas, Dr. Rehm attended SHM board meetings at the group’s Philadelphia headquarters over the past two years.

“I’ve been lucky enough to attend the fall board meeting in Philadelphia and observe the board in action, and I think that has helped me get to know some of the current board members and to have a little bit of a vision of what the meetings will be like,” she said.

 

SHM’s two newest board members – pediatric hospitalist Kris Rehm, MD, SFHM, and perioperative specialist Rachel Thompson, MD, MPH, SFHM – will bring their expertise to bear on the society’s top panel.

However, neither woman sees her role as shaping the board. In fact, they see themselves as lucky to be joining the team.

“It’s a true honor to be able to sit on the board and serve the community of hospitalists,” said Dr. Thompson, outgoing chair of SHM’s chapter support committee and head of the section of hospital medicine at the University of Nebraska in Omaha.

“I really want to hear everyone’s voice, and I hope to see how we can all move to better places together,” added Dr. Rehm, associate professor of clinical pediatrics and director of the division of hospital medicine at Vanderbilt University in Nashville.

Both board members were officially seated for three-year terms at HM17 in Las Vegas. They replace former SHM president Robert Harrington, MD, SFHM, and veteran pediatric hospitalist Erin Stucky Fisher, MD, MHM.

Each of the new board members brings a strong perspective to the panel.

For Dr. Thompson, that viewpoint is based in engagement. She is the former chair of SHM’s Pacific Northwest chapter and has spent the past few years leading the perioperative issues for the society’s work group.

“We get to a certain point of our career as hospitalists, and if we’re just plugging in and working, doing our shifts, somewhere in that 8- to 10-year range, we might get a little bored, tired, worn out,” Dr. Thompson said. “I believe, if we have the community and professional home to keep us engaged, that helps us see the value in what we’re doing every day. It helps us continue to grow, so we don’t hit that wall.”

Given Dr. Thompson’s involvement both with her chapter and the society’s chapter support committee, she will likely continue that effort to make sure SHM’s board sees the value of encouraging and partnering with local chapters. She will also work with SHM president Ron Greeno, MD, FCCP, MHM, on policy issues, as her background in public health has aligned her interests on health care reform and other headwinds facing the specialty.

“I went in to do my masters in public health with the idea that I wanted to build the skill set so that I could be more analytical in how I approach our problem solving, our discovery in the hospital setting,” she said. “It really speaks to a part of me that has always been interested in finding ways to prevent illness and moving beyond that reactivity that we have in medicine into a prevention-based [approach].”

Dr. Thompson noted that her background in perioperative medicine helps her work as part of a team because it “entirely relies on collaboration and coordination of care, which is pretty much the basis of what we do in the hospital any day.”

Dr. Rehm, who serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, said she will also bring a teamwork-focused perspective to the SHM board.

She could be expected to view everything through the lens of inpatient pediatrics, but that’s not her style.

“I think we have so many similarities and so many things that [pediatric and adult hospitalists] can partner to do together,” she said. “We all are involved in, for example, medication reconciliation or discharge-management planning or postacute care follow-up. There’s a lot of synergy, and I think we can learn so much from each other.”

Dr. Rehm, who chairs SHM’s Pediatrics Committee and the 2017 Pediatric Hospital Medicine meeting, pointed out that working well with others is a natural skill set for hospitalists.

“Collaboration is probably my biggest skill set and that of many hospital medicine providers,” she said. “I think I do that in my job here at Vanderbilt in thinking about complicated patients that requirement multiple subspecialists and in bringing together people to figure out the question at hand. That is definitely my leadership style.”

If Dr. Rehm has one goal on the board, it is to become a little bit more like Dr. Thompson and focus on chapter development for pediatric hospitalists.

“I’m really interested in engaging with members to better understand the struggles on the front line so that we can make sure that, as an organization, we’re offering a brand of things that our membership needs,” she said. “So, I’m really looking forward to becoming more involved in the chapter engagement and development. The Nashville chapter is getting re-engaged now and I’m excited to be involved.”

To prepare for her debut board meeting in Las Vegas, Dr. Rehm attended SHM board meetings at the group’s Philadelphia headquarters over the past two years.

“I’ve been lucky enough to attend the fall board meeting in Philadelphia and observe the board in action, and I think that has helped me get to know some of the current board members and to have a little bit of a vision of what the meetings will be like,” she said.

 

SHM’s two newest board members – pediatric hospitalist Kris Rehm, MD, SFHM, and perioperative specialist Rachel Thompson, MD, MPH, SFHM – will bring their expertise to bear on the society’s top panel.

However, neither woman sees her role as shaping the board. In fact, they see themselves as lucky to be joining the team.

“It’s a true honor to be able to sit on the board and serve the community of hospitalists,” said Dr. Thompson, outgoing chair of SHM’s chapter support committee and head of the section of hospital medicine at the University of Nebraska in Omaha.

“I really want to hear everyone’s voice, and I hope to see how we can all move to better places together,” added Dr. Rehm, associate professor of clinical pediatrics and director of the division of hospital medicine at Vanderbilt University in Nashville.

Both board members were officially seated for three-year terms at HM17 in Las Vegas. They replace former SHM president Robert Harrington, MD, SFHM, and veteran pediatric hospitalist Erin Stucky Fisher, MD, MHM.

Each of the new board members brings a strong perspective to the panel.

For Dr. Thompson, that viewpoint is based in engagement. She is the former chair of SHM’s Pacific Northwest chapter and has spent the past few years leading the perioperative issues for the society’s work group.

“We get to a certain point of our career as hospitalists, and if we’re just plugging in and working, doing our shifts, somewhere in that 8- to 10-year range, we might get a little bored, tired, worn out,” Dr. Thompson said. “I believe, if we have the community and professional home to keep us engaged, that helps us see the value in what we’re doing every day. It helps us continue to grow, so we don’t hit that wall.”

Given Dr. Thompson’s involvement both with her chapter and the society’s chapter support committee, she will likely continue that effort to make sure SHM’s board sees the value of encouraging and partnering with local chapters. She will also work with SHM president Ron Greeno, MD, FCCP, MHM, on policy issues, as her background in public health has aligned her interests on health care reform and other headwinds facing the specialty.

“I went in to do my masters in public health with the idea that I wanted to build the skill set so that I could be more analytical in how I approach our problem solving, our discovery in the hospital setting,” she said. “It really speaks to a part of me that has always been interested in finding ways to prevent illness and moving beyond that reactivity that we have in medicine into a prevention-based [approach].”

Dr. Thompson noted that her background in perioperative medicine helps her work as part of a team because it “entirely relies on collaboration and coordination of care, which is pretty much the basis of what we do in the hospital any day.”

Dr. Rehm, who serves as a pediatric hospitalist at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, said she will also bring a teamwork-focused perspective to the SHM board.

She could be expected to view everything through the lens of inpatient pediatrics, but that’s not her style.

“I think we have so many similarities and so many things that [pediatric and adult hospitalists] can partner to do together,” she said. “We all are involved in, for example, medication reconciliation or discharge-management planning or postacute care follow-up. There’s a lot of synergy, and I think we can learn so much from each other.”

Dr. Rehm, who chairs SHM’s Pediatrics Committee and the 2017 Pediatric Hospital Medicine meeting, pointed out that working well with others is a natural skill set for hospitalists.

“Collaboration is probably my biggest skill set and that of many hospital medicine providers,” she said. “I think I do that in my job here at Vanderbilt in thinking about complicated patients that requirement multiple subspecialists and in bringing together people to figure out the question at hand. That is definitely my leadership style.”

If Dr. Rehm has one goal on the board, it is to become a little bit more like Dr. Thompson and focus on chapter development for pediatric hospitalists.

“I’m really interested in engaging with members to better understand the struggles on the front line so that we can make sure that, as an organization, we’re offering a brand of things that our membership needs,” she said. “So, I’m really looking forward to becoming more involved in the chapter engagement and development. The Nashville chapter is getting re-engaged now and I’m excited to be involved.”

To prepare for her debut board meeting in Las Vegas, Dr. Rehm attended SHM board meetings at the group’s Philadelphia headquarters over the past two years.

“I’ve been lucky enough to attend the fall board meeting in Philadelphia and observe the board in action, and I think that has helped me get to know some of the current board members and to have a little bit of a vision of what the meetings will be like,” she said.

 

If you are a hospitalist and leader in your health care organization, the ongoing controversies surrounding the Affordable Care Act repeal and replace campaign are unsettling. No matter your politics, Washington’s political drama and gamesmanship pose a genuine threat to the solvency of your hospital’s budget, services, workforce, and patients.

Health care has devolved into a political football, tossed from skirmish to skirmish. Political leaders warn of the implosion of the health care system as a political tactic, not an outcome that could cost and ruin lives. Both Democrats and Republicans hope that if or when that happens, it does so in ways that allow them to blame the other side. For them, this is a game of partisan advantage that wagers the well-being of your health care system.

For you, the situation remains predictably unpredictable. The future directives from Washington are unknowable. This makes your strategic planning – and health care leadership itself – a complex and puzzling task. Your job now is not simply leading your organization for today. Your more important mission is preparing your organization to perform in this unpredictable and perplexing future.

Forecasting is the life blood of leadership: Craft a vision and the work to achieve it; be mindful of the range of obstacles and opportunities; and know and coalesce your followers. The problem is that today’s prospects are loaded with puzzling twists and turns. The viability of both the private insurance market and public dollars are – maybe! – in future jeopardy. Patients and the workforce are understandably jittery. What is a hospitalist leader to do?

It is time to refresh your thinking, to take a big picture view of what is happening and to assess what can be done about it. There is a tendency for leaders to look at problems and then wonder how to fit solutions into their established organizational framework. In other words, solutions are cast into the mold of retaining what you have, ignoring larger options and innovative possibilities. Solutions are expected to adapt to the organization rather than the organization adapting to the solutions.

The hospitalist movement grew as early leaders – true innovators – recognized the problems of costly, inefficient and uncoordinated care. Rather than tinkering with what was, hospitalist leaders introduced a new and proactive model to provide care. It had to first prove itself and once it did, a once revolutionary idea evolved into an institutionalized solution.

No matter what emerges from the current policy debate, the national pressures on the health care system persist: rising expectations for access; decreasing patience for spending; increasing appetite for breakthrough technology; shifting workforce requirements; all combined with a population that is aging and more in need of care. These are meta-trends that will redefine how the health system operates and what it will achieve. What is a health care leader to do?

Think and act like a “meta-leader.” This framework, developed at the Harvard T.H. Chan School of Public Health, guides leaders facing complex and transformational problem solving. The prefix “meta-” encourages expansive analysis directed toward a wide range of options and opportunities. In keeping with the strategies employed by hospitalist pioneers, rather than building solutions around “what already is,” meta-leaders pursue “what could be.” In this way, solutions are designed and constructed to fit the problems they are intended to overcome.

There are three critical dimensions to the thinking and practices of meta-leadership.

The first is the Person of the meta-leader. This is who you are, your priorities and values. This is how other people regard your leadership, translated into the respect, trust, and “followership” you garner. Be a role model. This involves building your own confidence for the task at hand so that you gain and then foster the confidence of those you lead. As a meta-leader, you shape your mindset and that of others for innovation, sharpening the curiosity necessary for fostering discovery and exploration of new ideas. Be ready to take appropriate risks.

The second dimension of meta-leadership practice is the Situation. This is what is happening and what can be done about it. You did not create the complex circumstances that derive from the political showdown in Washington. However, it is your job to understand them and to develop effective strategies and operations in response. This is where the “think big” of meta-leadership comes into play. You distinguish the chasm between the adversarial policy confrontation in Washington and the collaborative solution building needed in your home institution. You want to set the stage to meaningfully coalesce the thinking, resources, and people in your organization. The invigorated shared mission is a health care system that leads into the future.

The third dimension of meta-leadership practice is about building the Connectivity needed to make that happen. This involves developing the communication, coordination, and cooperation necessary for constructing something new. Many of your answers lie within the walls of your organization, even the most innovative among them. This is where you sow adaptability and flexibility. It translates into necessary change and transformation. This is reorienting what you and others do and how you go about doing it, from shifts and adjustments to, when necessary, disruptive innovation.

A recent Harvard Business School and Harvard Medical School forum on health care innovation identified five imperatives for meeting innovation challenges in health care: 1) Creating value is the key aim for innovation and it requires a combination of care coordination along with communication; 2) Seek opportunities for process improvement that allows new ideas to be tested, accepting that failure is a step on the road to discovery; 3) Adopt a consumerism strategy for service organization that engages and involves active patients; 4) Decentralize problem solving to encourage field innovation and collaboration; and 5) Integrate new models into established institutions, introducing fresh thinking to replace outdated practices.

Meta-leadership is not a formula for an easy fix. While much remains unpredictable, an impending economic squeeze is a likely scenario. There is nothing easy about a shortage of dollars to serve more and more people in need of clinical care. This may very well be the prompt – today – that encourages the sort of innovative thinking and disruptive solution development that the future requires. Will you and your organization get ahead of this curve?

Your mission as a hospitalist meta-leader is in forging this process of discovery. Perceive what is going on through a wide lens. Orient yourself to emerging trends. Predict what is likely to emerge from this unpredictable policy environment. Take decisions and operationalize them in ways responsive to the circumstances at hand. And then communicate with your constituencies, not only to inform them of direction but also to learn from them what is working and what not. And then you start the process again, trying on ideas and practices, learning from them and through this continuous process, finding solutions that fit your situation at hand.

Health care meta-leaders today must keep both eyes firmly on their feet, to know that current operations are achieving necessary success. At the same time, they must also keep both eyes focused on the horizon, to ensure that when conditions change, their organizations are ready to adaptively innovate and transform.
 

 

Leonard J. Marcus, Ph.D. is coauthor of Renegotiating Health Care: Resolving Conflict to Build Collaboration, Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected]

 

If you are a hospitalist and leader in your health care organization, the ongoing controversies surrounding the Affordable Care Act repeal and replace campaign are unsettling. No matter your politics, Washington’s political drama and gamesmanship pose a genuine threat to the solvency of your hospital’s budget, services, workforce, and patients.

Health care has devolved into a political football, tossed from skirmish to skirmish. Political leaders warn of the implosion of the health care system as a political tactic, not an outcome that could cost and ruin lives. Both Democrats and Republicans hope that if or when that happens, it does so in ways that allow them to blame the other side. For them, this is a game of partisan advantage that wagers the well-being of your health care system.

For you, the situation remains predictably unpredictable. The future directives from Washington are unknowable. This makes your strategic planning – and health care leadership itself – a complex and puzzling task. Your job now is not simply leading your organization for today. Your more important mission is preparing your organization to perform in this unpredictable and perplexing future.

Forecasting is the life blood of leadership: Craft a vision and the work to achieve it; be mindful of the range of obstacles and opportunities; and know and coalesce your followers. The problem is that today’s prospects are loaded with puzzling twists and turns. The viability of both the private insurance market and public dollars are – maybe! – in future jeopardy. Patients and the workforce are understandably jittery. What is a hospitalist leader to do?

It is time to refresh your thinking, to take a big picture view of what is happening and to assess what can be done about it. There is a tendency for leaders to look at problems and then wonder how to fit solutions into their established organizational framework. In other words, solutions are cast into the mold of retaining what you have, ignoring larger options and innovative possibilities. Solutions are expected to adapt to the organization rather than the organization adapting to the solutions.

The hospitalist movement grew as early leaders – true innovators – recognized the problems of costly, inefficient and uncoordinated care. Rather than tinkering with what was, hospitalist leaders introduced a new and proactive model to provide care. It had to first prove itself and once it did, a once revolutionary idea evolved into an institutionalized solution.

No matter what emerges from the current policy debate, the national pressures on the health care system persist: rising expectations for access; decreasing patience for spending; increasing appetite for breakthrough technology; shifting workforce requirements; all combined with a population that is aging and more in need of care. These are meta-trends that will redefine how the health system operates and what it will achieve. What is a health care leader to do?

Think and act like a “meta-leader.” This framework, developed at the Harvard T.H. Chan School of Public Health, guides leaders facing complex and transformational problem solving. The prefix “meta-” encourages expansive analysis directed toward a wide range of options and opportunities. In keeping with the strategies employed by hospitalist pioneers, rather than building solutions around “what already is,” meta-leaders pursue “what could be.” In this way, solutions are designed and constructed to fit the problems they are intended to overcome.

There are three critical dimensions to the thinking and practices of meta-leadership.

The first is the Person of the meta-leader. This is who you are, your priorities and values. This is how other people regard your leadership, translated into the respect, trust, and “followership” you garner. Be a role model. This involves building your own confidence for the task at hand so that you gain and then foster the confidence of those you lead. As a meta-leader, you shape your mindset and that of others for innovation, sharpening the curiosity necessary for fostering discovery and exploration of new ideas. Be ready to take appropriate risks.

The second dimension of meta-leadership practice is the Situation. This is what is happening and what can be done about it. You did not create the complex circumstances that derive from the political showdown in Washington. However, it is your job to understand them and to develop effective strategies and operations in response. This is where the “think big” of meta-leadership comes into play. You distinguish the chasm between the adversarial policy confrontation in Washington and the collaborative solution building needed in your home institution. You want to set the stage to meaningfully coalesce the thinking, resources, and people in your organization. The invigorated shared mission is a health care system that leads into the future.

The third dimension of meta-leadership practice is about building the Connectivity needed to make that happen. This involves developing the communication, coordination, and cooperation necessary for constructing something new. Many of your answers lie within the walls of your organization, even the most innovative among them. This is where you sow adaptability and flexibility. It translates into necessary change and transformation. This is reorienting what you and others do and how you go about doing it, from shifts and adjustments to, when necessary, disruptive innovation.

A recent Harvard Business School and Harvard Medical School forum on health care innovation identified five imperatives for meeting innovation challenges in health care: 1) Creating value is the key aim for innovation and it requires a combination of care coordination along with communication; 2) Seek opportunities for process improvement that allows new ideas to be tested, accepting that failure is a step on the road to discovery; 3) Adopt a consumerism strategy for service organization that engages and involves active patients; 4) Decentralize problem solving to encourage field innovation and collaboration; and 5) Integrate new models into established institutions, introducing fresh thinking to replace outdated practices.

Meta-leadership is not a formula for an easy fix. While much remains unpredictable, an impending economic squeeze is a likely scenario. There is nothing easy about a shortage of dollars to serve more and more people in need of clinical care. This may very well be the prompt – today – that encourages the sort of innovative thinking and disruptive solution development that the future requires. Will you and your organization get ahead of this curve?

Your mission as a hospitalist meta-leader is in forging this process of discovery. Perceive what is going on through a wide lens. Orient yourself to emerging trends. Predict what is likely to emerge from this unpredictable policy environment. Take decisions and operationalize them in ways responsive to the circumstances at hand. And then communicate with your constituencies, not only to inform them of direction but also to learn from them what is working and what not. And then you start the process again, trying on ideas and practices, learning from them and through this continuous process, finding solutions that fit your situation at hand.

Health care meta-leaders today must keep both eyes firmly on their feet, to know that current operations are achieving necessary success. At the same time, they must also keep both eyes focused on the horizon, to ensure that when conditions change, their organizations are ready to adaptively innovate and transform.
 

 

Leonard J. Marcus, Ph.D. is coauthor of Renegotiating Health Care: Resolving Conflict to Build Collaboration, Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected]

 

If you are a hospitalist and leader in your health care organization, the ongoing controversies surrounding the Affordable Care Act repeal and replace campaign are unsettling. No matter your politics, Washington’s political drama and gamesmanship pose a genuine threat to the solvency of your hospital’s budget, services, workforce, and patients.

Health care has devolved into a political football, tossed from skirmish to skirmish. Political leaders warn of the implosion of the health care system as a political tactic, not an outcome that could cost and ruin lives. Both Democrats and Republicans hope that if or when that happens, it does so in ways that allow them to blame the other side. For them, this is a game of partisan advantage that wagers the well-being of your health care system.

For you, the situation remains predictably unpredictable. The future directives from Washington are unknowable. This makes your strategic planning – and health care leadership itself – a complex and puzzling task. Your job now is not simply leading your organization for today. Your more important mission is preparing your organization to perform in this unpredictable and perplexing future.

Forecasting is the life blood of leadership: Craft a vision and the work to achieve it; be mindful of the range of obstacles and opportunities; and know and coalesce your followers. The problem is that today’s prospects are loaded with puzzling twists and turns. The viability of both the private insurance market and public dollars are – maybe! – in future jeopardy. Patients and the workforce are understandably jittery. What is a hospitalist leader to do?

It is time to refresh your thinking, to take a big picture view of what is happening and to assess what can be done about it. There is a tendency for leaders to look at problems and then wonder how to fit solutions into their established organizational framework. In other words, solutions are cast into the mold of retaining what you have, ignoring larger options and innovative possibilities. Solutions are expected to adapt to the organization rather than the organization adapting to the solutions.

The hospitalist movement grew as early leaders – true innovators – recognized the problems of costly, inefficient and uncoordinated care. Rather than tinkering with what was, hospitalist leaders introduced a new and proactive model to provide care. It had to first prove itself and once it did, a once revolutionary idea evolved into an institutionalized solution.

No matter what emerges from the current policy debate, the national pressures on the health care system persist: rising expectations for access; decreasing patience for spending; increasing appetite for breakthrough technology; shifting workforce requirements; all combined with a population that is aging and more in need of care. These are meta-trends that will redefine how the health system operates and what it will achieve. What is a health care leader to do?

Think and act like a “meta-leader.” This framework, developed at the Harvard T.H. Chan School of Public Health, guides leaders facing complex and transformational problem solving. The prefix “meta-” encourages expansive analysis directed toward a wide range of options and opportunities. In keeping with the strategies employed by hospitalist pioneers, rather than building solutions around “what already is,” meta-leaders pursue “what could be.” In this way, solutions are designed and constructed to fit the problems they are intended to overcome.

There are three critical dimensions to the thinking and practices of meta-leadership.

The first is the Person of the meta-leader. This is who you are, your priorities and values. This is how other people regard your leadership, translated into the respect, trust, and “followership” you garner. Be a role model. This involves building your own confidence for the task at hand so that you gain and then foster the confidence of those you lead. As a meta-leader, you shape your mindset and that of others for innovation, sharpening the curiosity necessary for fostering discovery and exploration of new ideas. Be ready to take appropriate risks.

The second dimension of meta-leadership practice is the Situation. This is what is happening and what can be done about it. You did not create the complex circumstances that derive from the political showdown in Washington. However, it is your job to understand them and to develop effective strategies and operations in response. This is where the “think big” of meta-leadership comes into play. You distinguish the chasm between the adversarial policy confrontation in Washington and the collaborative solution building needed in your home institution. You want to set the stage to meaningfully coalesce the thinking, resources, and people in your organization. The invigorated shared mission is a health care system that leads into the future.

The third dimension of meta-leadership practice is about building the Connectivity needed to make that happen. This involves developing the communication, coordination, and cooperation necessary for constructing something new. Many of your answers lie within the walls of your organization, even the most innovative among them. This is where you sow adaptability and flexibility. It translates into necessary change and transformation. This is reorienting what you and others do and how you go about doing it, from shifts and adjustments to, when necessary, disruptive innovation.

A recent Harvard Business School and Harvard Medical School forum on health care innovation identified five imperatives for meeting innovation challenges in health care: 1) Creating value is the key aim for innovation and it requires a combination of care coordination along with communication; 2) Seek opportunities for process improvement that allows new ideas to be tested, accepting that failure is a step on the road to discovery; 3) Adopt a consumerism strategy for service organization that engages and involves active patients; 4) Decentralize problem solving to encourage field innovation and collaboration; and 5) Integrate new models into established institutions, introducing fresh thinking to replace outdated practices.

Meta-leadership is not a formula for an easy fix. While much remains unpredictable, an impending economic squeeze is a likely scenario. There is nothing easy about a shortage of dollars to serve more and more people in need of clinical care. This may very well be the prompt – today – that encourages the sort of innovative thinking and disruptive solution development that the future requires. Will you and your organization get ahead of this curve?

Your mission as a hospitalist meta-leader is in forging this process of discovery. Perceive what is going on through a wide lens. Orient yourself to emerging trends. Predict what is likely to emerge from this unpredictable policy environment. Take decisions and operationalize them in ways responsive to the circumstances at hand. And then communicate with your constituencies, not only to inform them of direction but also to learn from them what is working and what not. And then you start the process again, trying on ideas and practices, learning from them and through this continuous process, finding solutions that fit your situation at hand.

Health care meta-leaders today must keep both eyes firmly on their feet, to know that current operations are achieving necessary success. At the same time, they must also keep both eyes focused on the horizon, to ensure that when conditions change, their organizations are ready to adaptively innovate and transform.
 

 

Leonard J. Marcus, Ph.D. is coauthor of Renegotiating Health Care: Resolving Conflict to Build Collaboration, Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected]