Lisa Ryan

The patient had a number of wounds to her battered body, but her most pressing question was how to stanch the flow of milk from her breasts, recalls Lisa Luly-Rivera, MD. The woman was in an endless line of people Dr. Luly-Rivera, a hospitalist at the University of Miami (Fla.) Hospital, cared for during a five-day medical volunteer mission to Haiti in the aftermath of the January earthquake that devastated much of the country.

“She had lost everything, including her seven-month-old baby, who she watched die in the earthquake. She was still lactating and wanted to know how to get the milk to stop,” Dr. Luly-Rivera says. “I heard story after story after story like this. For me, it was emotionally jarring.”

A Haitian-American who has extended-family members in Haiti who survived the Jan. 12 earthquake, Dr. Luly-Rivera leaped at the chance to participate in the medical relief effort organized by the university’s Miller School of Medicine in conjunction with Project Medishare and Jackson Memorial Hospital in Miami. But soon after arriving in the Haitian capital of Port-au-Prince on Jan. 20 and witnessing the magnitude of human suffering there, she second-guessed her decision, wondering if she was emotionally strong enough to deal with such tragedy.

She wasn’t the only one with reservations. Some at the University of Miami Hospital were skeptical that hospitalists could help the situation in Haiti. They questioned why she and her colleagues were included on the volunteer team, Dr. Luly-Rivera says. Ultimately, she proved herself—and the doubters—wrong.

“As internists, we were very valuable there,” says Dr. Luly-Rivera, who logged long hours treating patients and listening to their stories.

Determined to do their part to help survivors of the earthquake, hospitalists across the country joined a surge of American medical personnel in Haiti. Once there, they faced a severely traumatized populace (the Haitian government estimates more than 215,000 were killed and 300,000 injured in the quake), a crippled hospital infrastructure, and a debilitated public health system that had failed even before the earthquake to provide adequate sanitation, vaccinations, infectious-disease control, and basic primary care.

“If Haiti wasn’t chronically poor, if it hadn’t suffered for so long outside of the eye of the world community, then the devastation would have never been so great,” says Sriram Shamasunder, MD, a hospitalist and assistant clinical professor at the University of California at San Francisco’s Department of Medicine who volunteered in the relief effort with the Boston-based nonprofit group Partners in Health. “The house that crumbled is the one chronic poverty built.”

Worthy Cause, Unimaginable Conditions

Mario A. Reyes, MD, FHM, director of the Division of Pediatric Hospital Medicine at Miami Children’s Hospital, shakes his head when he thinks of the conditions in Haiti, one of the poorest nations in the Western Hemisphere. “This is how unfair the world is, that you can fly one and a half hours from a country of such plenty to a country with so much poverty,” says Dr. Reyes, who made his third trip to the island nation in as many years. “Once you go the first time, you feel a connection to the country and the people. It’s a sense of duty to help a very poor neighbor.”

This time, Dr. Reyes and colleague Andrea Maggioni, MD, organized the 75-cot pediatric unit of a 250-bed tent hospital that the University of Miami opened Jan. 21 at the airport in Port-au-Prince in collaboration with Jackson Memorial Hospital and Miami-based Project Medishare, a nonprofit organization founded by doctors from the University of Miami’s medical school in an effort to bring quality healthcare and development services to Haiti.

“There were a few general pediatricians there. They relied on us to lead the way,” Dr. Reyes says. “When I got to the pediatric tent, I saw so many kids screaming at the same time, some with bones sticking out of their body. There’s nothing more gut-wrenching than that. I spent the first night giving morphine and antibiotics like lollipops.”

Before the tent hospital—four tents in all, one for supplies, one for volunteers to sleep in, and two for patients—was set up at the airport, doctors from the University of Miami and its partnering organizations treated adult and pediatric patients at a facility in the United Nations compound in Port-au-Prince. It was utter chaos, according to Amir Jaffer, MD, FHM, chief of the Division of Hospital Medicine and an associate professor of medicine at the Miller School of Medicine. He described earthquake survivors walking around in a daze amidst the rubble, and huge numbers of people searching for food and water.

Same Work, Makeshift Surroundings

Drawing on his HM experience, Dr. Jaffer helped orchestrate the transfer of approximately 140 patients from the makeshift U.N. hospital to the university’s tent hospital a couple of miles away. He also helped lead the effort to organize patients once they arrived at the new facility, which featured a supply tent, staff sleeping tent, medical tent, and surgical tent with four operating rooms. Each patient received a medical wristband and medical record number, and had their medical care charted.

An ICU was set up for those patients who were in more serious condition, and severely ill and injured patients were airlifted to medical centers in Florida and the USNS Comfort, a U.S. Navy ship dispatched to Haiti to provide full hospital service to earthquake survivors. The tent hospital had nearly 250 patients by the end of his five-day trip, Dr. Jaffer says.

Hospitalists administered IV fluids, prescribed antibiotics and pain medication, treated infected wounds, managed patients with dehydration, gastroenteritis, and tetanus, and triaged patients. “Many patients had splints placed in the field, and we would do X-rays to confirm the diagnosis. Patients were being casted right after diagnosis,” Dr. Jaffer says.

Outside the Capital

Hospitalists volunteering with Partners in Health (PIH) were tasked with maximizing the time the surgical team could spend in the OR by assessing incoming patients, triaging cases, providing post-op care, monitoring for development of medical issues related to trauma, and ensuring that every patient was seen daily, says Jonathan Crocker, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Crocker arrived in Haiti four days after the earthquake and was sent to Clinique Bon Saveur, a hospital in Cange, a town located two hours outside the capital on the country’s Central Plateau. The hospital is one of 10 health facilities run by Zamni Lasante, PIH’s sister organization in Haiti. Dr. Shamasunder, of UC San Francisco, arrived in the country a few days later and was stationed at St. Marc Hospital, on the west coast of the island, about 60 miles from Port-au-Prince.

At St. Marc’s, conditions were “chaotic but functioning, bare-bones but a work in progress,” as Haitian doctors began returning to work and Creole-speaking nurses from the U.S. reached the hospital, Dr. Shamasunder explains. PIH volunteers coordinated with teams from Canada and Nepal to provide the best possible medical care to patients dealing with sepsis, serious wounds, and heart failure.

Hundreds of patients, many with multiple injuries, had been streaming into Clinique Bon Saveur since the day the earthquake struck. When Dr. Crocker arrived, the hospital was overcrowded, spilling into makeshift wards that had been set up in a church and a nearby school.

“As a hospitalist, my first concern upon arrival was anticipating the likely medical complications we would encounter with a large population of patients having experienced physical trauma,” Dr. Crocker says. “These complications included, namely, DVT and PE events, compartment syndrome, rhabdomyolysis with renal failure, hyperkalemia, wound infection, and sepsis.”

After speaking with their Haitian colleagues, PIH volunteers placed all adult patients at Clinique Bon Saveur on heparin prophylaxis. They also instituted a standard antibiotic regimen for all patients with open fractures, ensured patients received tetanus shots, and made it a priority to see every patient daily in an effort to prevent compartment syndrome and complications from rhabdomyolysis.

“As we identified more patients with acute renal failure, we moved into active screening with ‘creatinine rounds,’ where we performed BUN/Cr checks on any patient suspected of having suffered major crush injuries,” says Dr. Crocker, who used a portable ultrasound to assess patients for suspected lower-extremity DVTs. “As a team, we made a daily A, B, and C priority list for patients in need of surgeries available at the hospital, and a list of patients with injuries too complex for our surgical teams requiring transfer.”

Resume Expansion

Back at the University of Miami’s tent facility, hospitalists were chipping in wherever help was needed. “I cleaned rooms, I took out the trash, I swept floors, I dispensed medicine from the pharmacy. I just did everything,” Dr. Luly-Rivera says. “You have to go with an open mind and be prepared to do things outside your own discipline.”

Volunteers must be prepared to deal with difficult patients who are under considerable stress over their present and future situations, Dr. Luly-Rivera explains. She worries about what is to come for a country that’s ill-equipped to handle so many physically disabled people. For years, there will be a pressing need for orthopedic surgeons and physical and occupational therapists, she says.

Earthquake survivors also will need help in coping with the psychological trauma they’ve endured, says Dr. Reyes, who frequently played the role of hospital clown in the tent facility’s pediatric ward—just to help the children to laugh a bit.

“These kids are fully traumatized. They don’t want to go inside buildings because they’re afraid they will collapse,” he says. “There’s a high percentage of them who lost at least one parent in the disaster. When you go to discharge them, many don’t have a home to go to. You just feel tremendous sadness.”

Emotional Connection

The sorrow intensified when Dr. Reyes returned to work after returning from his trip to Haiti. “You can barely eat because you have a knot in your throat,” he says.

Upon her return to Miami, Dr. Luly-Rivera spent almost every spare minute watching news coverage on television and reading about the relief effort online. It was difficult for her to concentrate when working, she admits.

“It wasn’t that I felt the patients here didn’t need me,” she says. “It’s just that my mind was still in Haiti and thinking about my patients there. I had to let it go.”

Feelings of sadness and grief are common reactions to witnessing acute injuries and loss of life, says Dr. Jaffer. Some people react by refusing to leave until the work is done, or returning to the relief effort before they are ready.

“Medical volunteerism shows you there is life beyond what you do in your workplace. It allows you to bridge the gap between your job and people who are less fortunate. The experience can be invigorating, but it can also be stress-inducing and lead to depression,” Dr. Jaffer says. “It’s always good to have someone you pair up with to monitor your stress level.”

After taking time to decompress, Drs. Luly-Rivera and Reyes plan to return to Haiti. They hope healthcare workers from all parts of the U.S. will continue to volunteer in the months ahead. Haiti’s weighty issues demand that non-governmental organizations (NGOs) working in the country stay and better coordinate their efforts, Dr. Reyes says.

“Ultimately, it is going to be important for any group present in Haiti to work to support the Haitian medical community,” Dr. Crocker adds. “The long-term recovery and rehabilitation of so many thousands of patients will be possible only through a robust, functional, public healthcare delivery system.”

It remains to be seen how many NGOs and volunteers will still be in Haiti a few months from now, the hospitalists said.

It’s always a concern that the attention of the global community may shift away from Haiti when the next calamity strikes in another part of the world, Dr. Jaffer notes. If the focus stays on Haiti as it rebuilds, then possibly some good will come out of the earthquake, Dr. Luly-Rivera says. But if NGOs begin to leave in the short term, the quake would only be the latest setback for one of the world’s poorest and most underdeveloped countries.

Even if the latter were to happen, Dr. Luly-Rivera still says she and other volunteers make a difference. “I’m still glad I went,” she says. “The people were so thankful.”

“You see the best of the American people there,” Dr. Reyes adds. “It’s encouraging and uplifting. It brings back faith in the medical profession and faith in people.” TH

Lisa Ryan is a freelance writer based in New Jersey.

The patient had a number of wounds to her battered body, but her most pressing question was how to stanch the flow of milk from her breasts, recalls Lisa Luly-Rivera, MD. The woman was in an endless line of people Dr. Luly-Rivera, a hospitalist at the University of Miami (Fla.) Hospital, cared for during a five-day medical volunteer mission to Haiti in the aftermath of the January earthquake that devastated much of the country.

“She had lost everything, including her seven-month-old baby, who she watched die in the earthquake. She was still lactating and wanted to know how to get the milk to stop,” Dr. Luly-Rivera says. “I heard story after story after story like this. For me, it was emotionally jarring.”

A Haitian-American who has extended-family members in Haiti who survived the Jan. 12 earthquake, Dr. Luly-Rivera leaped at the chance to participate in the medical relief effort organized by the university’s Miller School of Medicine in conjunction with Project Medishare and Jackson Memorial Hospital in Miami. But soon after arriving in the Haitian capital of Port-au-Prince on Jan. 20 and witnessing the magnitude of human suffering there, she second-guessed her decision, wondering if she was emotionally strong enough to deal with such tragedy.

She wasn’t the only one with reservations. Some at the University of Miami Hospital were skeptical that hospitalists could help the situation in Haiti. They questioned why she and her colleagues were included on the volunteer team, Dr. Luly-Rivera says. Ultimately, she proved herself—and the doubters—wrong.

“As internists, we were very valuable there,” says Dr. Luly-Rivera, who logged long hours treating patients and listening to their stories.

Determined to do their part to help survivors of the earthquake, hospitalists across the country joined a surge of American medical personnel in Haiti. Once there, they faced a severely traumatized populace (the Haitian government estimates more than 215,000 were killed and 300,000 injured in the quake), a crippled hospital infrastructure, and a debilitated public health system that had failed even before the earthquake to provide adequate sanitation, vaccinations, infectious-disease control, and basic primary care.

“If Haiti wasn’t chronically poor, if it hadn’t suffered for so long outside of the eye of the world community, then the devastation would have never been so great,” says Sriram Shamasunder, MD, a hospitalist and assistant clinical professor at the University of California at San Francisco’s Department of Medicine who volunteered in the relief effort with the Boston-based nonprofit group Partners in Health. “The house that crumbled is the one chronic poverty built.”

Worthy Cause, Unimaginable Conditions

Mario A. Reyes, MD, FHM, director of the Division of Pediatric Hospital Medicine at Miami Children’s Hospital, shakes his head when he thinks of the conditions in Haiti, one of the poorest nations in the Western Hemisphere. “This is how unfair the world is, that you can fly one and a half hours from a country of such plenty to a country with so much poverty,” says Dr. Reyes, who made his third trip to the island nation in as many years. “Once you go the first time, you feel a connection to the country and the people. It’s a sense of duty to help a very poor neighbor.”

This time, Dr. Reyes and colleague Andrea Maggioni, MD, organized the 75-cot pediatric unit of a 250-bed tent hospital that the University of Miami opened Jan. 21 at the airport in Port-au-Prince in collaboration with Jackson Memorial Hospital and Miami-based Project Medishare, a nonprofit organization founded by doctors from the University of Miami’s medical school in an effort to bring quality healthcare and development services to Haiti.

“There were a few general pediatricians there. They relied on us to lead the way,” Dr. Reyes says. “When I got to the pediatric tent, I saw so many kids screaming at the same time, some with bones sticking out of their body. There’s nothing more gut-wrenching than that. I spent the first night giving morphine and antibiotics like lollipops.”

Before the tent hospital—four tents in all, one for supplies, one for volunteers to sleep in, and two for patients—was set up at the airport, doctors from the University of Miami and its partnering organizations treated adult and pediatric patients at a facility in the United Nations compound in Port-au-Prince. It was utter chaos, according to Amir Jaffer, MD, FHM, chief of the Division of Hospital Medicine and an associate professor of medicine at the Miller School of Medicine. He described earthquake survivors walking around in a daze amidst the rubble, and huge numbers of people searching for food and water.

Same Work, Makeshift Surroundings

Drawing on his HM experience, Dr. Jaffer helped orchestrate the transfer of approximately 140 patients from the makeshift U.N. hospital to the university’s tent hospital a couple of miles away. He also helped lead the effort to organize patients once they arrived at the new facility, which featured a supply tent, staff sleeping tent, medical tent, and surgical tent with four operating rooms. Each patient received a medical wristband and medical record number, and had their medical care charted.

An ICU was set up for those patients who were in more serious condition, and severely ill and injured patients were airlifted to medical centers in Florida and the USNS Comfort, a U.S. Navy ship dispatched to Haiti to provide full hospital service to earthquake survivors. The tent hospital had nearly 250 patients by the end of his five-day trip, Dr. Jaffer says.

Hospitalists administered IV fluids, prescribed antibiotics and pain medication, treated infected wounds, managed patients with dehydration, gastroenteritis, and tetanus, and triaged patients. “Many patients had splints placed in the field, and we would do X-rays to confirm the diagnosis. Patients were being casted right after diagnosis,” Dr. Jaffer says.

Outside the Capital

Hospitalists volunteering with Partners in Health (PIH) were tasked with maximizing the time the surgical team could spend in the OR by assessing incoming patients, triaging cases, providing post-op care, monitoring for development of medical issues related to trauma, and ensuring that every patient was seen daily, says Jonathan Crocker, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Crocker arrived in Haiti four days after the earthquake and was sent to Clinique Bon Saveur, a hospital in Cange, a town located two hours outside the capital on the country’s Central Plateau. The hospital is one of 10 health facilities run by Zamni Lasante, PIH’s sister organization in Haiti. Dr. Shamasunder, of UC San Francisco, arrived in the country a few days later and was stationed at St. Marc Hospital, on the west coast of the island, about 60 miles from Port-au-Prince.

At St. Marc’s, conditions were “chaotic but functioning, bare-bones but a work in progress,” as Haitian doctors began returning to work and Creole-speaking nurses from the U.S. reached the hospital, Dr. Shamasunder explains. PIH volunteers coordinated with teams from Canada and Nepal to provide the best possible medical care to patients dealing with sepsis, serious wounds, and heart failure.

Hundreds of patients, many with multiple injuries, had been streaming into Clinique Bon Saveur since the day the earthquake struck. When Dr. Crocker arrived, the hospital was overcrowded, spilling into makeshift wards that had been set up in a church and a nearby school.

“As a hospitalist, my first concern upon arrival was anticipating the likely medical complications we would encounter with a large population of patients having experienced physical trauma,” Dr. Crocker says. “These complications included, namely, DVT and PE events, compartment syndrome, rhabdomyolysis with renal failure, hyperkalemia, wound infection, and sepsis.”

After speaking with their Haitian colleagues, PIH volunteers placed all adult patients at Clinique Bon Saveur on heparin prophylaxis. They also instituted a standard antibiotic regimen for all patients with open fractures, ensured patients received tetanus shots, and made it a priority to see every patient daily in an effort to prevent compartment syndrome and complications from rhabdomyolysis.

“As we identified more patients with acute renal failure, we moved into active screening with ‘creatinine rounds,’ where we performed BUN/Cr checks on any patient suspected of having suffered major crush injuries,” says Dr. Crocker, who used a portable ultrasound to assess patients for suspected lower-extremity DVTs. “As a team, we made a daily A, B, and C priority list for patients in need of surgeries available at the hospital, and a list of patients with injuries too complex for our surgical teams requiring transfer.”

Resume Expansion

Back at the University of Miami’s tent facility, hospitalists were chipping in wherever help was needed. “I cleaned rooms, I took out the trash, I swept floors, I dispensed medicine from the pharmacy. I just did everything,” Dr. Luly-Rivera says. “You have to go with an open mind and be prepared to do things outside your own discipline.”

Volunteers must be prepared to deal with difficult patients who are under considerable stress over their present and future situations, Dr. Luly-Rivera explains. She worries about what is to come for a country that’s ill-equipped to handle so many physically disabled people. For years, there will be a pressing need for orthopedic surgeons and physical and occupational therapists, she says.

Earthquake survivors also will need help in coping with the psychological trauma they’ve endured, says Dr. Reyes, who frequently played the role of hospital clown in the tent facility’s pediatric ward—just to help the children to laugh a bit.

“These kids are fully traumatized. They don’t want to go inside buildings because they’re afraid they will collapse,” he says. “There’s a high percentage of them who lost at least one parent in the disaster. When you go to discharge them, many don’t have a home to go to. You just feel tremendous sadness.”

Emotional Connection

The sorrow intensified when Dr. Reyes returned to work after returning from his trip to Haiti. “You can barely eat because you have a knot in your throat,” he says.

Upon her return to Miami, Dr. Luly-Rivera spent almost every spare minute watching news coverage on television and reading about the relief effort online. It was difficult for her to concentrate when working, she admits.

“It wasn’t that I felt the patients here didn’t need me,” she says. “It’s just that my mind was still in Haiti and thinking about my patients there. I had to let it go.”

Feelings of sadness and grief are common reactions to witnessing acute injuries and loss of life, says Dr. Jaffer. Some people react by refusing to leave until the work is done, or returning to the relief effort before they are ready.

“Medical volunteerism shows you there is life beyond what you do in your workplace. It allows you to bridge the gap between your job and people who are less fortunate. The experience can be invigorating, but it can also be stress-inducing and lead to depression,” Dr. Jaffer says. “It’s always good to have someone you pair up with to monitor your stress level.”

After taking time to decompress, Drs. Luly-Rivera and Reyes plan to return to Haiti. They hope healthcare workers from all parts of the U.S. will continue to volunteer in the months ahead. Haiti’s weighty issues demand that non-governmental organizations (NGOs) working in the country stay and better coordinate their efforts, Dr. Reyes says.

“Ultimately, it is going to be important for any group present in Haiti to work to support the Haitian medical community,” Dr. Crocker adds. “The long-term recovery and rehabilitation of so many thousands of patients will be possible only through a robust, functional, public healthcare delivery system.”

It remains to be seen how many NGOs and volunteers will still be in Haiti a few months from now, the hospitalists said.

It’s always a concern that the attention of the global community may shift away from Haiti when the next calamity strikes in another part of the world, Dr. Jaffer notes. If the focus stays on Haiti as it rebuilds, then possibly some good will come out of the earthquake, Dr. Luly-Rivera says. But if NGOs begin to leave in the short term, the quake would only be the latest setback for one of the world’s poorest and most underdeveloped countries.

Even if the latter were to happen, Dr. Luly-Rivera still says she and other volunteers make a difference. “I’m still glad I went,” she says. “The people were so thankful.”

“You see the best of the American people there,” Dr. Reyes adds. “It’s encouraging and uplifting. It brings back faith in the medical profession and faith in people.” TH

Lisa Ryan is a freelance writer based in New Jersey.

The patient had a number of wounds to her battered body, but her most pressing question was how to stanch the flow of milk from her breasts, recalls Lisa Luly-Rivera, MD. The woman was in an endless line of people Dr. Luly-Rivera, a hospitalist at the University of Miami (Fla.) Hospital, cared for during a five-day medical volunteer mission to Haiti in the aftermath of the January earthquake that devastated much of the country.

“She had lost everything, including her seven-month-old baby, who she watched die in the earthquake. She was still lactating and wanted to know how to get the milk to stop,” Dr. Luly-Rivera says. “I heard story after story after story like this. For me, it was emotionally jarring.”

A Haitian-American who has extended-family members in Haiti who survived the Jan. 12 earthquake, Dr. Luly-Rivera leaped at the chance to participate in the medical relief effort organized by the university’s Miller School of Medicine in conjunction with Project Medishare and Jackson Memorial Hospital in Miami. But soon after arriving in the Haitian capital of Port-au-Prince on Jan. 20 and witnessing the magnitude of human suffering there, she second-guessed her decision, wondering if she was emotionally strong enough to deal with such tragedy.

She wasn’t the only one with reservations. Some at the University of Miami Hospital were skeptical that hospitalists could help the situation in Haiti. They questioned why she and her colleagues were included on the volunteer team, Dr. Luly-Rivera says. Ultimately, she proved herself—and the doubters—wrong.

“As internists, we were very valuable there,” says Dr. Luly-Rivera, who logged long hours treating patients and listening to their stories.

Determined to do their part to help survivors of the earthquake, hospitalists across the country joined a surge of American medical personnel in Haiti. Once there, they faced a severely traumatized populace (the Haitian government estimates more than 215,000 were killed and 300,000 injured in the quake), a crippled hospital infrastructure, and a debilitated public health system that had failed even before the earthquake to provide adequate sanitation, vaccinations, infectious-disease control, and basic primary care.

“If Haiti wasn’t chronically poor, if it hadn’t suffered for so long outside of the eye of the world community, then the devastation would have never been so great,” says Sriram Shamasunder, MD, a hospitalist and assistant clinical professor at the University of California at San Francisco’s Department of Medicine who volunteered in the relief effort with the Boston-based nonprofit group Partners in Health. “The house that crumbled is the one chronic poverty built.”

Worthy Cause, Unimaginable Conditions

Mario A. Reyes, MD, FHM, director of the Division of Pediatric Hospital Medicine at Miami Children’s Hospital, shakes his head when he thinks of the conditions in Haiti, one of the poorest nations in the Western Hemisphere. “This is how unfair the world is, that you can fly one and a half hours from a country of such plenty to a country with so much poverty,” says Dr. Reyes, who made his third trip to the island nation in as many years. “Once you go the first time, you feel a connection to the country and the people. It’s a sense of duty to help a very poor neighbor.”

This time, Dr. Reyes and colleague Andrea Maggioni, MD, organized the 75-cot pediatric unit of a 250-bed tent hospital that the University of Miami opened Jan. 21 at the airport in Port-au-Prince in collaboration with Jackson Memorial Hospital and Miami-based Project Medishare, a nonprofit organization founded by doctors from the University of Miami’s medical school in an effort to bring quality healthcare and development services to Haiti.

“There were a few general pediatricians there. They relied on us to lead the way,” Dr. Reyes says. “When I got to the pediatric tent, I saw so many kids screaming at the same time, some with bones sticking out of their body. There’s nothing more gut-wrenching than that. I spent the first night giving morphine and antibiotics like lollipops.”

Before the tent hospital—four tents in all, one for supplies, one for volunteers to sleep in, and two for patients—was set up at the airport, doctors from the University of Miami and its partnering organizations treated adult and pediatric patients at a facility in the United Nations compound in Port-au-Prince. It was utter chaos, according to Amir Jaffer, MD, FHM, chief of the Division of Hospital Medicine and an associate professor of medicine at the Miller School of Medicine. He described earthquake survivors walking around in a daze amidst the rubble, and huge numbers of people searching for food and water.

Same Work, Makeshift Surroundings

Drawing on his HM experience, Dr. Jaffer helped orchestrate the transfer of approximately 140 patients from the makeshift U.N. hospital to the university’s tent hospital a couple of miles away. He also helped lead the effort to organize patients once they arrived at the new facility, which featured a supply tent, staff sleeping tent, medical tent, and surgical tent with four operating rooms. Each patient received a medical wristband and medical record number, and had their medical care charted.

An ICU was set up for those patients who were in more serious condition, and severely ill and injured patients were airlifted to medical centers in Florida and the USNS Comfort, a U.S. Navy ship dispatched to Haiti to provide full hospital service to earthquake survivors. The tent hospital had nearly 250 patients by the end of his five-day trip, Dr. Jaffer says.

Hospitalists administered IV fluids, prescribed antibiotics and pain medication, treated infected wounds, managed patients with dehydration, gastroenteritis, and tetanus, and triaged patients. “Many patients had splints placed in the field, and we would do X-rays to confirm the diagnosis. Patients were being casted right after diagnosis,” Dr. Jaffer says.

Outside the Capital

Hospitalists volunteering with Partners in Health (PIH) were tasked with maximizing the time the surgical team could spend in the OR by assessing incoming patients, triaging cases, providing post-op care, monitoring for development of medical issues related to trauma, and ensuring that every patient was seen daily, says Jonathan Crocker, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Crocker arrived in Haiti four days after the earthquake and was sent to Clinique Bon Saveur, a hospital in Cange, a town located two hours outside the capital on the country’s Central Plateau. The hospital is one of 10 health facilities run by Zamni Lasante, PIH’s sister organization in Haiti. Dr. Shamasunder, of UC San Francisco, arrived in the country a few days later and was stationed at St. Marc Hospital, on the west coast of the island, about 60 miles from Port-au-Prince.

At St. Marc’s, conditions were “chaotic but functioning, bare-bones but a work in progress,” as Haitian doctors began returning to work and Creole-speaking nurses from the U.S. reached the hospital, Dr. Shamasunder explains. PIH volunteers coordinated with teams from Canada and Nepal to provide the best possible medical care to patients dealing with sepsis, serious wounds, and heart failure.

Hundreds of patients, many with multiple injuries, had been streaming into Clinique Bon Saveur since the day the earthquake struck. When Dr. Crocker arrived, the hospital was overcrowded, spilling into makeshift wards that had been set up in a church and a nearby school.

“As a hospitalist, my first concern upon arrival was anticipating the likely medical complications we would encounter with a large population of patients having experienced physical trauma,” Dr. Crocker says. “These complications included, namely, DVT and PE events, compartment syndrome, rhabdomyolysis with renal failure, hyperkalemia, wound infection, and sepsis.”

After speaking with their Haitian colleagues, PIH volunteers placed all adult patients at Clinique Bon Saveur on heparin prophylaxis. They also instituted a standard antibiotic regimen for all patients with open fractures, ensured patients received tetanus shots, and made it a priority to see every patient daily in an effort to prevent compartment syndrome and complications from rhabdomyolysis.

“As we identified more patients with acute renal failure, we moved into active screening with ‘creatinine rounds,’ where we performed BUN/Cr checks on any patient suspected of having suffered major crush injuries,” says Dr. Crocker, who used a portable ultrasound to assess patients for suspected lower-extremity DVTs. “As a team, we made a daily A, B, and C priority list for patients in need of surgeries available at the hospital, and a list of patients with injuries too complex for our surgical teams requiring transfer.”

Resume Expansion

Back at the University of Miami’s tent facility, hospitalists were chipping in wherever help was needed. “I cleaned rooms, I took out the trash, I swept floors, I dispensed medicine from the pharmacy. I just did everything,” Dr. Luly-Rivera says. “You have to go with an open mind and be prepared to do things outside your own discipline.”

Volunteers must be prepared to deal with difficult patients who are under considerable stress over their present and future situations, Dr. Luly-Rivera explains. She worries about what is to come for a country that’s ill-equipped to handle so many physically disabled people. For years, there will be a pressing need for orthopedic surgeons and physical and occupational therapists, she says.

Earthquake survivors also will need help in coping with the psychological trauma they’ve endured, says Dr. Reyes, who frequently played the role of hospital clown in the tent facility’s pediatric ward—just to help the children to laugh a bit.

“These kids are fully traumatized. They don’t want to go inside buildings because they’re afraid they will collapse,” he says. “There’s a high percentage of them who lost at least one parent in the disaster. When you go to discharge them, many don’t have a home to go to. You just feel tremendous sadness.”

Emotional Connection

The sorrow intensified when Dr. Reyes returned to work after returning from his trip to Haiti. “You can barely eat because you have a knot in your throat,” he says.

Upon her return to Miami, Dr. Luly-Rivera spent almost every spare minute watching news coverage on television and reading about the relief effort online. It was difficult for her to concentrate when working, she admits.

“It wasn’t that I felt the patients here didn’t need me,” she says. “It’s just that my mind was still in Haiti and thinking about my patients there. I had to let it go.”

Feelings of sadness and grief are common reactions to witnessing acute injuries and loss of life, says Dr. Jaffer. Some people react by refusing to leave until the work is done, or returning to the relief effort before they are ready.

“Medical volunteerism shows you there is life beyond what you do in your workplace. It allows you to bridge the gap between your job and people who are less fortunate. The experience can be invigorating, but it can also be stress-inducing and lead to depression,” Dr. Jaffer says. “It’s always good to have someone you pair up with to monitor your stress level.”

After taking time to decompress, Drs. Luly-Rivera and Reyes plan to return to Haiti. They hope healthcare workers from all parts of the U.S. will continue to volunteer in the months ahead. Haiti’s weighty issues demand that non-governmental organizations (NGOs) working in the country stay and better coordinate their efforts, Dr. Reyes says.

“Ultimately, it is going to be important for any group present in Haiti to work to support the Haitian medical community,” Dr. Crocker adds. “The long-term recovery and rehabilitation of so many thousands of patients will be possible only through a robust, functional, public healthcare delivery system.”

It remains to be seen how many NGOs and volunteers will still be in Haiti a few months from now, the hospitalists said.

It’s always a concern that the attention of the global community may shift away from Haiti when the next calamity strikes in another part of the world, Dr. Jaffer notes. If the focus stays on Haiti as it rebuilds, then possibly some good will come out of the earthquake, Dr. Luly-Rivera says. But if NGOs begin to leave in the short term, the quake would only be the latest setback for one of the world’s poorest and most underdeveloped countries.

Even if the latter were to happen, Dr. Luly-Rivera still says she and other volunteers make a difference. “I’m still glad I went,” she says. “The people were so thankful.”

“You see the best of the American people there,” Dr. Reyes adds. “It’s encouraging and uplifting. It brings back faith in the medical profession and faith in people.” TH

Lisa Ryan is a freelance writer based in New Jersey.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

Accepting a job in a new city, state, or country can be invigorating for professional and personal reasons, but making the actual move often is stressful, irritating, and more than a little overwhelming. Multiple factors are involved when you transition from one community to another.

For hospitalists relocating for a new job, the good news is it’s almost a given you will receive financial assistance and more than a little guidance to make the move as smooth and hassle-free as possible, says Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins & Associates, a recruitment firm that specializes in the placement of permanent physicians. Ninety-eight percent of physician and certified registered nurse anesthetists are provided relocation assistance, according to a Merritt Hawkins review of recruiting incentives conducted from April 2008 to March 2009. The Irving, Texas-based firm found that the average relocation allowance is $10,427, the highest amount offered since it began tracking recruiting incentives in 2005.

The Upper Hand: HM Still in Demand

While the struggling economy has put a damper on relocation allowances in other professions, it has not had a similar effect on HM, says Cheryl Slack, vice president of human resources for Cogent Healthcare, a Brentwood, Tenn.-based company that partners with hospitals to build and manage hospitalist programs. Hospitalists have become harder and harder to recruit as demand for their services continues to far outpace their supply, she says.

“Relocation assistance is the nature of the beast,” says Slack, whose company typically covers a hospitalist’s move from Point A to Point B, storage fees for a few months, and sometimes travel costs to and from their former home to tie up loose ends. “We see it as the cost of doing business.”

Because most relocation allowances are not tied to a time or service commitment, hospitalists can use the money to facilitate their move without the worry of having to pay some of it back if the job doesn’t work out. They can get the most mileage out of the assistance by comparison shopping (see “Internet Resources for Relocations,” right) or using companies that have a relationship with their recruiter or employer. “We actually have an in-house relocation team and a preferred-rate contract with a national moving company,” Bohannon says. “The vast majority of our candidates work with the in-house team. We help them with the physical move itself. We assist them in taking an inventory of their belongings to get an idea of how much it will cost to move, and we get the moving company in contact with them.”

Temporary vs. Permanent Decisions

Hospitalists might want to consider renting or taking advantage of temporary housing, if offered by the new employer, in order to get acclimated with the new community and its neighborhoods, says Christian Rutherford, president and CEO of Kendall & Davis, a St. Louis-based physician recruitment firm. In the current housing market, renting or using temporary housing might be the best option for hospitalists who are still trying to sell their last home.

When hospitalists are ready to buy a home in their new community, they should check with people at their new job or their recruiter to get names of real estate agents who have considerable insight into the community and local property values. “When we first discuss an opportunity with a candidate, we will pass along pretty detailed information about neighborhoods, schools, housing costs, churches, local clubs that cater to their interests, and hobbies,” Bohannon says. “The market has changed to where the candidate is interviewing the opportunity. We’re pretty hands-on to make sure they have access to the information they need to make a good decision.”

Community Comes First

For most job candidates, 50% of the “sale”—the decision to relocate—is the community in which they will work and live, says Mark Dotson, Cogent Healthcare’s senior director of recruitment. Candidates want to know about the neighborhoods, school systems, and cost of living, and nearby entertainment, cultural, and social amenities. Even though a lot of information is available on the Internet, it is not always dependable. Recruiters and potential employers often provide comprehensive community information packets for hospitalists; many organize a community tour while hospitalists are in town for their on-site interview. Some employers and recruiters schedule meetings with real estate agents, school administrators, even Chamber of Commerce representatives.

“I’ve talked to hospitals about providers’ spouses and where they might be able to find work. It’s all part of the recruitment process and determining what the individual provider’s needs are,” says Mimi Hagan, regional director of hospitalist accounts for Hospital Physician Partners of Fort Lauderdale, Fla., a medical management company that partners with hospitals to build emergency and hospitalist practices. “The last thing we want is for a provider to walk into the hospital thinking this isn’t the right fit for them. It’s not good for the provider, it’s not good for the hospital, and it’s not good for us.”

Hagan and Rutherford advise hospitalists who are seriously contemplating relocating and have families to bring their partners with them for the on-site interview. They might want to consider making another trip to their new community with the children in tow. “Relocating to a different area is a really big cultural change. Candidates have to make sure their spouse is as excited about the change as they are,” Rutherford says. “Don’t ever underestimate how much of a strain this can be on the kids and the spouse.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Accepting a job in a new city, state, or country can be invigorating for professional and personal reasons, but making the actual move often is stressful, irritating, and more than a little overwhelming. Multiple factors are involved when you transition from one community to another.

For hospitalists relocating for a new job, the good news is it’s almost a given you will receive financial assistance and more than a little guidance to make the move as smooth and hassle-free as possible, says Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins & Associates, a recruitment firm that specializes in the placement of permanent physicians. Ninety-eight percent of physician and certified registered nurse anesthetists are provided relocation assistance, according to a Merritt Hawkins review of recruiting incentives conducted from April 2008 to March 2009. The Irving, Texas-based firm found that the average relocation allowance is $10,427, the highest amount offered since it began tracking recruiting incentives in 2005.

The Upper Hand: HM Still in Demand

While the struggling economy has put a damper on relocation allowances in other professions, it has not had a similar effect on HM, says Cheryl Slack, vice president of human resources for Cogent Healthcare, a Brentwood, Tenn.-based company that partners with hospitals to build and manage hospitalist programs. Hospitalists have become harder and harder to recruit as demand for their services continues to far outpace their supply, she says.

“Relocation assistance is the nature of the beast,” says Slack, whose company typically covers a hospitalist’s move from Point A to Point B, storage fees for a few months, and sometimes travel costs to and from their former home to tie up loose ends. “We see it as the cost of doing business.”

Because most relocation allowances are not tied to a time or service commitment, hospitalists can use the money to facilitate their move without the worry of having to pay some of it back if the job doesn’t work out. They can get the most mileage out of the assistance by comparison shopping (see “Internet Resources for Relocations,” right) or using companies that have a relationship with their recruiter or employer. “We actually have an in-house relocation team and a preferred-rate contract with a national moving company,” Bohannon says. “The vast majority of our candidates work with the in-house team. We help them with the physical move itself. We assist them in taking an inventory of their belongings to get an idea of how much it will cost to move, and we get the moving company in contact with them.”

Temporary vs. Permanent Decisions

Hospitalists might want to consider renting or taking advantage of temporary housing, if offered by the new employer, in order to get acclimated with the new community and its neighborhoods, says Christian Rutherford, president and CEO of Kendall & Davis, a St. Louis-based physician recruitment firm. In the current housing market, renting or using temporary housing might be the best option for hospitalists who are still trying to sell their last home.

When hospitalists are ready to buy a home in their new community, they should check with people at their new job or their recruiter to get names of real estate agents who have considerable insight into the community and local property values. “When we first discuss an opportunity with a candidate, we will pass along pretty detailed information about neighborhoods, schools, housing costs, churches, local clubs that cater to their interests, and hobbies,” Bohannon says. “The market has changed to where the candidate is interviewing the opportunity. We’re pretty hands-on to make sure they have access to the information they need to make a good decision.”

Community Comes First

For most job candidates, 50% of the “sale”—the decision to relocate—is the community in which they will work and live, says Mark Dotson, Cogent Healthcare’s senior director of recruitment. Candidates want to know about the neighborhoods, school systems, and cost of living, and nearby entertainment, cultural, and social amenities. Even though a lot of information is available on the Internet, it is not always dependable. Recruiters and potential employers often provide comprehensive community information packets for hospitalists; many organize a community tour while hospitalists are in town for their on-site interview. Some employers and recruiters schedule meetings with real estate agents, school administrators, even Chamber of Commerce representatives.

“I’ve talked to hospitals about providers’ spouses and where they might be able to find work. It’s all part of the recruitment process and determining what the individual provider’s needs are,” says Mimi Hagan, regional director of hospitalist accounts for Hospital Physician Partners of Fort Lauderdale, Fla., a medical management company that partners with hospitals to build emergency and hospitalist practices. “The last thing we want is for a provider to walk into the hospital thinking this isn’t the right fit for them. It’s not good for the provider, it’s not good for the hospital, and it’s not good for us.”

Hagan and Rutherford advise hospitalists who are seriously contemplating relocating and have families to bring their partners with them for the on-site interview. They might want to consider making another trip to their new community with the children in tow. “Relocating to a different area is a really big cultural change. Candidates have to make sure their spouse is as excited about the change as they are,” Rutherford says. “Don’t ever underestimate how much of a strain this can be on the kids and the spouse.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Accepting a job in a new city, state, or country can be invigorating for professional and personal reasons, but making the actual move often is stressful, irritating, and more than a little overwhelming. Multiple factors are involved when you transition from one community to another.

For hospitalists relocating for a new job, the good news is it’s almost a given you will receive financial assistance and more than a little guidance to make the move as smooth and hassle-free as possible, says Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins & Associates, a recruitment firm that specializes in the placement of permanent physicians. Ninety-eight percent of physician and certified registered nurse anesthetists are provided relocation assistance, according to a Merritt Hawkins review of recruiting incentives conducted from April 2008 to March 2009. The Irving, Texas-based firm found that the average relocation allowance is $10,427, the highest amount offered since it began tracking recruiting incentives in 2005.

The Upper Hand: HM Still in Demand

While the struggling economy has put a damper on relocation allowances in other professions, it has not had a similar effect on HM, says Cheryl Slack, vice president of human resources for Cogent Healthcare, a Brentwood, Tenn.-based company that partners with hospitals to build and manage hospitalist programs. Hospitalists have become harder and harder to recruit as demand for their services continues to far outpace their supply, she says.

“Relocation assistance is the nature of the beast,” says Slack, whose company typically covers a hospitalist’s move from Point A to Point B, storage fees for a few months, and sometimes travel costs to and from their former home to tie up loose ends. “We see it as the cost of doing business.”

Because most relocation allowances are not tied to a time or service commitment, hospitalists can use the money to facilitate their move without the worry of having to pay some of it back if the job doesn’t work out. They can get the most mileage out of the assistance by comparison shopping (see “Internet Resources for Relocations,” right) or using companies that have a relationship with their recruiter or employer. “We actually have an in-house relocation team and a preferred-rate contract with a national moving company,” Bohannon says. “The vast majority of our candidates work with the in-house team. We help them with the physical move itself. We assist them in taking an inventory of their belongings to get an idea of how much it will cost to move, and we get the moving company in contact with them.”

Temporary vs. Permanent Decisions

Hospitalists might want to consider renting or taking advantage of temporary housing, if offered by the new employer, in order to get acclimated with the new community and its neighborhoods, says Christian Rutherford, president and CEO of Kendall & Davis, a St. Louis-based physician recruitment firm. In the current housing market, renting or using temporary housing might be the best option for hospitalists who are still trying to sell their last home.

When hospitalists are ready to buy a home in their new community, they should check with people at their new job or their recruiter to get names of real estate agents who have considerable insight into the community and local property values. “When we first discuss an opportunity with a candidate, we will pass along pretty detailed information about neighborhoods, schools, housing costs, churches, local clubs that cater to their interests, and hobbies,” Bohannon says. “The market has changed to where the candidate is interviewing the opportunity. We’re pretty hands-on to make sure they have access to the information they need to make a good decision.”

Community Comes First

For most job candidates, 50% of the “sale”—the decision to relocate—is the community in which they will work and live, says Mark Dotson, Cogent Healthcare’s senior director of recruitment. Candidates want to know about the neighborhoods, school systems, and cost of living, and nearby entertainment, cultural, and social amenities. Even though a lot of information is available on the Internet, it is not always dependable. Recruiters and potential employers often provide comprehensive community information packets for hospitalists; many organize a community tour while hospitalists are in town for their on-site interview. Some employers and recruiters schedule meetings with real estate agents, school administrators, even Chamber of Commerce representatives.

“I’ve talked to hospitals about providers’ spouses and where they might be able to find work. It’s all part of the recruitment process and determining what the individual provider’s needs are,” says Mimi Hagan, regional director of hospitalist accounts for Hospital Physician Partners of Fort Lauderdale, Fla., a medical management company that partners with hospitals to build emergency and hospitalist practices. “The last thing we want is for a provider to walk into the hospital thinking this isn’t the right fit for them. It’s not good for the provider, it’s not good for the hospital, and it’s not good for us.”

Hagan and Rutherford advise hospitalists who are seriously contemplating relocating and have families to bring their partners with them for the on-site interview. They might want to consider making another trip to their new community with the children in tow. “Relocating to a different area is a really big cultural change. Candidates have to make sure their spouse is as excited about the change as they are,” Rutherford says. “Don’t ever underestimate how much of a strain this can be on the kids and the spouse.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Although Web sites like Facebook, Linked In, and Ning are touted as valuable tools for social and professional networking, if users aren’t careful, career-related catastrophes can occur. It bears repeating that no online activity is anonymous, especially with more and more healthcare employers and recruiters visiting these sites to learn about job candidates, says Roberta Renaldy, a senior staffing specialist at Northwestern Memorial Hospital in Chicago.

“They’re becoming your resume before your resume,” Renaldy says of social networking sites.

To keep career opportunities open, hospitalists should avoid dishing out “digital dirt”—aka put-downs—about other people, she says. Vulgarity, unsavory photos, incorrect spelling and grammar, angry online disputes, and dispensing medical advice also are taboo. Even strong points of view on controversial issues can run hospitalists the risk of getting passed over for a job or promotion.

“Someone might be willing to take this risk, but I encourage people to really think before they express their opinions,” Renaldy says.

On the flip side, hospitalists should create a personal brand that’s compelling and consistent across their social networking profiles, says E. Chandlee Bryan, a certified career coach at the firm Best Fit Forward in New York City. Be accurate about expertise and keep visitors interested by providing constant career updates, she says. Always thank network contacts for the slightest bit of advice, and don’t hesitate to offer others help, Bryan suggests.

Renaldy emphasizes the old-fashioned approach. “Using the Internet is a way to spark a networking relationship, but many times it doesn’t develop the relationship,” she says. “Nothing replaces face-to-face contact in furthering your professional career.”

Although Web sites like Facebook, Linked In, and Ning are touted as valuable tools for social and professional networking, if users aren’t careful, career-related catastrophes can occur. It bears repeating that no online activity is anonymous, especially with more and more healthcare employers and recruiters visiting these sites to learn about job candidates, says Roberta Renaldy, a senior staffing specialist at Northwestern Memorial Hospital in Chicago.

“They’re becoming your resume before your resume,” Renaldy says of social networking sites.

To keep career opportunities open, hospitalists should avoid dishing out “digital dirt”—aka put-downs—about other people, she says. Vulgarity, unsavory photos, incorrect spelling and grammar, angry online disputes, and dispensing medical advice also are taboo. Even strong points of view on controversial issues can run hospitalists the risk of getting passed over for a job or promotion.

“Someone might be willing to take this risk, but I encourage people to really think before they express their opinions,” Renaldy says.

On the flip side, hospitalists should create a personal brand that’s compelling and consistent across their social networking profiles, says E. Chandlee Bryan, a certified career coach at the firm Best Fit Forward in New York City. Be accurate about expertise and keep visitors interested by providing constant career updates, she says. Always thank network contacts for the slightest bit of advice, and don’t hesitate to offer others help, Bryan suggests.

Renaldy emphasizes the old-fashioned approach. “Using the Internet is a way to spark a networking relationship, but many times it doesn’t develop the relationship,” she says. “Nothing replaces face-to-face contact in furthering your professional career.”

Although Web sites like Facebook, Linked In, and Ning are touted as valuable tools for social and professional networking, if users aren’t careful, career-related catastrophes can occur. It bears repeating that no online activity is anonymous, especially with more and more healthcare employers and recruiters visiting these sites to learn about job candidates, says Roberta Renaldy, a senior staffing specialist at Northwestern Memorial Hospital in Chicago.

“They’re becoming your resume before your resume,” Renaldy says of social networking sites.

To keep career opportunities open, hospitalists should avoid dishing out “digital dirt”—aka put-downs—about other people, she says. Vulgarity, unsavory photos, incorrect spelling and grammar, angry online disputes, and dispensing medical advice also are taboo. Even strong points of view on controversial issues can run hospitalists the risk of getting passed over for a job or promotion.

“Someone might be willing to take this risk, but I encourage people to really think before they express their opinions,” Renaldy says.

On the flip side, hospitalists should create a personal brand that’s compelling and consistent across their social networking profiles, says E. Chandlee Bryan, a certified career coach at the firm Best Fit Forward in New York City. Be accurate about expertise and keep visitors interested by providing constant career updates, she says. Always thank network contacts for the slightest bit of advice, and don’t hesitate to offer others help, Bryan suggests.

Renaldy emphasizes the old-fashioned approach. “Using the Internet is a way to spark a networking relationship, but many times it doesn’t develop the relationship,” she says. “Nothing replaces face-to-face contact in furthering your professional career.”

There are times when Dan Hale, MD, FAAP, wishes he had more standardized tools to use when he leads a team of four full-time and four part-time pediatric hospitalists at Central Maine Medical Center (CMMC) in Lewiston. Even after five years at the community hospital, the pediatric HM program still is searching for the best way to hand off patients who are leaving the hospital to their primary-care physicians (PCPs).

It also would be beneficial to have markers against which CMMC could compare itself with similarly sized pediatric HM programs around the country, says Dr. Hale, chief of pediatrics at the medical center. CMMC, which averages about 4,000 patient encounters per year, is one of three hospitals in the state with a pediatric HM program. “It would be nice to see progress being made in these areas,” he says.

Dr. Hale might not have to wait long to see his wishes granted. More than 20 pediatric hospitalists from across the nation met in Chicago earlier this year, intent on developing a strategic framework for pediatric HM (PHM). About 10% of the 30,000-plus hospitalists practicing in the U.S. focus exclusively on pediatrics, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” Like the hospitalist movement in general, PHM is growing in number and influence as pediatric hospitalists take on leadership roles and develop working relationships with hospital administrators. The time has come to clearly define the discipline for other physicians, as well as patients and their families, and leverage PHM’s growth and usefulness to improve medical care for children, says Erin Stucky, MD, FHM, a pediatric hospitalist at Rady Children’s Hospital and Health Center in San Diego.

With this dashboard, we want to be able to say, “Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.”

—Jennifer Daru, MD, FAAP, FHM, chief, division of pediatric hospital medicine, California Pacific Medical Center, San Francisco

“It’s a little bit of pie in the sky, a little bit of rose-colored glasses, but it’s good to aim high,” she says.

Some PHM leaders think the subspecialty has advanced enough in recent years to apply its collective knowledge and influence on a broader stage. “We have gone through our adolescence, and now we are a big community,” says Jack Percelay, MD, MPH, FHM, a pediatric hospitalist at Saint Barnabas Medical Center in New York City and SHM board member. “We’re active at almost all the major medical centers and we need to step up to the plate. We need to start the hard work of bringing our vision to fruition.”

Definition and Strategy

Drs. Stucky and Percelay attended the Pediatric Hospital Medicine (PHM) Strategic Planning Roundtable and serve on the roundtable’s planning committee. SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) sponsored the gathering, which included young and veteran pediatric hospitalists, clinicians, researchers, and hospitalists from academic, children’s, and community hospitals. The net was cast far and wide to gather information from a broad cross-section of stakeholders.

We have gone through our adolescence and now we are a big community. We’re active at almost all the major medical centers and we need to step up to the plate.

—Jack Percelay, MD, MPH, FHM, pediatric hospitalist, Saint Barnabas Medical Center, New York City, SHM board member

As pediatric hospitalists strive to better demonstrate how they can help hospitals improve the quality of patient care and safety while decreasing its cost, the roundtable is charged with defining and educating healthcare professionals on the key issues. Also in the crosshairs: simultaneously advancing evidence-based medicine and family-based care.

“We need to distinguish that we are not just house physicians, but really establish ourselves as content-area knowledge experts,” Dr. Percelay says. In other words, pediatric hospitalists are physicians who specialize in effective and efficient medicine in resource-intensive facilities.

Pediatric hospitalists also grapple with how to enhance career satisfaction and sustainability at a time when many PHM programs require a burdensome clinical load that fosters burnout. Many PHM leaders also think pediatric hospitalists need extra training but fear they will lose those physicians to fellowships. And as the PHM ranks fill with physicians who have little or no outpatient training, there is the challenge of explaining the capabilities and limitations pediatric hospitalists and primary-care physicians (PCPs) have in order to avoid unrealistic expectations and friction.

Participants in the strategic roundtable aim to address several broad goals outlined in an executive summary, which can be viewed in the “Section on Hospital Medicine” on the AAP Web site (www.aap.org/sections/hospcare/default.cfm). The following are some of the goals:

• Ensure care for hospitalized children is fully integrated and includes the medical home;
• Design and support systems for children that eliminate harm associated with hospital care;
• Develop a skilled and stable workforce that provides expert care for hospitalized children;
• Use collaborative research models to answer questions of clinical efficacy, comparative effectiveness, and quality improvement inclusive of patient safety, and deliver care based on that knowledge;
• Provide the expertise that supports innovative continuing education in the care of the hospitalized child for pediatric hospitalists, trainees, midlevel providers, and hospital staff;
• Create value and provide academic and systems leadership for patients and organizations based on pediatric hospitalists’ unique expertise in PHM clinical care, research, and education; and
• Be leaders and influential agents in local, state, and national healthcare policies that affect hospital care.

Although it was discussed, the roundtable decided against the establishment of a professional organization for pediatric hospitalists. Instead, the group agreed to continue to utilize the resources and organizational support provided by SHM, APA, and AAP. All three groups contributed money to the roundtable, sent representatives to the meeting, and are interested in the results.

DRASCHWARTZ/ISTOCKPHOTO.COM

“The Academic Pediatric Association has been involved with pediatric hospital medicine from the beginning, and we plan on continuing our involvement,” says Daniel Rauch, MD, FHM, associate director of pediatrics at Elmhurst Hospital Center in New York City and co-chair of the APA’s Hospital Medicine Special Interest Group, which is paying close attention to PHM education and research issues.

Strategic Initiatives

The roundtable established four workgroups: clinical practice/workforce, quality and safety, research, and education. The workgroups are directed to create strategic initiative projects focused on advancing the goals laid out at the roundtable meeting and complete most of the projects no later than the July 2010 PHM Conference in Minneapolis (see “A Closer Look at the Pediatric Hospital Medicine Initiatives,” p. 7). At the 2009 PHM conference in Tampa, Fla., roundtable participants reported on some of the initiatives’ preliminary results.

“I walked away … energized and ready to help change the world, which is a pretty great feeling,” says Jennifer Daru, MD, FAAP, FHM, chief of the division of pediatric hospital medicine at California Pacific Medical Center in San Francisco and co-leader of the roundtable’s clinical practice/workforce workgroup.

One of Dr. Daru’s workgroup’s strategic initiative projects should make Dr. Hale and his pediatric hospitalists at Central Maine Medical Center happy. Dr. Daru’s group is creating a clinical practice dashboard template that PHM programs can use to internally track patient care and compare themselves with other programs and national standards.

“I think very few programs have a dashboard, because it’s a relatively newer thing for pediatric hospital medicine,” Dr. Daru says. “With this dashboard, we want to be able to say, ‘Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.’ ”

Steve Narang, MD, medical director of quality/safety and pediatric emergency services at Our Lady of the Lake Regional Medical Center and Children’s Hospital in Baton Rouge, La., is leading the quality and safety workgroup, which is focused on patient identification, patient handoffs between pediatric hospitalists and PCPs, and clinical outcomes for common pediatric diagnoses.

“Most doctors don’t like standardized forms or cookbook medicine, but they do understand good care. Hopefully, we will show success in these initiatives and they will serve as a launching pad to other initiatives,” Dr. Narang says.

Dr. Hale, for one, is excited by the initiatives and workgroups, and optimistic the strategic projects will help his program. In recent years, the PHM community has talked about these kinds of advances, and he’s encouraged to see them moving forward. “These initiatives contribute to the strength of our field,” says Dr. Hale, who also serves on the executive board of AAP’s Maine chapter.

About 80 pediatric hospitalists have volunteered to help with the strategic initiatives. Earlier this year, a request for help was broadcast over the Section on Hospital Medicine listserv run by the AAP. It was announced at HM09 in Chicago and the PHM conference in Tampa. Everyone who submitted a resume or CV, references, and a statement of interest is included, Dr. Percelay says. “This is not supposed to be some exclusive club that no one can get into,” he says. “We are committed to a transparent process.”

While the application deadline has passed, organizers expect additional calls for volunteers in the future as strategic projects move forward, projects are added, and current volunteers depart (see “How to Get Involved,” above).

“They will be the next volunteer go-tos. We will essentially build them into new projects that come up or if gaps emerge,” Dr. Daru says. “We want to have as many people as possible who are really motivated.”

Group Effort

You don’t necessarily have to volunteer for workgroups to be a part of the broader effort. You can read and comment on draft reports released by some of the project teams, or review the roundtable’s executive summary and find ways to apply the vision and goals to your own PHM program, says Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and pediatric editor of The Hospitalist.

“If each pediatric hospitalist set strategic initiatives for their own group or hospital, chances are they would find remarkable similarity between what they came up with and what the strategic planning roundtable came up with,” says Dr. Shen, who is directing one of the quality and safety workgroup’s initiatives. “There are plenty of ways to think globally and act locally.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Top Image Source: HOMER SYKES/ALAMY

A Closer Look at the Pediatric Hospital Medicine Initiatives

Four workgroups emerged from the Pediatric Hospital Medicine Strategic Planning Roundtable in February. Each group was charged with directing strategic initiative projects over the next 16 to 18 months. The mission is to transform the delivery of hospital care for children. Here is a synopsis of the workgroup initiatives, some of which have estimated completion dates:

SJLOCKE/ISTOCKPHOTO.COM

Clinical Practice/Workforce

• Create a PHM position paper that defines what it means to be a pediatric hospitalist and where the field is headed. A progress report is to be published within the next few months.
• Create a clinical practice dashboard template that PHM programs can use to monitor patient care and eventually compare their program with other programs and national standards. The template will include such markers as patient readmissions and pediatric rapid response events that PHM programs should measure and track. The first version of the dashboard template should be ready by the end of 2009; test sites are to be selected by 2010.
• Develop a “return on investment” document to help pediatric hospitalists effectively discuss with hospital administrators and other stakeholders the benefits of adding or expanding PHM programs. Target deadline: February 2010.
• Assess career satisfaction among pediatric hospitalists. A large part of this initiative will involve SHM’s career satisfaction survey.

Quality and Safety

• Launch a safety project involving six to eight hospitals that is aimed at improving pediatric patient identification. Preliminary results are expected by July 2010.
• Develop a standardized communications tool that pediatric hospitalists can use when handing off patients to primary-care physicians after patients leave the hospital.
• Create a benchmarking process for the most common pediatric inpatient diagnoses (e.g., bronchiolitis, skin infections, and pneumonia) by expanding the Value in Inpatient Pediatrics (VIP) Network, a pediatric-hospitalist-led effort to find cost-effective ways to treat patients.

Research

• Restructure the existing Pediatric Research in Inpatient Settings (PRIS) network, an independent entity founded through a joint SHM-AAP-APA effort, to better advance research on issues important to pediatric care.
• Secure funding to conduct studies relevant to inpatient pediatrics. Tap into American Recovery and Reinvestment Act of 2009 (ARRA) funding for comparative effectiveness research. Target deadline: ARRA proposals by fall 2009.
• Create a mentorship system to connect pediatric hospitalists who are interested in research with PHM researchers through the AAP listserv.

Education

• Develop an educational plan supporting PHM core competencies to assist medical schools, post-graduate training programs, and continuing medical education programs in PHM teaching. The core competencies should be released by the end of the year.
• Meet the needs of PHM educators by focusing efforts on topics of interest to them, such as family-centered rounds, night float curriculum, and handoffs. Establish a repository of curriculum information that educators can access for guidance.

There are times when Dan Hale, MD, FAAP, wishes he had more standardized tools to use when he leads a team of four full-time and four part-time pediatric hospitalists at Central Maine Medical Center (CMMC) in Lewiston. Even after five years at the community hospital, the pediatric HM program still is searching for the best way to hand off patients who are leaving the hospital to their primary-care physicians (PCPs).

It also would be beneficial to have markers against which CMMC could compare itself with similarly sized pediatric HM programs around the country, says Dr. Hale, chief of pediatrics at the medical center. CMMC, which averages about 4,000 patient encounters per year, is one of three hospitals in the state with a pediatric HM program. “It would be nice to see progress being made in these areas,” he says.

Dr. Hale might not have to wait long to see his wishes granted. More than 20 pediatric hospitalists from across the nation met in Chicago earlier this year, intent on developing a strategic framework for pediatric HM (PHM). About 10% of the 30,000-plus hospitalists practicing in the U.S. focus exclusively on pediatrics, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” Like the hospitalist movement in general, PHM is growing in number and influence as pediatric hospitalists take on leadership roles and develop working relationships with hospital administrators. The time has come to clearly define the discipline for other physicians, as well as patients and their families, and leverage PHM’s growth and usefulness to improve medical care for children, says Erin Stucky, MD, FHM, a pediatric hospitalist at Rady Children’s Hospital and Health Center in San Diego.

With this dashboard, we want to be able to say, “Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.”

—Jennifer Daru, MD, FAAP, FHM, chief, division of pediatric hospital medicine, California Pacific Medical Center, San Francisco

“It’s a little bit of pie in the sky, a little bit of rose-colored glasses, but it’s good to aim high,” she says.

Some PHM leaders think the subspecialty has advanced enough in recent years to apply its collective knowledge and influence on a broader stage. “We have gone through our adolescence, and now we are a big community,” says Jack Percelay, MD, MPH, FHM, a pediatric hospitalist at Saint Barnabas Medical Center in New York City and SHM board member. “We’re active at almost all the major medical centers and we need to step up to the plate. We need to start the hard work of bringing our vision to fruition.”

Definition and Strategy

Drs. Stucky and Percelay attended the Pediatric Hospital Medicine (PHM) Strategic Planning Roundtable and serve on the roundtable’s planning committee. SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) sponsored the gathering, which included young and veteran pediatric hospitalists, clinicians, researchers, and hospitalists from academic, children’s, and community hospitals. The net was cast far and wide to gather information from a broad cross-section of stakeholders.

We have gone through our adolescence and now we are a big community. We’re active at almost all the major medical centers and we need to step up to the plate.

—Jack Percelay, MD, MPH, FHM, pediatric hospitalist, Saint Barnabas Medical Center, New York City, SHM board member

As pediatric hospitalists strive to better demonstrate how they can help hospitals improve the quality of patient care and safety while decreasing its cost, the roundtable is charged with defining and educating healthcare professionals on the key issues. Also in the crosshairs: simultaneously advancing evidence-based medicine and family-based care.

“We need to distinguish that we are not just house physicians, but really establish ourselves as content-area knowledge experts,” Dr. Percelay says. In other words, pediatric hospitalists are physicians who specialize in effective and efficient medicine in resource-intensive facilities.

Pediatric hospitalists also grapple with how to enhance career satisfaction and sustainability at a time when many PHM programs require a burdensome clinical load that fosters burnout. Many PHM leaders also think pediatric hospitalists need extra training but fear they will lose those physicians to fellowships. And as the PHM ranks fill with physicians who have little or no outpatient training, there is the challenge of explaining the capabilities and limitations pediatric hospitalists and primary-care physicians (PCPs) have in order to avoid unrealistic expectations and friction.

Participants in the strategic roundtable aim to address several broad goals outlined in an executive summary, which can be viewed in the “Section on Hospital Medicine” on the AAP Web site (www.aap.org/sections/hospcare/default.cfm). The following are some of the goals:

• Ensure care for hospitalized children is fully integrated and includes the medical home;
• Design and support systems for children that eliminate harm associated with hospital care;
• Develop a skilled and stable workforce that provides expert care for hospitalized children;
• Use collaborative research models to answer questions of clinical efficacy, comparative effectiveness, and quality improvement inclusive of patient safety, and deliver care based on that knowledge;
• Provide the expertise that supports innovative continuing education in the care of the hospitalized child for pediatric hospitalists, trainees, midlevel providers, and hospital staff;
• Create value and provide academic and systems leadership for patients and organizations based on pediatric hospitalists’ unique expertise in PHM clinical care, research, and education; and
• Be leaders and influential agents in local, state, and national healthcare policies that affect hospital care.

Although it was discussed, the roundtable decided against the establishment of a professional organization for pediatric hospitalists. Instead, the group agreed to continue to utilize the resources and organizational support provided by SHM, APA, and AAP. All three groups contributed money to the roundtable, sent representatives to the meeting, and are interested in the results.

DRASCHWARTZ/ISTOCKPHOTO.COM

“The Academic Pediatric Association has been involved with pediatric hospital medicine from the beginning, and we plan on continuing our involvement,” says Daniel Rauch, MD, FHM, associate director of pediatrics at Elmhurst Hospital Center in New York City and co-chair of the APA’s Hospital Medicine Special Interest Group, which is paying close attention to PHM education and research issues.

Strategic Initiatives

The roundtable established four workgroups: clinical practice/workforce, quality and safety, research, and education. The workgroups are directed to create strategic initiative projects focused on advancing the goals laid out at the roundtable meeting and complete most of the projects no later than the July 2010 PHM Conference in Minneapolis (see “A Closer Look at the Pediatric Hospital Medicine Initiatives,” p. 7). At the 2009 PHM conference in Tampa, Fla., roundtable participants reported on some of the initiatives’ preliminary results.

“I walked away … energized and ready to help change the world, which is a pretty great feeling,” says Jennifer Daru, MD, FAAP, FHM, chief of the division of pediatric hospital medicine at California Pacific Medical Center in San Francisco and co-leader of the roundtable’s clinical practice/workforce workgroup.

One of Dr. Daru’s workgroup’s strategic initiative projects should make Dr. Hale and his pediatric hospitalists at Central Maine Medical Center happy. Dr. Daru’s group is creating a clinical practice dashboard template that PHM programs can use to internally track patient care and compare themselves with other programs and national standards.

“I think very few programs have a dashboard, because it’s a relatively newer thing for pediatric hospital medicine,” Dr. Daru says. “With this dashboard, we want to be able to say, ‘Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.’ ”

Steve Narang, MD, medical director of quality/safety and pediatric emergency services at Our Lady of the Lake Regional Medical Center and Children’s Hospital in Baton Rouge, La., is leading the quality and safety workgroup, which is focused on patient identification, patient handoffs between pediatric hospitalists and PCPs, and clinical outcomes for common pediatric diagnoses.

“Most doctors don’t like standardized forms or cookbook medicine, but they do understand good care. Hopefully, we will show success in these initiatives and they will serve as a launching pad to other initiatives,” Dr. Narang says.

Dr. Hale, for one, is excited by the initiatives and workgroups, and optimistic the strategic projects will help his program. In recent years, the PHM community has talked about these kinds of advances, and he’s encouraged to see them moving forward. “These initiatives contribute to the strength of our field,” says Dr. Hale, who also serves on the executive board of AAP’s Maine chapter.

About 80 pediatric hospitalists have volunteered to help with the strategic initiatives. Earlier this year, a request for help was broadcast over the Section on Hospital Medicine listserv run by the AAP. It was announced at HM09 in Chicago and the PHM conference in Tampa. Everyone who submitted a resume or CV, references, and a statement of interest is included, Dr. Percelay says. “This is not supposed to be some exclusive club that no one can get into,” he says. “We are committed to a transparent process.”

While the application deadline has passed, organizers expect additional calls for volunteers in the future as strategic projects move forward, projects are added, and current volunteers depart (see “How to Get Involved,” above).

“They will be the next volunteer go-tos. We will essentially build them into new projects that come up or if gaps emerge,” Dr. Daru says. “We want to have as many people as possible who are really motivated.”

Group Effort

You don’t necessarily have to volunteer for workgroups to be a part of the broader effort. You can read and comment on draft reports released by some of the project teams, or review the roundtable’s executive summary and find ways to apply the vision and goals to your own PHM program, says Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and pediatric editor of The Hospitalist.

“If each pediatric hospitalist set strategic initiatives for their own group or hospital, chances are they would find remarkable similarity between what they came up with and what the strategic planning roundtable came up with,” says Dr. Shen, who is directing one of the quality and safety workgroup’s initiatives. “There are plenty of ways to think globally and act locally.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Top Image Source: HOMER SYKES/ALAMY

A Closer Look at the Pediatric Hospital Medicine Initiatives

Four workgroups emerged from the Pediatric Hospital Medicine Strategic Planning Roundtable in February. Each group was charged with directing strategic initiative projects over the next 16 to 18 months. The mission is to transform the delivery of hospital care for children. Here is a synopsis of the workgroup initiatives, some of which have estimated completion dates:

SJLOCKE/ISTOCKPHOTO.COM

Clinical Practice/Workforce

• Create a PHM position paper that defines what it means to be a pediatric hospitalist and where the field is headed. A progress report is to be published within the next few months.
• Create a clinical practice dashboard template that PHM programs can use to monitor patient care and eventually compare their program with other programs and national standards. The template will include such markers as patient readmissions and pediatric rapid response events that PHM programs should measure and track. The first version of the dashboard template should be ready by the end of 2009; test sites are to be selected by 2010.
• Develop a “return on investment” document to help pediatric hospitalists effectively discuss with hospital administrators and other stakeholders the benefits of adding or expanding PHM programs. Target deadline: February 2010.
• Assess career satisfaction among pediatric hospitalists. A large part of this initiative will involve SHM’s career satisfaction survey.

Quality and Safety

• Launch a safety project involving six to eight hospitals that is aimed at improving pediatric patient identification. Preliminary results are expected by July 2010.
• Develop a standardized communications tool that pediatric hospitalists can use when handing off patients to primary-care physicians after patients leave the hospital.
• Create a benchmarking process for the most common pediatric inpatient diagnoses (e.g., bronchiolitis, skin infections, and pneumonia) by expanding the Value in Inpatient Pediatrics (VIP) Network, a pediatric-hospitalist-led effort to find cost-effective ways to treat patients.

Research

• Restructure the existing Pediatric Research in Inpatient Settings (PRIS) network, an independent entity founded through a joint SHM-AAP-APA effort, to better advance research on issues important to pediatric care.
• Secure funding to conduct studies relevant to inpatient pediatrics. Tap into American Recovery and Reinvestment Act of 2009 (ARRA) funding for comparative effectiveness research. Target deadline: ARRA proposals by fall 2009.
• Create a mentorship system to connect pediatric hospitalists who are interested in research with PHM researchers through the AAP listserv.

Education

• Develop an educational plan supporting PHM core competencies to assist medical schools, post-graduate training programs, and continuing medical education programs in PHM teaching. The core competencies should be released by the end of the year.
• Meet the needs of PHM educators by focusing efforts on topics of interest to them, such as family-centered rounds, night float curriculum, and handoffs. Establish a repository of curriculum information that educators can access for guidance.

There are times when Dan Hale, MD, FAAP, wishes he had more standardized tools to use when he leads a team of four full-time and four part-time pediatric hospitalists at Central Maine Medical Center (CMMC) in Lewiston. Even after five years at the community hospital, the pediatric HM program still is searching for the best way to hand off patients who are leaving the hospital to their primary-care physicians (PCPs).

It also would be beneficial to have markers against which CMMC could compare itself with similarly sized pediatric HM programs around the country, says Dr. Hale, chief of pediatrics at the medical center. CMMC, which averages about 4,000 patient encounters per year, is one of three hospitals in the state with a pediatric HM program. “It would be nice to see progress being made in these areas,” he says.

Dr. Hale might not have to wait long to see his wishes granted. More than 20 pediatric hospitalists from across the nation met in Chicago earlier this year, intent on developing a strategic framework for pediatric HM (PHM). About 10% of the 30,000-plus hospitalists practicing in the U.S. focus exclusively on pediatrics, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” Like the hospitalist movement in general, PHM is growing in number and influence as pediatric hospitalists take on leadership roles and develop working relationships with hospital administrators. The time has come to clearly define the discipline for other physicians, as well as patients and their families, and leverage PHM’s growth and usefulness to improve medical care for children, says Erin Stucky, MD, FHM, a pediatric hospitalist at Rady Children’s Hospital and Health Center in San Diego.

With this dashboard, we want to be able to say, “Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.”

—Jennifer Daru, MD, FAAP, FHM, chief, division of pediatric hospital medicine, California Pacific Medical Center, San Francisco

“It’s a little bit of pie in the sky, a little bit of rose-colored glasses, but it’s good to aim high,” she says.

Some PHM leaders think the subspecialty has advanced enough in recent years to apply its collective knowledge and influence on a broader stage. “We have gone through our adolescence, and now we are a big community,” says Jack Percelay, MD, MPH, FHM, a pediatric hospitalist at Saint Barnabas Medical Center in New York City and SHM board member. “We’re active at almost all the major medical centers and we need to step up to the plate. We need to start the hard work of bringing our vision to fruition.”

Definition and Strategy

Drs. Stucky and Percelay attended the Pediatric Hospital Medicine (PHM) Strategic Planning Roundtable and serve on the roundtable’s planning committee. SHM, the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) sponsored the gathering, which included young and veteran pediatric hospitalists, clinicians, researchers, and hospitalists from academic, children’s, and community hospitals. The net was cast far and wide to gather information from a broad cross-section of stakeholders.

We have gone through our adolescence and now we are a big community. We’re active at almost all the major medical centers and we need to step up to the plate.

—Jack Percelay, MD, MPH, FHM, pediatric hospitalist, Saint Barnabas Medical Center, New York City, SHM board member

As pediatric hospitalists strive to better demonstrate how they can help hospitals improve the quality of patient care and safety while decreasing its cost, the roundtable is charged with defining and educating healthcare professionals on the key issues. Also in the crosshairs: simultaneously advancing evidence-based medicine and family-based care.

“We need to distinguish that we are not just house physicians, but really establish ourselves as content-area knowledge experts,” Dr. Percelay says. In other words, pediatric hospitalists are physicians who specialize in effective and efficient medicine in resource-intensive facilities.

Pediatric hospitalists also grapple with how to enhance career satisfaction and sustainability at a time when many PHM programs require a burdensome clinical load that fosters burnout. Many PHM leaders also think pediatric hospitalists need extra training but fear they will lose those physicians to fellowships. And as the PHM ranks fill with physicians who have little or no outpatient training, there is the challenge of explaining the capabilities and limitations pediatric hospitalists and primary-care physicians (PCPs) have in order to avoid unrealistic expectations and friction.

Participants in the strategic roundtable aim to address several broad goals outlined in an executive summary, which can be viewed in the “Section on Hospital Medicine” on the AAP Web site (www.aap.org/sections/hospcare/default.cfm). The following are some of the goals:

• Ensure care for hospitalized children is fully integrated and includes the medical home;
• Design and support systems for children that eliminate harm associated with hospital care;
• Develop a skilled and stable workforce that provides expert care for hospitalized children;
• Use collaborative research models to answer questions of clinical efficacy, comparative effectiveness, and quality improvement inclusive of patient safety, and deliver care based on that knowledge;
• Provide the expertise that supports innovative continuing education in the care of the hospitalized child for pediatric hospitalists, trainees, midlevel providers, and hospital staff;
• Create value and provide academic and systems leadership for patients and organizations based on pediatric hospitalists’ unique expertise in PHM clinical care, research, and education; and
• Be leaders and influential agents in local, state, and national healthcare policies that affect hospital care.

Although it was discussed, the roundtable decided against the establishment of a professional organization for pediatric hospitalists. Instead, the group agreed to continue to utilize the resources and organizational support provided by SHM, APA, and AAP. All three groups contributed money to the roundtable, sent representatives to the meeting, and are interested in the results.

DRASCHWARTZ/ISTOCKPHOTO.COM

“The Academic Pediatric Association has been involved with pediatric hospital medicine from the beginning, and we plan on continuing our involvement,” says Daniel Rauch, MD, FHM, associate director of pediatrics at Elmhurst Hospital Center in New York City and co-chair of the APA’s Hospital Medicine Special Interest Group, which is paying close attention to PHM education and research issues.

Strategic Initiatives

The roundtable established four workgroups: clinical practice/workforce, quality and safety, research, and education. The workgroups are directed to create strategic initiative projects focused on advancing the goals laid out at the roundtable meeting and complete most of the projects no later than the July 2010 PHM Conference in Minneapolis (see “A Closer Look at the Pediatric Hospital Medicine Initiatives,” p. 7). At the 2009 PHM conference in Tampa, Fla., roundtable participants reported on some of the initiatives’ preliminary results.

“I walked away … energized and ready to help change the world, which is a pretty great feeling,” says Jennifer Daru, MD, FAAP, FHM, chief of the division of pediatric hospital medicine at California Pacific Medical Center in San Francisco and co-leader of the roundtable’s clinical practice/workforce workgroup.

One of Dr. Daru’s workgroup’s strategic initiative projects should make Dr. Hale and his pediatric hospitalists at Central Maine Medical Center happy. Dr. Daru’s group is creating a clinical practice dashboard template that PHM programs can use to internally track patient care and compare themselves with other programs and national standards.

“I think very few programs have a dashboard, because it’s a relatively newer thing for pediatric hospital medicine,” Dr. Daru says. “With this dashboard, we want to be able to say, ‘Here are the things you should look at to ensure quality care for your kids, and as you look at them, you should probably track them over time.’ ”

Steve Narang, MD, medical director of quality/safety and pediatric emergency services at Our Lady of the Lake Regional Medical Center and Children’s Hospital in Baton Rouge, La., is leading the quality and safety workgroup, which is focused on patient identification, patient handoffs between pediatric hospitalists and PCPs, and clinical outcomes for common pediatric diagnoses.

“Most doctors don’t like standardized forms or cookbook medicine, but they do understand good care. Hopefully, we will show success in these initiatives and they will serve as a launching pad to other initiatives,” Dr. Narang says.

Dr. Hale, for one, is excited by the initiatives and workgroups, and optimistic the strategic projects will help his program. In recent years, the PHM community has talked about these kinds of advances, and he’s encouraged to see them moving forward. “These initiatives contribute to the strength of our field,” says Dr. Hale, who also serves on the executive board of AAP’s Maine chapter.

About 80 pediatric hospitalists have volunteered to help with the strategic initiatives. Earlier this year, a request for help was broadcast over the Section on Hospital Medicine listserv run by the AAP. It was announced at HM09 in Chicago and the PHM conference in Tampa. Everyone who submitted a resume or CV, references, and a statement of interest is included, Dr. Percelay says. “This is not supposed to be some exclusive club that no one can get into,” he says. “We are committed to a transparent process.”

While the application deadline has passed, organizers expect additional calls for volunteers in the future as strategic projects move forward, projects are added, and current volunteers depart (see “How to Get Involved,” above).

“They will be the next volunteer go-tos. We will essentially build them into new projects that come up or if gaps emerge,” Dr. Daru says. “We want to have as many people as possible who are really motivated.”

Group Effort

You don’t necessarily have to volunteer for workgroups to be a part of the broader effort. You can read and comment on draft reports released by some of the project teams, or review the roundtable’s executive summary and find ways to apply the vision and goals to your own PHM program, says Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas, and pediatric editor of The Hospitalist.

“If each pediatric hospitalist set strategic initiatives for their own group or hospital, chances are they would find remarkable similarity between what they came up with and what the strategic planning roundtable came up with,” says Dr. Shen, who is directing one of the quality and safety workgroup’s initiatives. “There are plenty of ways to think globally and act locally.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Top Image Source: HOMER SYKES/ALAMY

A Closer Look at the Pediatric Hospital Medicine Initiatives

Four workgroups emerged from the Pediatric Hospital Medicine Strategic Planning Roundtable in February. Each group was charged with directing strategic initiative projects over the next 16 to 18 months. The mission is to transform the delivery of hospital care for children. Here is a synopsis of the workgroup initiatives, some of which have estimated completion dates:

SJLOCKE/ISTOCKPHOTO.COM

Clinical Practice/Workforce

• Create a PHM position paper that defines what it means to be a pediatric hospitalist and where the field is headed. A progress report is to be published within the next few months.
• Create a clinical practice dashboard template that PHM programs can use to monitor patient care and eventually compare their program with other programs and national standards. The template will include such markers as patient readmissions and pediatric rapid response events that PHM programs should measure and track. The first version of the dashboard template should be ready by the end of 2009; test sites are to be selected by 2010.
• Develop a “return on investment” document to help pediatric hospitalists effectively discuss with hospital administrators and other stakeholders the benefits of adding or expanding PHM programs. Target deadline: February 2010.
• Assess career satisfaction among pediatric hospitalists. A large part of this initiative will involve SHM’s career satisfaction survey.

Quality and Safety

• Launch a safety project involving six to eight hospitals that is aimed at improving pediatric patient identification. Preliminary results are expected by July 2010.
• Develop a standardized communications tool that pediatric hospitalists can use when handing off patients to primary-care physicians after patients leave the hospital.
• Create a benchmarking process for the most common pediatric inpatient diagnoses (e.g., bronchiolitis, skin infections, and pneumonia) by expanding the Value in Inpatient Pediatrics (VIP) Network, a pediatric-hospitalist-led effort to find cost-effective ways to treat patients.

Research

• Restructure the existing Pediatric Research in Inpatient Settings (PRIS) network, an independent entity founded through a joint SHM-AAP-APA effort, to better advance research on issues important to pediatric care.
• Secure funding to conduct studies relevant to inpatient pediatrics. Tap into American Recovery and Reinvestment Act of 2009 (ARRA) funding for comparative effectiveness research. Target deadline: ARRA proposals by fall 2009.
• Create a mentorship system to connect pediatric hospitalists who are interested in research with PHM researchers through the AAP listserv.

Education

• Develop an educational plan supporting PHM core competencies to assist medical schools, post-graduate training programs, and continuing medical education programs in PHM teaching. The core competencies should be released by the end of the year.
• Meet the needs of PHM educators by focusing efforts on topics of interest to them, such as family-centered rounds, night float curriculum, and handoffs. Establish a repository of curriculum information that educators can access for guidance.

The economy might be in the doldrums, but recruiters are looking for candidates to fill HM positions, says Mark Dotson, senior director of recruitment for Cogent Healthcare, a Brentwood, Tenn.-based company that manages HM programs nationwide. He recently spoke with The Hospitalist eWire about how hospitalists can take advantage of the bullish job market.

Question: What do you look for in HM job candidates?

Answer: We obviously look at their credentials, their training, and the focus of their training in inpatient medicine. We strive to look for physicians who are able to and interested in working in a team environment. They should have a good bedside manner and good communication skills. They should be able to show they have a team-based approach to their work.

Q: What alternative jobs are there in HM that hospitalists might not know about?

A: There are sometimes opportunities to chair a committee that hospitalists aren't aware of. There are also ways to get involved with more specialties by working with physicians on the hospital campus and building relationships with them.

Q: Has the current economic climate affected hospitalist recruiting?

A: Not so much. The demand is still there. But I do think more hospitalists aren’t looking to make a change, because they want stability in their workplace right now. Hospital medicine is a specialty that's growing, so there is stability. Hospitalists have to decide what’s best for their clinical skills and personal interests and not let the economy stop them. There are a hundred more opportunities out there waiting for them.

The economy might be in the doldrums, but recruiters are looking for candidates to fill HM positions, says Mark Dotson, senior director of recruitment for Cogent Healthcare, a Brentwood, Tenn.-based company that manages HM programs nationwide. He recently spoke with The Hospitalist eWire about how hospitalists can take advantage of the bullish job market.

Question: What do you look for in HM job candidates?

Answer: We obviously look at their credentials, their training, and the focus of their training in inpatient medicine. We strive to look for physicians who are able to and interested in working in a team environment. They should have a good bedside manner and good communication skills. They should be able to show they have a team-based approach to their work.

Q: What alternative jobs are there in HM that hospitalists might not know about?

A: There are sometimes opportunities to chair a committee that hospitalists aren't aware of. There are also ways to get involved with more specialties by working with physicians on the hospital campus and building relationships with them.

Q: Has the current economic climate affected hospitalist recruiting?

A: Not so much. The demand is still there. But I do think more hospitalists aren’t looking to make a change, because they want stability in their workplace right now. Hospital medicine is a specialty that's growing, so there is stability. Hospitalists have to decide what’s best for their clinical skills and personal interests and not let the economy stop them. There are a hundred more opportunities out there waiting for them.

The economy might be in the doldrums, but recruiters are looking for candidates to fill HM positions, says Mark Dotson, senior director of recruitment for Cogent Healthcare, a Brentwood, Tenn.-based company that manages HM programs nationwide. He recently spoke with The Hospitalist eWire about how hospitalists can take advantage of the bullish job market.

Question: What do you look for in HM job candidates?

Answer: We obviously look at their credentials, their training, and the focus of their training in inpatient medicine. We strive to look for physicians who are able to and interested in working in a team environment. They should have a good bedside manner and good communication skills. They should be able to show they have a team-based approach to their work.

Q: What alternative jobs are there in HM that hospitalists might not know about?

A: There are sometimes opportunities to chair a committee that hospitalists aren't aware of. There are also ways to get involved with more specialties by working with physicians on the hospital campus and building relationships with them.

Q: Has the current economic climate affected hospitalist recruiting?

A: Not so much. The demand is still there. But I do think more hospitalists aren’t looking to make a change, because they want stability in their workplace right now. Hospital medicine is a specialty that's growing, so there is stability. Hospitalists have to decide what’s best for their clinical skills and personal interests and not let the economy stop them. There are a hundred more opportunities out there waiting for them.

Indu Michael remembers the one-page medical field survey she filled out around this time last year. A pre-med student at the University of California at Los Angeles, she provided the correct job descriptions for surgeons, pediatricians, OB/GYNs, psychiatrists, and internal medicine physicians. Only one medical specialty stumped her.

“I had no idea what a hospitalist did,” says Michael, 21, a senior.

The anonymous survey was part of the application and interview process for the Undergraduate Preceptorship in Internal Medicine (UPIM), a program that was launched last summer at UCLA Medical Center. By the time Michael finished the three-week program in early September, she had a complete understanding of what hospitalists do. She also says she’s leaning toward an internal medicine (IM) career—and might become a hospitalist.

“I’m seriously thinking [Hem-Onc] may not be the direction I want to take,” Michael says. “I realized oncologists are mainly consultative doctors and it’s really the general medicine team that does the medicine.”

Those kind of comments are music to Nasim Afsar-manesh’s ear. Dr. Afsar-manesh, a hospitalist and assistant clinical professor at UCLA, developed the UPIM program from scratch as a way to expose pre-med undergrads to internal medicine. The ultimate goal, of course, is steering them toward an internist career. She is well aware of medical students’ declining interest in IM, and she believes outreach to undergrads and first-year medical students will help reverse the trend.

“Undergraduates are like sponges,” Dr. Afsar-manesh says. “They are so genuinely excited about the possibilities of getting to do this stuff. … You can appeal to their idealism.” She created the program because “the general field of medicine has become so complex that students who are thinking about making it a career don’t have a good chance to see what the day-to-day practicing of medicine is like.”

HM Test Drive

Michael was one of seven students in the inaugural UPIM session. The program is open to UCLA undergrads who volunteer at least 80 hours at the medical center and pre-med students at the California Institute of Technology, where Dr. Afsar-manesh received her undergraduate degree. Seventeen students applied for the first session; the seven who were selected were chosen based on their motivation, maturity, and enthusiasm for medicine. The plan is simple: UPIM aims to offer an early spark of excitement that will stay with students and serve as positive reinforcement as they proceed through medical school and confront the challenges of an IM career.

UPIM participants were integrated into teams of attendings, residents, and medical school students, and they spent time on hospital units and subspecialty consult services. The undergrads observed residents in their patient evaluations, daily rounds, and discussions with patient families. They witnessed a number of procedures, including central-line placement and bone-marrow biopsies. Although the attendings and residents weren’t required to teach the undergrads, many volunteered a significant amount of their time, Dr. Afsar-manesh says. Some of the students spent night shifts at the hospital.

“The students felt they had participated in something special. They felt the experience had overshadowed anything they had previously done,” says Dr. Afsar-manesh, a member of SHM’s Young Physicians Committee. “I think it’s a program that can really quickly grow.”

Every Friday, undergrads participated in a teaching session, during which they had to present a medically, socially, or ethically challenging case from the previous week. They received lectures on common HM topics, such as coronary artery disease, hypertension, and diabetes mellitus. The sessions featured guest speakers who touched on career options in IM and HM, research careers, tips for getting into medical school, and international health issues.

“I loved the patient interaction, as well as discussing a case with fellow students. I didn’t even mind the long hours,” says Stacey Yudin, 23, a senior pre-med student at UCLA. “While on rounds, medical students and doctors took the time to explain concepts while we were scurrying from patient to patient. The program gave me the opportunity to test-drive my dream. We always test-drive a car before we hand over thousands of dollars for it. Shouldn’t future medical students be able to at least safely experience the practice of medicine?”

Round Two: Upgrade

This summer, Dr. Afsar-manesh is improving the student presentation and guest speaker component of the Friday sessions. She will add QI and patient-safety sessions. But the biggest change to the program is expansion, as she and fellow UCLA hospitalist Ed Ha, MD, will offer a summer session for medical students between their first and second years.

Dr. Afsar-manesh also is busy reaching out to other academic IM and HM programs interested in establishing a preceptorship program. So far, she’s made headway with 10 institutions, including Northwestern University, Stanford University, the University of Michigan Health System, and a handful of the campuses within the University of California system. She’s invited the institutions to participate in a research collaborative to combine their data on program results. “We ultimately need to see how many participants will go into IM and compare that to the national numbers. That will take years,” she says.

click for large version

Uphill Battle

Mark Schwartz, MD, an associate professor in the division of general IM at New York University’s School of Medicine, believes UPIM and programs like it will help—even if only marginally—address the declining interest in IM careers among medical students.

“It will take more than tinkering around in the educational environment,” says Dr. Schwartz, who believes workforce planning, changes in reimbursement, and redesigning medical practices are essential to recruiting medical students to internal medicine (see “A Good Start, But Not Enough”).

Nevertheless, SHM is ready to support a combined IM/HM preceptorship program that targets medical school students in their first and second years, says Larry Wellikson, MD, FHM, CEO of SHM. The society already has assigned staff to manage the project and named Dr. Afsar-manesh as the lead physician. The plan is to track preceptorship participants as they make their way through medical school and residency, and see if the program changes their attitudes toward IM careers.

Even though the number of medical students who aspire to hospitalist careers continues to increase every year, SHM believes it must move to counteract the lackluster IM numbers, because that is where most medical students are introduced to HM, Dr. Wellikson says. “The problem of people not picking internal medicine could affect hospital medicine down the road,” he says. “We can’t sit passively by and see who picks to be a hospitalist. We believe we need to be active.”

One of the last things Dr. Afsar-manesh did at the conclusion of the inaugural UPIM program was collect the students’ e-mail addresses and phone numbers so she can stay in touch and track their career paths. The UPIM survey results give her hope: After UPIM, 100% of the students were “extremely confident” in their decision to pursue medicine; 57% indicated they were “very likely” to consider IM as a specialty; and 47% were “very likely” to think about HM.

“This program is a great way to encourage students to enter into internal medicine,” Yudin says. “I am sure that all my subsequent experiences working in a hospital will be measured against my first experience rounding with the IM department.” It seems as though the student took the words right out of the doctor’s mouth. TH

Lisa Ryan is a freelance writer based in New Jersey.

Reference

1. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

Indu Michael remembers the one-page medical field survey she filled out around this time last year. A pre-med student at the University of California at Los Angeles, she provided the correct job descriptions for surgeons, pediatricians, OB/GYNs, psychiatrists, and internal medicine physicians. Only one medical specialty stumped her.

“I had no idea what a hospitalist did,” says Michael, 21, a senior.

The anonymous survey was part of the application and interview process for the Undergraduate Preceptorship in Internal Medicine (UPIM), a program that was launched last summer at UCLA Medical Center. By the time Michael finished the three-week program in early September, she had a complete understanding of what hospitalists do. She also says she’s leaning toward an internal medicine (IM) career—and might become a hospitalist.

“I’m seriously thinking [Hem-Onc] may not be the direction I want to take,” Michael says. “I realized oncologists are mainly consultative doctors and it’s really the general medicine team that does the medicine.”

Those kind of comments are music to Nasim Afsar-manesh’s ear. Dr. Afsar-manesh, a hospitalist and assistant clinical professor at UCLA, developed the UPIM program from scratch as a way to expose pre-med undergrads to internal medicine. The ultimate goal, of course, is steering them toward an internist career. She is well aware of medical students’ declining interest in IM, and she believes outreach to undergrads and first-year medical students will help reverse the trend.

“Undergraduates are like sponges,” Dr. Afsar-manesh says. “They are so genuinely excited about the possibilities of getting to do this stuff. … You can appeal to their idealism.” She created the program because “the general field of medicine has become so complex that students who are thinking about making it a career don’t have a good chance to see what the day-to-day practicing of medicine is like.”

HM Test Drive

Michael was one of seven students in the inaugural UPIM session. The program is open to UCLA undergrads who volunteer at least 80 hours at the medical center and pre-med students at the California Institute of Technology, where Dr. Afsar-manesh received her undergraduate degree. Seventeen students applied for the first session; the seven who were selected were chosen based on their motivation, maturity, and enthusiasm for medicine. The plan is simple: UPIM aims to offer an early spark of excitement that will stay with students and serve as positive reinforcement as they proceed through medical school and confront the challenges of an IM career.

UPIM participants were integrated into teams of attendings, residents, and medical school students, and they spent time on hospital units and subspecialty consult services. The undergrads observed residents in their patient evaluations, daily rounds, and discussions with patient families. They witnessed a number of procedures, including central-line placement and bone-marrow biopsies. Although the attendings and residents weren’t required to teach the undergrads, many volunteered a significant amount of their time, Dr. Afsar-manesh says. Some of the students spent night shifts at the hospital.

“The students felt they had participated in something special. They felt the experience had overshadowed anything they had previously done,” says Dr. Afsar-manesh, a member of SHM’s Young Physicians Committee. “I think it’s a program that can really quickly grow.”

Every Friday, undergrads participated in a teaching session, during which they had to present a medically, socially, or ethically challenging case from the previous week. They received lectures on common HM topics, such as coronary artery disease, hypertension, and diabetes mellitus. The sessions featured guest speakers who touched on career options in IM and HM, research careers, tips for getting into medical school, and international health issues.

“I loved the patient interaction, as well as discussing a case with fellow students. I didn’t even mind the long hours,” says Stacey Yudin, 23, a senior pre-med student at UCLA. “While on rounds, medical students and doctors took the time to explain concepts while we were scurrying from patient to patient. The program gave me the opportunity to test-drive my dream. We always test-drive a car before we hand over thousands of dollars for it. Shouldn’t future medical students be able to at least safely experience the practice of medicine?”

Round Two: Upgrade

This summer, Dr. Afsar-manesh is improving the student presentation and guest speaker component of the Friday sessions. She will add QI and patient-safety sessions. But the biggest change to the program is expansion, as she and fellow UCLA hospitalist Ed Ha, MD, will offer a summer session for medical students between their first and second years.

Dr. Afsar-manesh also is busy reaching out to other academic IM and HM programs interested in establishing a preceptorship program. So far, she’s made headway with 10 institutions, including Northwestern University, Stanford University, the University of Michigan Health System, and a handful of the campuses within the University of California system. She’s invited the institutions to participate in a research collaborative to combine their data on program results. “We ultimately need to see how many participants will go into IM and compare that to the national numbers. That will take years,” she says.

click for large version

Uphill Battle

Mark Schwartz, MD, an associate professor in the division of general IM at New York University’s School of Medicine, believes UPIM and programs like it will help—even if only marginally—address the declining interest in IM careers among medical students.

“It will take more than tinkering around in the educational environment,” says Dr. Schwartz, who believes workforce planning, changes in reimbursement, and redesigning medical practices are essential to recruiting medical students to internal medicine (see “A Good Start, But Not Enough”).

Nevertheless, SHM is ready to support a combined IM/HM preceptorship program that targets medical school students in their first and second years, says Larry Wellikson, MD, FHM, CEO of SHM. The society already has assigned staff to manage the project and named Dr. Afsar-manesh as the lead physician. The plan is to track preceptorship participants as they make their way through medical school and residency, and see if the program changes their attitudes toward IM careers.

Even though the number of medical students who aspire to hospitalist careers continues to increase every year, SHM believes it must move to counteract the lackluster IM numbers, because that is where most medical students are introduced to HM, Dr. Wellikson says. “The problem of people not picking internal medicine could affect hospital medicine down the road,” he says. “We can’t sit passively by and see who picks to be a hospitalist. We believe we need to be active.”

One of the last things Dr. Afsar-manesh did at the conclusion of the inaugural UPIM program was collect the students’ e-mail addresses and phone numbers so she can stay in touch and track their career paths. The UPIM survey results give her hope: After UPIM, 100% of the students were “extremely confident” in their decision to pursue medicine; 57% indicated they were “very likely” to consider IM as a specialty; and 47% were “very likely” to think about HM.

“This program is a great way to encourage students to enter into internal medicine,” Yudin says. “I am sure that all my subsequent experiences working in a hospital will be measured against my first experience rounding with the IM department.” It seems as though the student took the words right out of the doctor’s mouth. TH

Lisa Ryan is a freelance writer based in New Jersey.

Reference

1. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

Indu Michael remembers the one-page medical field survey she filled out around this time last year. A pre-med student at the University of California at Los Angeles, she provided the correct job descriptions for surgeons, pediatricians, OB/GYNs, psychiatrists, and internal medicine physicians. Only one medical specialty stumped her.

“I had no idea what a hospitalist did,” says Michael, 21, a senior.

The anonymous survey was part of the application and interview process for the Undergraduate Preceptorship in Internal Medicine (UPIM), a program that was launched last summer at UCLA Medical Center. By the time Michael finished the three-week program in early September, she had a complete understanding of what hospitalists do. She also says she’s leaning toward an internal medicine (IM) career—and might become a hospitalist.

“I’m seriously thinking [Hem-Onc] may not be the direction I want to take,” Michael says. “I realized oncologists are mainly consultative doctors and it’s really the general medicine team that does the medicine.”

Those kind of comments are music to Nasim Afsar-manesh’s ear. Dr. Afsar-manesh, a hospitalist and assistant clinical professor at UCLA, developed the UPIM program from scratch as a way to expose pre-med undergrads to internal medicine. The ultimate goal, of course, is steering them toward an internist career. She is well aware of medical students’ declining interest in IM, and she believes outreach to undergrads and first-year medical students will help reverse the trend.

“Undergraduates are like sponges,” Dr. Afsar-manesh says. “They are so genuinely excited about the possibilities of getting to do this stuff. … You can appeal to their idealism.” She created the program because “the general field of medicine has become so complex that students who are thinking about making it a career don’t have a good chance to see what the day-to-day practicing of medicine is like.”

HM Test Drive

Michael was one of seven students in the inaugural UPIM session. The program is open to UCLA undergrads who volunteer at least 80 hours at the medical center and pre-med students at the California Institute of Technology, where Dr. Afsar-manesh received her undergraduate degree. Seventeen students applied for the first session; the seven who were selected were chosen based on their motivation, maturity, and enthusiasm for medicine. The plan is simple: UPIM aims to offer an early spark of excitement that will stay with students and serve as positive reinforcement as they proceed through medical school and confront the challenges of an IM career.

UPIM participants were integrated into teams of attendings, residents, and medical school students, and they spent time on hospital units and subspecialty consult services. The undergrads observed residents in their patient evaluations, daily rounds, and discussions with patient families. They witnessed a number of procedures, including central-line placement and bone-marrow biopsies. Although the attendings and residents weren’t required to teach the undergrads, many volunteered a significant amount of their time, Dr. Afsar-manesh says. Some of the students spent night shifts at the hospital.

“The students felt they had participated in something special. They felt the experience had overshadowed anything they had previously done,” says Dr. Afsar-manesh, a member of SHM’s Young Physicians Committee. “I think it’s a program that can really quickly grow.”

Every Friday, undergrads participated in a teaching session, during which they had to present a medically, socially, or ethically challenging case from the previous week. They received lectures on common HM topics, such as coronary artery disease, hypertension, and diabetes mellitus. The sessions featured guest speakers who touched on career options in IM and HM, research careers, tips for getting into medical school, and international health issues.

“I loved the patient interaction, as well as discussing a case with fellow students. I didn’t even mind the long hours,” says Stacey Yudin, 23, a senior pre-med student at UCLA. “While on rounds, medical students and doctors took the time to explain concepts while we were scurrying from patient to patient. The program gave me the opportunity to test-drive my dream. We always test-drive a car before we hand over thousands of dollars for it. Shouldn’t future medical students be able to at least safely experience the practice of medicine?”

Round Two: Upgrade

This summer, Dr. Afsar-manesh is improving the student presentation and guest speaker component of the Friday sessions. She will add QI and patient-safety sessions. But the biggest change to the program is expansion, as she and fellow UCLA hospitalist Ed Ha, MD, will offer a summer session for medical students between their first and second years.

Dr. Afsar-manesh also is busy reaching out to other academic IM and HM programs interested in establishing a preceptorship program. So far, she’s made headway with 10 institutions, including Northwestern University, Stanford University, the University of Michigan Health System, and a handful of the campuses within the University of California system. She’s invited the institutions to participate in a research collaborative to combine their data on program results. “We ultimately need to see how many participants will go into IM and compare that to the national numbers. That will take years,” she says.

click for large version

Uphill Battle

Mark Schwartz, MD, an associate professor in the division of general IM at New York University’s School of Medicine, believes UPIM and programs like it will help—even if only marginally—address the declining interest in IM careers among medical students.

“It will take more than tinkering around in the educational environment,” says Dr. Schwartz, who believes workforce planning, changes in reimbursement, and redesigning medical practices are essential to recruiting medical students to internal medicine (see “A Good Start, But Not Enough”).

Nevertheless, SHM is ready to support a combined IM/HM preceptorship program that targets medical school students in their first and second years, says Larry Wellikson, MD, FHM, CEO of SHM. The society already has assigned staff to manage the project and named Dr. Afsar-manesh as the lead physician. The plan is to track preceptorship participants as they make their way through medical school and residency, and see if the program changes their attitudes toward IM careers.

Even though the number of medical students who aspire to hospitalist careers continues to increase every year, SHM believes it must move to counteract the lackluster IM numbers, because that is where most medical students are introduced to HM, Dr. Wellikson says. “The problem of people not picking internal medicine could affect hospital medicine down the road,” he says. “We can’t sit passively by and see who picks to be a hospitalist. We believe we need to be active.”

One of the last things Dr. Afsar-manesh did at the conclusion of the inaugural UPIM program was collect the students’ e-mail addresses and phone numbers so she can stay in touch and track their career paths. The UPIM survey results give her hope: After UPIM, 100% of the students were “extremely confident” in their decision to pursue medicine; 57% indicated they were “very likely” to consider IM as a specialty; and 47% were “very likely” to think about HM.

“This program is a great way to encourage students to enter into internal medicine,” Yudin says. “I am sure that all my subsequent experiences working in a hospital will be measured against my first experience rounding with the IM department.” It seems as though the student took the words right out of the doctor’s mouth. TH

Lisa Ryan is a freelance writer based in New Jersey.

Reference

1. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

Not once has Vanessa Yasmin Calderón regretted her decision to go into primary care, but she admits she’s disquieted by the amount of debt she’s accumulated while attending the University of California at Los Angeles for medical school and Harvard University’s Kennedy School of Government in pursuit of a master’s degree in public policy.

“I will be 30 years old when I graduate,” says Calderón, who plans to receive her medical degree in 2010. “Right now, I have no retirement account, and I’m staring at loads of debt in a bad economy. There’s a lot to think about.”

Calderón estimates she will have more than $146,000 in loans when she graduates—a daunting sum for someone who used scholarship money and a part-time job to put herself through college. Although Calderón is committed to a career in emergency or general internal medicine (IM), she has watched many of her peers forgo primary care in favor of anesthesiology, dermatology, and surgical specialties—partly because they are worried about how they are going to pay back their education debt.

“I guarantee you that primary care is being the most affected by rising debt,” says Calderón, vice president of finances for the American Medical Student Association (AMSA).

Her personal observations correlate with more than 15 years’ worth of published medical studies that have found compensation plays a role in dissuading medical students who are facing mountains of debt from choosing primary care. That includes careers in IM and, by extension, careers in HM, as more than 82% of hospitalists consider themselves IM specialists, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” This doesn’t bode well for the nation’s future, experts say, because primary care and IM comprise the foundation of our nation’s healthcare system.

While the steep decline in IM recruits has leveled off in recent years, the number of medical students choosing IM residency (2,632 seniors entered three-year IM residency programs in 2009) is nowhere near the high point (3,884) of the mid-1980s, says Steven E. Weinberger, MD, FACP, senior vice president for medical education and publishing for the American College of Physicians (ACP).

“If there is not a change in how we support students going through medical school, how can we be surprised when they choose a higher-paying specialty?” says Michael Rosenthal, MD, professor and vice chairman of academic programs and research in the Department of Family and Community Medicine at Thomas Jefferson University in Philadelphia.

click for large version

Loan Obligations

In 2006, more than 84% of medical school graduates had educational debt, with a median debt of $120,000 for graduates of public medical schools and $160,000 for graduates of private medical schools, according to a 2007 report by the Association of American Medical Colleges (AAMC). In comparison, the same report shows that, in 2001, the median debt for public and private medical school graduates was $86,000 and $120,000, respectively.

Just as the rising cost of healthcare leads to skyrocketing health insurance premiums, so, too, does it result in higher tuition and fees for medical students, says Brian Hurley, MD, MBA, president of AMSA. Public medical schools in particular are affected as state governments, which are obliged to annually balance their budgets, often pay for burgeoning healthcare expenses by cutting subsidies to higher education, he says.

“In a way, universities are balancing their squeezed budgets on the backs of their students,” says Dr. Hurley, who recently graduated from the University of Southern California’s Keck School of Medicine with $300,000 in educational debt.

There is no regulatory body in place that can moderate medical school tuition increases, he laments. But medical students are partly to blame for the spiraling tuition costs, Dr. Hurley says, because students rarely base their school selections on tuition costs. As a result, medical schools aren’t forced to decelerate tuition hikes, because students aren’t taking them to task.

“When pre-med students decide to go to medical school, they have this idea that they will have more opportunities if they can go to Harvard or some other top medical school,” Dr. Hurley says. “Students want to go to the best school they can, and they trust that everything will work itself out in the end.”

Meanwhile, escalating tuition costs and debt loads deter prospective medical students from low-income backgrounds from going to medical school, which hampers efforts to diversify the nation’s medical workforce and provide quality healthcare in poorer communities. “People tend to practice medicine where they came from,” Dr. Hurley says. “It’s not a perfect correlation, but it does match up.”

For its part, AMSA is educating pre-med students on how to select more affordable medical schools that provide a quality education. The association also focuses on teaching medical students how to manage educational debt. “The public perception is that physicians are rich, and it’s a perception we haven’t successfully been able to combat,” Dr. Hurley says. “Right now, medical student debt is not seen as a healthcare issue. We can try to work within the Higher Education Act to better subsidize medical students’ education, but lawmakers tend to focus on undergraduate education.”

click for large version

Nonprocedurals at Risk

But medical students’ rising debt is a healthcare issue, experts say. “Many students are now leaving medical school with over $200,000 in debt,” says Daniel Dressler, MD, FHM, SHM board member and education director for the HM section and associate program director for the IM residency program at Emory University’s School of Medicine in Atlanta. “As the cost of education increases each year and significantly outpaces the rate of increase in physician salaries, students may look toward specialties where they can pay that off within a more reasonable time frame while they begin their families and build their lives.”

Aside from primary care and IM, the medical fields that have been at the losing end of the bloated-educational-debt trend are nonprocedural-based IM specialties such as geriatrics, endocrinology, pulmonary/critical care, rheumatology, and infectious disease, says Jeffrey Wiese, MD, FACP, FHM, SHM president-elect and associate dean of graduate medical education and director of the IM residency program at Tulane University Hospital in New Orleans.

Doctors in nonprocedural-based IM specialties generally receive lower compensation than those in procedural-based IM specialties like cardiology, gastroenterology, and nephrology. For example, the median annual compensation for private-practice physicians in cardiology and gastroenterology is nearly $385,000; the median salary of endocrinologists and rheumatologists is $184,000; and the median salary for general internists is $166,000, according to a 2007 compensation survey by the Medical Group Management Association.

IM physician salaries always have been significantly less than the salaries of procedure-based specialists, Dr. Wiese says. “But now the workload of general internists has grown, and it hasn’t grown proportional to compensation, as compared to other specialties,” he says. “That’s compelling to students.”

Dr. Weinberger agrees the compensation disparity is disconcerting to medical students who consider IM because “they are choosing a harder lifestyle. It doesn’t help that the doctors who are practicing internal medicine complain about the hassles and the problems with reimbursement. The role models medical students look up to are not as happy as they used to be.”

HM Holds Its Own

Hospitalists seem to be surviving relatively well in these difficult times, according to data compiled by the American College of Physicians. In 2002, 4% of third-year IM residents surveyed said they were choosing HM. That number has risen steadily, to 10% in 2007 and 2008, Dr. Weinberger notes.

HM compensation varies widely, Dr. Wiese says; however, the mean salary for HM physicians was $196,700 in 2007, according to SHM survey data. That puts hospitalist salaries at the mid- to lower end of the scale when compared with all medical specialties but smack in the middle of IM specialties.

A 2008 study published in the Annals of Internal Medicine suggests that U.S. categorical IM residents with educational debt of $50,000 or more are more likely than those with no debt to choose a HM career, possibly because they can enter the work force right after residency training, as opposed to continuing with fellowship training for a subspecialty at substantially less compensation.1

For HM to continue gaining ground, many say the specialty has to go on the offensive and not wait for medical students and residents to decide to become hospitalists. “It will be more difficult to recruit from residency programs if there are fewer people going into internal medicine,” Dr. Dressler says. “Hospital medicine will simply be competing for a smaller pool of residents.”

Dr. Wiese says academia can contribute by providing a solid foundation in medicine and a clear path to HM careers as next-generation physicians and leaders. “Hospitalists assuming more of a teaching role are good not only for hospital medicine, but internal medicine education,” Dr. Wiese says. “The stronger the mentors, the more internal medicine students you’re going to recruit.”

The same can be said of medical practice settings, Dr. Weinberger explains. Many ambulatory settings in which medical students and residents work are among the most poorly supported and operated, even though they have the sickest patients, he says. That can be a huge turnoff for medical students. To counter that negative, students must be exposed to higher-quality ambulatory settings, Dr. Weinberger says.

Medical schools can help the cause by admitting students who show an inclination to go into primary care and IM, says Dr. Rosenthal, of Thomas Jefferson University. Those students are more likely to leave medical school in pursuit of a generalist career—especially if they’re matched with good IM mentors.

Federal and state governments should consider paying the educational loans of medical students who promise to practice primary care or IM for a certain period of time, especially in high-need communities, Dr. Rosenthal says. Fifteen years ago, he was a lead author in a study published in the Journal of the American Medical Association that found a significant number of fourth-year medical students would go into primary care, including general IM, if positive changes were made to income, hours worked, and loan repayment.2 Dr. Rosenthal says he’s not surprised physicians and researchers are writing about the same topic today.

“The article was written in the Clinton era, at a time when there was a sense the nation’s healthcare system might be reformed. But there was backlash to the plan,” Dr. Rosenthal says. “Today, we are again considering healthcare reform, except this time people are more willing to accept it because the high cost of healthcare is now affecting businesses and the economy.”

click for large version

Change in Outlook

President Obama’s stated goal of extending health insurance to more Americans makes increasing the ranks of primary-care physicians, general internists, and hospitalists even more urgent, experts say. In Massachusetts, a state that is experimenting with universal health coverage for all of its residents, a shortfall in the primary-care work force is evident, Dr. Weinberger says. It is troubling news, because research consistently shows that when a primary-care physician coordinates a patient’s care, the result is fewer visits to the ED and medical specialists, he says.

“What this means is, we need more internists in the outpatient side to care for these patients longitudinally,” Dr. Dressler says. “We need more hospitalists, as the burden of inpatient care is very likely to grow as well.”

Dr. Rosenthal says more students will be attracted to medicine in part because the recession is making solid, good-paying jobs that play a vital role in communities very attractive. If better support were available for students interested in primary care, he says, he would have reason to hope more students would choose generalist careers.

“There was this expectation among people in their 20s that, if they were bright and able, they would have a nice lifestyle without having to work too hard. But the recession is having an effect on this generation’s outlook,” Dr. Rosenthal says. “I think there is a changing landscape out there.” TH

Lisa Ryan is a freelance writer based in New Jersey.

References

1. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Intern Med. 2008;149(6): 416-420.
2. Rosenthal MP, Diamond JJ, Rabinowitz HK, et al. Influence of income, hours worked, and loan repayment on medical students’ decision to pursue a primary care career. JAMA. 1994;271(12):914-917.

Not once has Vanessa Yasmin Calderón regretted her decision to go into primary care, but she admits she’s disquieted by the amount of debt she’s accumulated while attending the University of California at Los Angeles for medical school and Harvard University’s Kennedy School of Government in pursuit of a master’s degree in public policy.

“I will be 30 years old when I graduate,” says Calderón, who plans to receive her medical degree in 2010. “Right now, I have no retirement account, and I’m staring at loads of debt in a bad economy. There’s a lot to think about.”

Calderón estimates she will have more than $146,000 in loans when she graduates—a daunting sum for someone who used scholarship money and a part-time job to put herself through college. Although Calderón is committed to a career in emergency or general internal medicine (IM), she has watched many of her peers forgo primary care in favor of anesthesiology, dermatology, and surgical specialties—partly because they are worried about how they are going to pay back their education debt.

“I guarantee you that primary care is being the most affected by rising debt,” says Calderón, vice president of finances for the American Medical Student Association (AMSA).

Her personal observations correlate with more than 15 years’ worth of published medical studies that have found compensation plays a role in dissuading medical students who are facing mountains of debt from choosing primary care. That includes careers in IM and, by extension, careers in HM, as more than 82% of hospitalists consider themselves IM specialists, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” This doesn’t bode well for the nation’s future, experts say, because primary care and IM comprise the foundation of our nation’s healthcare system.

While the steep decline in IM recruits has leveled off in recent years, the number of medical students choosing IM residency (2,632 seniors entered three-year IM residency programs in 2009) is nowhere near the high point (3,884) of the mid-1980s, says Steven E. Weinberger, MD, FACP, senior vice president for medical education and publishing for the American College of Physicians (ACP).

“If there is not a change in how we support students going through medical school, how can we be surprised when they choose a higher-paying specialty?” says Michael Rosenthal, MD, professor and vice chairman of academic programs and research in the Department of Family and Community Medicine at Thomas Jefferson University in Philadelphia.

click for large version

Loan Obligations

In 2006, more than 84% of medical school graduates had educational debt, with a median debt of $120,000 for graduates of public medical schools and $160,000 for graduates of private medical schools, according to a 2007 report by the Association of American Medical Colleges (AAMC). In comparison, the same report shows that, in 2001, the median debt for public and private medical school graduates was $86,000 and $120,000, respectively.

Just as the rising cost of healthcare leads to skyrocketing health insurance premiums, so, too, does it result in higher tuition and fees for medical students, says Brian Hurley, MD, MBA, president of AMSA. Public medical schools in particular are affected as state governments, which are obliged to annually balance their budgets, often pay for burgeoning healthcare expenses by cutting subsidies to higher education, he says.

“In a way, universities are balancing their squeezed budgets on the backs of their students,” says Dr. Hurley, who recently graduated from the University of Southern California’s Keck School of Medicine with $300,000 in educational debt.

There is no regulatory body in place that can moderate medical school tuition increases, he laments. But medical students are partly to blame for the spiraling tuition costs, Dr. Hurley says, because students rarely base their school selections on tuition costs. As a result, medical schools aren’t forced to decelerate tuition hikes, because students aren’t taking them to task.

“When pre-med students decide to go to medical school, they have this idea that they will have more opportunities if they can go to Harvard or some other top medical school,” Dr. Hurley says. “Students want to go to the best school they can, and they trust that everything will work itself out in the end.”

Meanwhile, escalating tuition costs and debt loads deter prospective medical students from low-income backgrounds from going to medical school, which hampers efforts to diversify the nation’s medical workforce and provide quality healthcare in poorer communities. “People tend to practice medicine where they came from,” Dr. Hurley says. “It’s not a perfect correlation, but it does match up.”

For its part, AMSA is educating pre-med students on how to select more affordable medical schools that provide a quality education. The association also focuses on teaching medical students how to manage educational debt. “The public perception is that physicians are rich, and it’s a perception we haven’t successfully been able to combat,” Dr. Hurley says. “Right now, medical student debt is not seen as a healthcare issue. We can try to work within the Higher Education Act to better subsidize medical students’ education, but lawmakers tend to focus on undergraduate education.”

click for large version

Nonprocedurals at Risk

But medical students’ rising debt is a healthcare issue, experts say. “Many students are now leaving medical school with over $200,000 in debt,” says Daniel Dressler, MD, FHM, SHM board member and education director for the HM section and associate program director for the IM residency program at Emory University’s School of Medicine in Atlanta. “As the cost of education increases each year and significantly outpaces the rate of increase in physician salaries, students may look toward specialties where they can pay that off within a more reasonable time frame while they begin their families and build their lives.”

Aside from primary care and IM, the medical fields that have been at the losing end of the bloated-educational-debt trend are nonprocedural-based IM specialties such as geriatrics, endocrinology, pulmonary/critical care, rheumatology, and infectious disease, says Jeffrey Wiese, MD, FACP, FHM, SHM president-elect and associate dean of graduate medical education and director of the IM residency program at Tulane University Hospital in New Orleans.

Doctors in nonprocedural-based IM specialties generally receive lower compensation than those in procedural-based IM specialties like cardiology, gastroenterology, and nephrology. For example, the median annual compensation for private-practice physicians in cardiology and gastroenterology is nearly $385,000; the median salary of endocrinologists and rheumatologists is $184,000; and the median salary for general internists is $166,000, according to a 2007 compensation survey by the Medical Group Management Association.

IM physician salaries always have been significantly less than the salaries of procedure-based specialists, Dr. Wiese says. “But now the workload of general internists has grown, and it hasn’t grown proportional to compensation, as compared to other specialties,” he says. “That’s compelling to students.”

Dr. Weinberger agrees the compensation disparity is disconcerting to medical students who consider IM because “they are choosing a harder lifestyle. It doesn’t help that the doctors who are practicing internal medicine complain about the hassles and the problems with reimbursement. The role models medical students look up to are not as happy as they used to be.”

HM Holds Its Own

Hospitalists seem to be surviving relatively well in these difficult times, according to data compiled by the American College of Physicians. In 2002, 4% of third-year IM residents surveyed said they were choosing HM. That number has risen steadily, to 10% in 2007 and 2008, Dr. Weinberger notes.

HM compensation varies widely, Dr. Wiese says; however, the mean salary for HM physicians was $196,700 in 2007, according to SHM survey data. That puts hospitalist salaries at the mid- to lower end of the scale when compared with all medical specialties but smack in the middle of IM specialties.

A 2008 study published in the Annals of Internal Medicine suggests that U.S. categorical IM residents with educational debt of $50,000 or more are more likely than those with no debt to choose a HM career, possibly because they can enter the work force right after residency training, as opposed to continuing with fellowship training for a subspecialty at substantially less compensation.1

For HM to continue gaining ground, many say the specialty has to go on the offensive and not wait for medical students and residents to decide to become hospitalists. “It will be more difficult to recruit from residency programs if there are fewer people going into internal medicine,” Dr. Dressler says. “Hospital medicine will simply be competing for a smaller pool of residents.”

Dr. Wiese says academia can contribute by providing a solid foundation in medicine and a clear path to HM careers as next-generation physicians and leaders. “Hospitalists assuming more of a teaching role are good not only for hospital medicine, but internal medicine education,” Dr. Wiese says. “The stronger the mentors, the more internal medicine students you’re going to recruit.”

The same can be said of medical practice settings, Dr. Weinberger explains. Many ambulatory settings in which medical students and residents work are among the most poorly supported and operated, even though they have the sickest patients, he says. That can be a huge turnoff for medical students. To counter that negative, students must be exposed to higher-quality ambulatory settings, Dr. Weinberger says.

Medical schools can help the cause by admitting students who show an inclination to go into primary care and IM, says Dr. Rosenthal, of Thomas Jefferson University. Those students are more likely to leave medical school in pursuit of a generalist career—especially if they’re matched with good IM mentors.

Federal and state governments should consider paying the educational loans of medical students who promise to practice primary care or IM for a certain period of time, especially in high-need communities, Dr. Rosenthal says. Fifteen years ago, he was a lead author in a study published in the Journal of the American Medical Association that found a significant number of fourth-year medical students would go into primary care, including general IM, if positive changes were made to income, hours worked, and loan repayment.2 Dr. Rosenthal says he’s not surprised physicians and researchers are writing about the same topic today.

“The article was written in the Clinton era, at a time when there was a sense the nation’s healthcare system might be reformed. But there was backlash to the plan,” Dr. Rosenthal says. “Today, we are again considering healthcare reform, except this time people are more willing to accept it because the high cost of healthcare is now affecting businesses and the economy.”

click for large version

Change in Outlook

President Obama’s stated goal of extending health insurance to more Americans makes increasing the ranks of primary-care physicians, general internists, and hospitalists even more urgent, experts say. In Massachusetts, a state that is experimenting with universal health coverage for all of its residents, a shortfall in the primary-care work force is evident, Dr. Weinberger says. It is troubling news, because research consistently shows that when a primary-care physician coordinates a patient’s care, the result is fewer visits to the ED and medical specialists, he says.

“What this means is, we need more internists in the outpatient side to care for these patients longitudinally,” Dr. Dressler says. “We need more hospitalists, as the burden of inpatient care is very likely to grow as well.”

Dr. Rosenthal says more students will be attracted to medicine in part because the recession is making solid, good-paying jobs that play a vital role in communities very attractive. If better support were available for students interested in primary care, he says, he would have reason to hope more students would choose generalist careers.

“There was this expectation among people in their 20s that, if they were bright and able, they would have a nice lifestyle without having to work too hard. But the recession is having an effect on this generation’s outlook,” Dr. Rosenthal says. “I think there is a changing landscape out there.” TH

Lisa Ryan is a freelance writer based in New Jersey.

References

1. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Intern Med. 2008;149(6): 416-420.
2. Rosenthal MP, Diamond JJ, Rabinowitz HK, et al. Influence of income, hours worked, and loan repayment on medical students’ decision to pursue a primary care career. JAMA. 1994;271(12):914-917.

Not once has Vanessa Yasmin Calderón regretted her decision to go into primary care, but she admits she’s disquieted by the amount of debt she’s accumulated while attending the University of California at Los Angeles for medical school and Harvard University’s Kennedy School of Government in pursuit of a master’s degree in public policy.

“I will be 30 years old when I graduate,” says Calderón, who plans to receive her medical degree in 2010. “Right now, I have no retirement account, and I’m staring at loads of debt in a bad economy. There’s a lot to think about.”

Calderón estimates she will have more than $146,000 in loans when she graduates—a daunting sum for someone who used scholarship money and a part-time job to put herself through college. Although Calderón is committed to a career in emergency or general internal medicine (IM), she has watched many of her peers forgo primary care in favor of anesthesiology, dermatology, and surgical specialties—partly because they are worried about how they are going to pay back their education debt.

“I guarantee you that primary care is being the most affected by rising debt,” says Calderón, vice president of finances for the American Medical Student Association (AMSA).

Her personal observations correlate with more than 15 years’ worth of published medical studies that have found compensation plays a role in dissuading medical students who are facing mountains of debt from choosing primary care. That includes careers in IM and, by extension, careers in HM, as more than 82% of hospitalists consider themselves IM specialists, according to SHM’s 2007-2008 “Bi-Annual Survey on the State of the Hospital Medicine Movement.” This doesn’t bode well for the nation’s future, experts say, because primary care and IM comprise the foundation of our nation’s healthcare system.

While the steep decline in IM recruits has leveled off in recent years, the number of medical students choosing IM residency (2,632 seniors entered three-year IM residency programs in 2009) is nowhere near the high point (3,884) of the mid-1980s, says Steven E. Weinberger, MD, FACP, senior vice president for medical education and publishing for the American College of Physicians (ACP).

“If there is not a change in how we support students going through medical school, how can we be surprised when they choose a higher-paying specialty?” says Michael Rosenthal, MD, professor and vice chairman of academic programs and research in the Department of Family and Community Medicine at Thomas Jefferson University in Philadelphia.

click for large version

Loan Obligations

In 2006, more than 84% of medical school graduates had educational debt, with a median debt of $120,000 for graduates of public medical schools and $160,000 for graduates of private medical schools, according to a 2007 report by the Association of American Medical Colleges (AAMC). In comparison, the same report shows that, in 2001, the median debt for public and private medical school graduates was $86,000 and $120,000, respectively.

Just as the rising cost of healthcare leads to skyrocketing health insurance premiums, so, too, does it result in higher tuition and fees for medical students, says Brian Hurley, MD, MBA, president of AMSA. Public medical schools in particular are affected as state governments, which are obliged to annually balance their budgets, often pay for burgeoning healthcare expenses by cutting subsidies to higher education, he says.

“In a way, universities are balancing their squeezed budgets on the backs of their students,” says Dr. Hurley, who recently graduated from the University of Southern California’s Keck School of Medicine with $300,000 in educational debt.

There is no regulatory body in place that can moderate medical school tuition increases, he laments. But medical students are partly to blame for the spiraling tuition costs, Dr. Hurley says, because students rarely base their school selections on tuition costs. As a result, medical schools aren’t forced to decelerate tuition hikes, because students aren’t taking them to task.

“When pre-med students decide to go to medical school, they have this idea that they will have more opportunities if they can go to Harvard or some other top medical school,” Dr. Hurley says. “Students want to go to the best school they can, and they trust that everything will work itself out in the end.”

Meanwhile, escalating tuition costs and debt loads deter prospective medical students from low-income backgrounds from going to medical school, which hampers efforts to diversify the nation’s medical workforce and provide quality healthcare in poorer communities. “People tend to practice medicine where they came from,” Dr. Hurley says. “It’s not a perfect correlation, but it does match up.”

For its part, AMSA is educating pre-med students on how to select more affordable medical schools that provide a quality education. The association also focuses on teaching medical students how to manage educational debt. “The public perception is that physicians are rich, and it’s a perception we haven’t successfully been able to combat,” Dr. Hurley says. “Right now, medical student debt is not seen as a healthcare issue. We can try to work within the Higher Education Act to better subsidize medical students’ education, but lawmakers tend to focus on undergraduate education.”

click for large version

Nonprocedurals at Risk

But medical students’ rising debt is a healthcare issue, experts say. “Many students are now leaving medical school with over $200,000 in debt,” says Daniel Dressler, MD, FHM, SHM board member and education director for the HM section and associate program director for the IM residency program at Emory University’s School of Medicine in Atlanta. “As the cost of education increases each year and significantly outpaces the rate of increase in physician salaries, students may look toward specialties where they can pay that off within a more reasonable time frame while they begin their families and build their lives.”

Aside from primary care and IM, the medical fields that have been at the losing end of the bloated-educational-debt trend are nonprocedural-based IM specialties such as geriatrics, endocrinology, pulmonary/critical care, rheumatology, and infectious disease, says Jeffrey Wiese, MD, FACP, FHM, SHM president-elect and associate dean of graduate medical education and director of the IM residency program at Tulane University Hospital in New Orleans.

Doctors in nonprocedural-based IM specialties generally receive lower compensation than those in procedural-based IM specialties like cardiology, gastroenterology, and nephrology. For example, the median annual compensation for private-practice physicians in cardiology and gastroenterology is nearly $385,000; the median salary of endocrinologists and rheumatologists is $184,000; and the median salary for general internists is $166,000, according to a 2007 compensation survey by the Medical Group Management Association.

IM physician salaries always have been significantly less than the salaries of procedure-based specialists, Dr. Wiese says. “But now the workload of general internists has grown, and it hasn’t grown proportional to compensation, as compared to other specialties,” he says. “That’s compelling to students.”

Dr. Weinberger agrees the compensation disparity is disconcerting to medical students who consider IM because “they are choosing a harder lifestyle. It doesn’t help that the doctors who are practicing internal medicine complain about the hassles and the problems with reimbursement. The role models medical students look up to are not as happy as they used to be.”

HM Holds Its Own

Hospitalists seem to be surviving relatively well in these difficult times, according to data compiled by the American College of Physicians. In 2002, 4% of third-year IM residents surveyed said they were choosing HM. That number has risen steadily, to 10% in 2007 and 2008, Dr. Weinberger notes.

HM compensation varies widely, Dr. Wiese says; however, the mean salary for HM physicians was $196,700 in 2007, according to SHM survey data. That puts hospitalist salaries at the mid- to lower end of the scale when compared with all medical specialties but smack in the middle of IM specialties.

A 2008 study published in the Annals of Internal Medicine suggests that U.S. categorical IM residents with educational debt of $50,000 or more are more likely than those with no debt to choose a HM career, possibly because they can enter the work force right after residency training, as opposed to continuing with fellowship training for a subspecialty at substantially less compensation.1

For HM to continue gaining ground, many say the specialty has to go on the offensive and not wait for medical students and residents to decide to become hospitalists. “It will be more difficult to recruit from residency programs if there are fewer people going into internal medicine,” Dr. Dressler says. “Hospital medicine will simply be competing for a smaller pool of residents.”

Dr. Wiese says academia can contribute by providing a solid foundation in medicine and a clear path to HM careers as next-generation physicians and leaders. “Hospitalists assuming more of a teaching role are good not only for hospital medicine, but internal medicine education,” Dr. Wiese says. “The stronger the mentors, the more internal medicine students you’re going to recruit.”

The same can be said of medical practice settings, Dr. Weinberger explains. Many ambulatory settings in which medical students and residents work are among the most poorly supported and operated, even though they have the sickest patients, he says. That can be a huge turnoff for medical students. To counter that negative, students must be exposed to higher-quality ambulatory settings, Dr. Weinberger says.

Medical schools can help the cause by admitting students who show an inclination to go into primary care and IM, says Dr. Rosenthal, of Thomas Jefferson University. Those students are more likely to leave medical school in pursuit of a generalist career—especially if they’re matched with good IM mentors.

Federal and state governments should consider paying the educational loans of medical students who promise to practice primary care or IM for a certain period of time, especially in high-need communities, Dr. Rosenthal says. Fifteen years ago, he was a lead author in a study published in the Journal of the American Medical Association that found a significant number of fourth-year medical students would go into primary care, including general IM, if positive changes were made to income, hours worked, and loan repayment.2 Dr. Rosenthal says he’s not surprised physicians and researchers are writing about the same topic today.

“The article was written in the Clinton era, at a time when there was a sense the nation’s healthcare system might be reformed. But there was backlash to the plan,” Dr. Rosenthal says. “Today, we are again considering healthcare reform, except this time people are more willing to accept it because the high cost of healthcare is now affecting businesses and the economy.”

click for large version

Change in Outlook

President Obama’s stated goal of extending health insurance to more Americans makes increasing the ranks of primary-care physicians, general internists, and hospitalists even more urgent, experts say. In Massachusetts, a state that is experimenting with universal health coverage for all of its residents, a shortfall in the primary-care work force is evident, Dr. Weinberger says. It is troubling news, because research consistently shows that when a primary-care physician coordinates a patient’s care, the result is fewer visits to the ED and medical specialists, he says.

“What this means is, we need more internists in the outpatient side to care for these patients longitudinally,” Dr. Dressler says. “We need more hospitalists, as the burden of inpatient care is very likely to grow as well.”

Dr. Rosenthal says more students will be attracted to medicine in part because the recession is making solid, good-paying jobs that play a vital role in communities very attractive. If better support were available for students interested in primary care, he says, he would have reason to hope more students would choose generalist careers.

“There was this expectation among people in their 20s that, if they were bright and able, they would have a nice lifestyle without having to work too hard. But the recession is having an effect on this generation’s outlook,” Dr. Rosenthal says. “I think there is a changing landscape out there.” TH

Lisa Ryan is a freelance writer based in New Jersey.

References

1. McDonald FS, West CP, Popkave C, Kolars JC. Educational debt and reported career plans among internal medicine residents. Ann Intern Med. 2008;149(6): 416-420.
2. Rosenthal MP, Diamond JJ, Rabinowitz HK, et al. Influence of income, hours worked, and loan repayment on medical students’ decision to pursue a primary care career. JAMA. 1994;271(12):914-917.

Karim Godamunne, MD, watched the moving images on the computer screen as he maneuvered the joystick with his hand. Using the computer screen as a guide, he traversed hallways, entered rooms, and zoomed the camera lens in on patients and equipment—all with a slight flick of the controller.

Sounds like a doc playing video games in the back office, right? But entertainment wasn’t what Dr. Godamunne, a hospitalist medical director with Eagle Hospital Physicians in Atlanta, was after. He was busy overseeing a study on admitting ED patients to St. Joseph’s Hospital in Atlanta, but he and the other participating physicians weren’t physically in the ED: With the help of a robot, a computer, and a secure high-speed Internet connection, the physicians obtained patients’ medical histories, performed physical exams, and admitted them in about the same time it normally takes on-site doctors.

“It’s like a video game, but much more. That’s how I describe it to people,” Dr. Godamunne says of the technology used in the study. “You have to be able to visualize what you’re doing.”

About 10 Eagle hospitalists participated in a pilot program last year that aimed to determine whether ED patients could be admitted by remote hospitalists using the RP-7 robot, which was developed by Santa Barbara, Calif.-based InTouch Health. Eagle was so pleased with the small study’s results that it began offering its remote-robot program to hospitals last October and anticipates deploying the first robot for HM work this spring. Eagle CEO Robert Young, MD, MPH, conceived the study and considers his company’s fledgling telemedicine program a solution to the hospitalist shortage, particularly for covering night shifts.

The Future of Round-the-Clock Rounds

Is telemedicine the right fit for your HM group? Consider the following pros and cons before you make a decision:

BENEFITS

• Less burnout for hospitalists, leading to higher productivity and longevity;
• Easier hospitalist recruitment, because applicants know they are less likely to work nights;
• Ability to cover multiple hospitals at one time, mitigating the hospitalist shortage that many areas face;
• Enhanced access for hospitalists and their patients to medical specialists;
• Higher technology comfort level among many patients; and
• Ability to expand hospital market area by employing telemedicine technology at outlying medical clinics and offices.

BARRIERS

• Reimbursement obstacles for Medicare and some private health insurers;
• Medical licensing can be time-consuming for telemedicine doctors who serve patients in multiple states;
• Difficulty getting buy-in from on-site doctors and primary-care physicians who are worried about liability and telemedicine doctors’ competence;
• Fear of lawsuits by patients treated via telemedicine;
• Startup technology and training costs; and
• Potential patient resistance to telemedicine.

“Eagle’s experience is that many hospitalists will be skeptical at first, but once they see it in action, not only does much of the resistance go away, but some become champions for its use,” Dr. Young says. “It is largely a matter of exposure to and experience in using the technology.”

While increasingly common in hospital ICUs and radiology departments, telemedicine is catching on more slowly in HM. Experts and practicing hospitalists cite reimbursement hiccups, a laborious medical licensing process, technology costs, physician and patient resistance, and risk aversion as the main reasons telemedicine isn’t embraced throughout HM. Some think it will take a concerted government effort to nudge hospitals and HM groups to buy into the technology.

Nevertheless, a growing number of physicians and administrators think telemedicine is inevitable, especially as the demand for HM services outpaces the supply. As in within the Eagle system, some hospitalists are positioning themselves to capitalize on the advancing technology.

The Future Isn’t Far

photo courtesy of The Night Hospitalist Co.

“I think it’s going to explode,” says Yomi Olusanya, MD, a hospitalist in rural Rolla, Mo., and founder of The Night Hospitalist Co., LLC, a startup that is busy developing a business model to provide nighttime hospital coverage via telemedicine. “I think with increased costs and the shortage of physicians, hospitalist groups are not going to have any choice but to find alternative ways of doing business. I really believe that.”

Dr. Olusanya envisions establishing a team of about 10 telehospitalists who would handle cross-coverage calls at multiple hospitals in multiple states. The hospitalists would use a mobile cart fashioned with a high-resolution, dual-focus video screen; a video camera; and diagnostic equipment, such as a digital stethoscope, to aid in physical exams. Hospital clients would be given a toll-free number to call to connect with a telehospitalist between

7 p.m. and 7 a.m., and on-site nurses would simply wheel the mobile cart into a patient’s room to begin the care. All overnight changes in medical management would be transmitted to the correct hospital floors for insertion into patients’ medical records. The Night Hospitalist plans to cover malpractice insurance for its physicians and charge a nightly rate, which would vary depending on the length of the contract.

The mobile cart costs between $20,000 and $30,000, and Dr. Olusanya is contemplating absorbing that expense just to get groups interested. At this point, he’s not promising prospective clients cost savings. Instead, he’s offering them a way to lighten the physician workload in order to increase productivity, job satisfaction and career longevity.

“We’re trying to sell the idea to hospitalists,” he says. “This is so new that I’m trying to figure out the best model.” After originally including hospital admissions in his business model, he ultimately decided to focus exclusively on cross-coverage calls and leave the admissions to an on-site physician. “At this point, I don’t see the telemed machine in the ED doing an admission of a new patient, because it becomes less efficient,” he explains.

Conversely, Eagle Hospital Physicians’ remote-robot program is designed to do hospital admissions. The RP-7 robot is mobile enough to aid in cross-coverage, but hospitals must be careful not to overburden the machine with floor calls because it takes the robot longer to travel around the hospital than it does for an on-site physician, says Betty Abbott, Eagle’s chief operating officer.

Through the robot, which stands 5 feet 6 inches tall, a remote hospitalist can interact with a patient, the patient’s family, and the physician or nurse through a live, two-way audio and video system. The remote hospitalist can move the robot’s head to view charts and vital signs on monitors, zoom in to look at a patient’s pupils, and use several diagnostic tools with the help of an on-site health provider to conduct a patient exam, Abbott says. The remote hospitalist also can split the robot’s screen to show a patient X-rays, test results, videos, or other multimedia imaging.

“Certainly, using a robot to interact with patients takes some thought,” Abbott says. “Doctors have to be good at using the robot to act like a human being rather than simply a stationary screen in a room.”

The robot received high marks from patients, hospitalists, ED staff, and healthcare providers who participated in the pilot program at St. Joseph’s Hospital, according to the results of Eagle’s unpublished study. The technology is user-friendly enough that all types of healthcare providers can be trained to use it, says Dr. Godamunne. He designed and helped implement the study, and he found patients quickly adapted to the robot once they focused on the physicians’ faces on the screen.

Financial, Philosophical Hurdles

Hospitalists like Suman Narumanchi, MD, who leads the HM team at Resurrection Medical Center in Chicago, surmise most patients and their primary-care physicians expect doctors—not a robot or telemed cart—to physically be at the bedside in the hospital. As a result, if something goes wrong, the patient and their primary-care physician might respond with lawsuits. For that reason, “there has to be consistency in telemedicine,” Dr. Narumanchi says. “I just think at this point, it is probably a different level of care based on pure luck, because you don’t know who is going to be working that particular night.”

The concept raises interesting questions, says Eric Samson, DO, HM director for IN Compass Health Inc. in Greensboro, N.C. “Such as that of accountability and ownership of outcomes. On the other hand, it seems enticing to limit the multitude of distractions that occur through nighttime floor calls by implementing a cross-cover specialist fielding floor calls from a more-humane time zone—‘Hey, I’m working night call, but during bankers’ hours.’ ”

photo courtesy of The Night Hospitalist Co.

Protocols vary from hospital to hospital, and it will be difficult for telehospitalists who cover multiple facilities to learn the differences, says John Nelson, MD, FACP, co-founder and past president of SHM, and principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm in La Quinta, Calif. The job becomes even harder if one or more of the hospitals does not have electronic medical records (EMRs) and instead has to fax patient records to the telehospitalist, he says. Before hospitals invest in this expensive technology, a better solution might be to invent another way to address night coverage, such as allowing nonphysician providers (e.g., nurses) sign off on routine items that now require a doctor’s signature, he says.

Robert Cimasi, president of Health Capital Consultants, a St. Louis-based healthcare financial and economic consulting firm, says telemedicine’s ability to connect patients with distant specialists and allow hospitals to share doctors is tremendous, but agrees the technology is expensive and shouldn’t be entered into without a solid game plan, staff buy-in, and a long-term outlook. Although telemedicine proponents insist EMRs aren’t necessary, Cimasi advises hospitals serious about telemedicine to invest in EMRs, along with electronic order entry for their pharmacies and a secure computer network.

“A lot of hospitals aren’t going to have the capital capacity to do this without government help,” Cimasi explains. “The question is whether the political will is there to have a sustained period of investment.”

Eagle’s remote-robot program is less expensive than hiring a nocturnist or using a locum tenens physician, Dr. Young says. He predicts rural hospitals will benefit the most from his company’s program and other telemedicine services in the market because rural hospitals are most affected by the shortage of inpatient physicians. That might be the case, but if telemedicine is to ever make inroads among hospitalists, it will happen at urban hospitals first because they have the patient populations to support it, Dr. Nelson says.

“At larger hospitals where hospitalists are very busy admitting patients and busy checking patients already admitted, I could see using telemedicine to do the cross-coverage,” he says. “But in a small hospital, that wouldn’t make much sense, because there’s not enough patient volume.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Karim Godamunne, MD, watched the moving images on the computer screen as he maneuvered the joystick with his hand. Using the computer screen as a guide, he traversed hallways, entered rooms, and zoomed the camera lens in on patients and equipment—all with a slight flick of the controller.

Sounds like a doc playing video games in the back office, right? But entertainment wasn’t what Dr. Godamunne, a hospitalist medical director with Eagle Hospital Physicians in Atlanta, was after. He was busy overseeing a study on admitting ED patients to St. Joseph’s Hospital in Atlanta, but he and the other participating physicians weren’t physically in the ED: With the help of a robot, a computer, and a secure high-speed Internet connection, the physicians obtained patients’ medical histories, performed physical exams, and admitted them in about the same time it normally takes on-site doctors.

“It’s like a video game, but much more. That’s how I describe it to people,” Dr. Godamunne says of the technology used in the study. “You have to be able to visualize what you’re doing.”

About 10 Eagle hospitalists participated in a pilot program last year that aimed to determine whether ED patients could be admitted by remote hospitalists using the RP-7 robot, which was developed by Santa Barbara, Calif.-based InTouch Health. Eagle was so pleased with the small study’s results that it began offering its remote-robot program to hospitals last October and anticipates deploying the first robot for HM work this spring. Eagle CEO Robert Young, MD, MPH, conceived the study and considers his company’s fledgling telemedicine program a solution to the hospitalist shortage, particularly for covering night shifts.

The Future of Round-the-Clock Rounds

Is telemedicine the right fit for your HM group? Consider the following pros and cons before you make a decision:

BENEFITS

• Less burnout for hospitalists, leading to higher productivity and longevity;
• Easier hospitalist recruitment, because applicants know they are less likely to work nights;
• Ability to cover multiple hospitals at one time, mitigating the hospitalist shortage that many areas face;
• Enhanced access for hospitalists and their patients to medical specialists;
• Higher technology comfort level among many patients; and
• Ability to expand hospital market area by employing telemedicine technology at outlying medical clinics and offices.

BARRIERS

• Reimbursement obstacles for Medicare and some private health insurers;
• Medical licensing can be time-consuming for telemedicine doctors who serve patients in multiple states;
• Difficulty getting buy-in from on-site doctors and primary-care physicians who are worried about liability and telemedicine doctors’ competence;
• Fear of lawsuits by patients treated via telemedicine;
• Startup technology and training costs; and
• Potential patient resistance to telemedicine.

“Eagle’s experience is that many hospitalists will be skeptical at first, but once they see it in action, not only does much of the resistance go away, but some become champions for its use,” Dr. Young says. “It is largely a matter of exposure to and experience in using the technology.”

While increasingly common in hospital ICUs and radiology departments, telemedicine is catching on more slowly in HM. Experts and practicing hospitalists cite reimbursement hiccups, a laborious medical licensing process, technology costs, physician and patient resistance, and risk aversion as the main reasons telemedicine isn’t embraced throughout HM. Some think it will take a concerted government effort to nudge hospitals and HM groups to buy into the technology.

Nevertheless, a growing number of physicians and administrators think telemedicine is inevitable, especially as the demand for HM services outpaces the supply. As in within the Eagle system, some hospitalists are positioning themselves to capitalize on the advancing technology.

The Future Isn’t Far

photo courtesy of The Night Hospitalist Co.

“I think it’s going to explode,” says Yomi Olusanya, MD, a hospitalist in rural Rolla, Mo., and founder of The Night Hospitalist Co., LLC, a startup that is busy developing a business model to provide nighttime hospital coverage via telemedicine. “I think with increased costs and the shortage of physicians, hospitalist groups are not going to have any choice but to find alternative ways of doing business. I really believe that.”

Dr. Olusanya envisions establishing a team of about 10 telehospitalists who would handle cross-coverage calls at multiple hospitals in multiple states. The hospitalists would use a mobile cart fashioned with a high-resolution, dual-focus video screen; a video camera; and diagnostic equipment, such as a digital stethoscope, to aid in physical exams. Hospital clients would be given a toll-free number to call to connect with a telehospitalist between

7 p.m. and 7 a.m., and on-site nurses would simply wheel the mobile cart into a patient’s room to begin the care. All overnight changes in medical management would be transmitted to the correct hospital floors for insertion into patients’ medical records. The Night Hospitalist plans to cover malpractice insurance for its physicians and charge a nightly rate, which would vary depending on the length of the contract.

The mobile cart costs between $20,000 and $30,000, and Dr. Olusanya is contemplating absorbing that expense just to get groups interested. At this point, he’s not promising prospective clients cost savings. Instead, he’s offering them a way to lighten the physician workload in order to increase productivity, job satisfaction and career longevity.

“We’re trying to sell the idea to hospitalists,” he says. “This is so new that I’m trying to figure out the best model.” After originally including hospital admissions in his business model, he ultimately decided to focus exclusively on cross-coverage calls and leave the admissions to an on-site physician. “At this point, I don’t see the telemed machine in the ED doing an admission of a new patient, because it becomes less efficient,” he explains.

Conversely, Eagle Hospital Physicians’ remote-robot program is designed to do hospital admissions. The RP-7 robot is mobile enough to aid in cross-coverage, but hospitals must be careful not to overburden the machine with floor calls because it takes the robot longer to travel around the hospital than it does for an on-site physician, says Betty Abbott, Eagle’s chief operating officer.

Through the robot, which stands 5 feet 6 inches tall, a remote hospitalist can interact with a patient, the patient’s family, and the physician or nurse through a live, two-way audio and video system. The remote hospitalist can move the robot’s head to view charts and vital signs on monitors, zoom in to look at a patient’s pupils, and use several diagnostic tools with the help of an on-site health provider to conduct a patient exam, Abbott says. The remote hospitalist also can split the robot’s screen to show a patient X-rays, test results, videos, or other multimedia imaging.

“Certainly, using a robot to interact with patients takes some thought,” Abbott says. “Doctors have to be good at using the robot to act like a human being rather than simply a stationary screen in a room.”

The robot received high marks from patients, hospitalists, ED staff, and healthcare providers who participated in the pilot program at St. Joseph’s Hospital, according to the results of Eagle’s unpublished study. The technology is user-friendly enough that all types of healthcare providers can be trained to use it, says Dr. Godamunne. He designed and helped implement the study, and he found patients quickly adapted to the robot once they focused on the physicians’ faces on the screen.

Financial, Philosophical Hurdles

Hospitalists like Suman Narumanchi, MD, who leads the HM team at Resurrection Medical Center in Chicago, surmise most patients and their primary-care physicians expect doctors—not a robot or telemed cart—to physically be at the bedside in the hospital. As a result, if something goes wrong, the patient and their primary-care physician might respond with lawsuits. For that reason, “there has to be consistency in telemedicine,” Dr. Narumanchi says. “I just think at this point, it is probably a different level of care based on pure luck, because you don’t know who is going to be working that particular night.”

The concept raises interesting questions, says Eric Samson, DO, HM director for IN Compass Health Inc. in Greensboro, N.C. “Such as that of accountability and ownership of outcomes. On the other hand, it seems enticing to limit the multitude of distractions that occur through nighttime floor calls by implementing a cross-cover specialist fielding floor calls from a more-humane time zone—‘Hey, I’m working night call, but during bankers’ hours.’ ”

photo courtesy of The Night Hospitalist Co.

Protocols vary from hospital to hospital, and it will be difficult for telehospitalists who cover multiple facilities to learn the differences, says John Nelson, MD, FACP, co-founder and past president of SHM, and principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm in La Quinta, Calif. The job becomes even harder if one or more of the hospitals does not have electronic medical records (EMRs) and instead has to fax patient records to the telehospitalist, he says. Before hospitals invest in this expensive technology, a better solution might be to invent another way to address night coverage, such as allowing nonphysician providers (e.g., nurses) sign off on routine items that now require a doctor’s signature, he says.

Robert Cimasi, president of Health Capital Consultants, a St. Louis-based healthcare financial and economic consulting firm, says telemedicine’s ability to connect patients with distant specialists and allow hospitals to share doctors is tremendous, but agrees the technology is expensive and shouldn’t be entered into without a solid game plan, staff buy-in, and a long-term outlook. Although telemedicine proponents insist EMRs aren’t necessary, Cimasi advises hospitals serious about telemedicine to invest in EMRs, along with electronic order entry for their pharmacies and a secure computer network.

“A lot of hospitals aren’t going to have the capital capacity to do this without government help,” Cimasi explains. “The question is whether the political will is there to have a sustained period of investment.”

Eagle’s remote-robot program is less expensive than hiring a nocturnist or using a locum tenens physician, Dr. Young says. He predicts rural hospitals will benefit the most from his company’s program and other telemedicine services in the market because rural hospitals are most affected by the shortage of inpatient physicians. That might be the case, but if telemedicine is to ever make inroads among hospitalists, it will happen at urban hospitals first because they have the patient populations to support it, Dr. Nelson says.

“At larger hospitals where hospitalists are very busy admitting patients and busy checking patients already admitted, I could see using telemedicine to do the cross-coverage,” he says. “But in a small hospital, that wouldn’t make much sense, because there’s not enough patient volume.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Karim Godamunne, MD, watched the moving images on the computer screen as he maneuvered the joystick with his hand. Using the computer screen as a guide, he traversed hallways, entered rooms, and zoomed the camera lens in on patients and equipment—all with a slight flick of the controller.

Sounds like a doc playing video games in the back office, right? But entertainment wasn’t what Dr. Godamunne, a hospitalist medical director with Eagle Hospital Physicians in Atlanta, was after. He was busy overseeing a study on admitting ED patients to St. Joseph’s Hospital in Atlanta, but he and the other participating physicians weren’t physically in the ED: With the help of a robot, a computer, and a secure high-speed Internet connection, the physicians obtained patients’ medical histories, performed physical exams, and admitted them in about the same time it normally takes on-site doctors.

“It’s like a video game, but much more. That’s how I describe it to people,” Dr. Godamunne says of the technology used in the study. “You have to be able to visualize what you’re doing.”

About 10 Eagle hospitalists participated in a pilot program last year that aimed to determine whether ED patients could be admitted by remote hospitalists using the RP-7 robot, which was developed by Santa Barbara, Calif.-based InTouch Health. Eagle was so pleased with the small study’s results that it began offering its remote-robot program to hospitals last October and anticipates deploying the first robot for HM work this spring. Eagle CEO Robert Young, MD, MPH, conceived the study and considers his company’s fledgling telemedicine program a solution to the hospitalist shortage, particularly for covering night shifts.

The Future of Round-the-Clock Rounds

Is telemedicine the right fit for your HM group? Consider the following pros and cons before you make a decision:

BENEFITS

• Less burnout for hospitalists, leading to higher productivity and longevity;
• Easier hospitalist recruitment, because applicants know they are less likely to work nights;
• Ability to cover multiple hospitals at one time, mitigating the hospitalist shortage that many areas face;
• Enhanced access for hospitalists and their patients to medical specialists;
• Higher technology comfort level among many patients; and
• Ability to expand hospital market area by employing telemedicine technology at outlying medical clinics and offices.

BARRIERS

• Reimbursement obstacles for Medicare and some private health insurers;
• Medical licensing can be time-consuming for telemedicine doctors who serve patients in multiple states;
• Difficulty getting buy-in from on-site doctors and primary-care physicians who are worried about liability and telemedicine doctors’ competence;
• Fear of lawsuits by patients treated via telemedicine;
• Startup technology and training costs; and
• Potential patient resistance to telemedicine.

“Eagle’s experience is that many hospitalists will be skeptical at first, but once they see it in action, not only does much of the resistance go away, but some become champions for its use,” Dr. Young says. “It is largely a matter of exposure to and experience in using the technology.”

While increasingly common in hospital ICUs and radiology departments, telemedicine is catching on more slowly in HM. Experts and practicing hospitalists cite reimbursement hiccups, a laborious medical licensing process, technology costs, physician and patient resistance, and risk aversion as the main reasons telemedicine isn’t embraced throughout HM. Some think it will take a concerted government effort to nudge hospitals and HM groups to buy into the technology.

Nevertheless, a growing number of physicians and administrators think telemedicine is inevitable, especially as the demand for HM services outpaces the supply. As in within the Eagle system, some hospitalists are positioning themselves to capitalize on the advancing technology.

The Future Isn’t Far

photo courtesy of The Night Hospitalist Co.

“I think it’s going to explode,” says Yomi Olusanya, MD, a hospitalist in rural Rolla, Mo., and founder of The Night Hospitalist Co., LLC, a startup that is busy developing a business model to provide nighttime hospital coverage via telemedicine. “I think with increased costs and the shortage of physicians, hospitalist groups are not going to have any choice but to find alternative ways of doing business. I really believe that.”

Dr. Olusanya envisions establishing a team of about 10 telehospitalists who would handle cross-coverage calls at multiple hospitals in multiple states. The hospitalists would use a mobile cart fashioned with a high-resolution, dual-focus video screen; a video camera; and diagnostic equipment, such as a digital stethoscope, to aid in physical exams. Hospital clients would be given a toll-free number to call to connect with a telehospitalist between

7 p.m. and 7 a.m., and on-site nurses would simply wheel the mobile cart into a patient’s room to begin the care. All overnight changes in medical management would be transmitted to the correct hospital floors for insertion into patients’ medical records. The Night Hospitalist plans to cover malpractice insurance for its physicians and charge a nightly rate, which would vary depending on the length of the contract.

The mobile cart costs between $20,000 and $30,000, and Dr. Olusanya is contemplating absorbing that expense just to get groups interested. At this point, he’s not promising prospective clients cost savings. Instead, he’s offering them a way to lighten the physician workload in order to increase productivity, job satisfaction and career longevity.

“We’re trying to sell the idea to hospitalists,” he says. “This is so new that I’m trying to figure out the best model.” After originally including hospital admissions in his business model, he ultimately decided to focus exclusively on cross-coverage calls and leave the admissions to an on-site physician. “At this point, I don’t see the telemed machine in the ED doing an admission of a new patient, because it becomes less efficient,” he explains.

Conversely, Eagle Hospital Physicians’ remote-robot program is designed to do hospital admissions. The RP-7 robot is mobile enough to aid in cross-coverage, but hospitals must be careful not to overburden the machine with floor calls because it takes the robot longer to travel around the hospital than it does for an on-site physician, says Betty Abbott, Eagle’s chief operating officer.

Through the robot, which stands 5 feet 6 inches tall, a remote hospitalist can interact with a patient, the patient’s family, and the physician or nurse through a live, two-way audio and video system. The remote hospitalist can move the robot’s head to view charts and vital signs on monitors, zoom in to look at a patient’s pupils, and use several diagnostic tools with the help of an on-site health provider to conduct a patient exam, Abbott says. The remote hospitalist also can split the robot’s screen to show a patient X-rays, test results, videos, or other multimedia imaging.

“Certainly, using a robot to interact with patients takes some thought,” Abbott says. “Doctors have to be good at using the robot to act like a human being rather than simply a stationary screen in a room.”

The robot received high marks from patients, hospitalists, ED staff, and healthcare providers who participated in the pilot program at St. Joseph’s Hospital, according to the results of Eagle’s unpublished study. The technology is user-friendly enough that all types of healthcare providers can be trained to use it, says Dr. Godamunne. He designed and helped implement the study, and he found patients quickly adapted to the robot once they focused on the physicians’ faces on the screen.

Financial, Philosophical Hurdles

Hospitalists like Suman Narumanchi, MD, who leads the HM team at Resurrection Medical Center in Chicago, surmise most patients and their primary-care physicians expect doctors—not a robot or telemed cart—to physically be at the bedside in the hospital. As a result, if something goes wrong, the patient and their primary-care physician might respond with lawsuits. For that reason, “there has to be consistency in telemedicine,” Dr. Narumanchi says. “I just think at this point, it is probably a different level of care based on pure luck, because you don’t know who is going to be working that particular night.”

The concept raises interesting questions, says Eric Samson, DO, HM director for IN Compass Health Inc. in Greensboro, N.C. “Such as that of accountability and ownership of outcomes. On the other hand, it seems enticing to limit the multitude of distractions that occur through nighttime floor calls by implementing a cross-cover specialist fielding floor calls from a more-humane time zone—‘Hey, I’m working night call, but during bankers’ hours.’ ”

photo courtesy of The Night Hospitalist Co.

Protocols vary from hospital to hospital, and it will be difficult for telehospitalists who cover multiple facilities to learn the differences, says John Nelson, MD, FACP, co-founder and past president of SHM, and principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm in La Quinta, Calif. The job becomes even harder if one or more of the hospitals does not have electronic medical records (EMRs) and instead has to fax patient records to the telehospitalist, he says. Before hospitals invest in this expensive technology, a better solution might be to invent another way to address night coverage, such as allowing nonphysician providers (e.g., nurses) sign off on routine items that now require a doctor’s signature, he says.

Robert Cimasi, president of Health Capital Consultants, a St. Louis-based healthcare financial and economic consulting firm, says telemedicine’s ability to connect patients with distant specialists and allow hospitals to share doctors is tremendous, but agrees the technology is expensive and shouldn’t be entered into without a solid game plan, staff buy-in, and a long-term outlook. Although telemedicine proponents insist EMRs aren’t necessary, Cimasi advises hospitals serious about telemedicine to invest in EMRs, along with electronic order entry for their pharmacies and a secure computer network.

“A lot of hospitals aren’t going to have the capital capacity to do this without government help,” Cimasi explains. “The question is whether the political will is there to have a sustained period of investment.”

Eagle’s remote-robot program is less expensive than hiring a nocturnist or using a locum tenens physician, Dr. Young says. He predicts rural hospitals will benefit the most from his company’s program and other telemedicine services in the market because rural hospitals are most affected by the shortage of inpatient physicians. That might be the case, but if telemedicine is to ever make inroads among hospitalists, it will happen at urban hospitals first because they have the patient populations to support it, Dr. Nelson says.

“At larger hospitals where hospitalists are very busy admitting patients and busy checking patients already admitted, I could see using telemedicine to do the cross-coverage,” he says. “But in a small hospital, that wouldn’t make much sense, because there’s not enough patient volume.” TH

Lisa Ryan is a freelance writer based in New Jersey.

The global economy is on life support, unemployment is marching upward, wars rage on in Iraq and Afghanistan, and the federal deficit is approaching $1 trillion. By necessity, President Obama will push campaign promises to lower healthcare costs and provide affordable, accessible health insurance to all Americans to the end of his “to do” list, right?

Not necessarily.

“If we want to overcome our economic challenges, we must also finally address our healthcare challenge,” Obama said in a Dec. 11, 2008, speech in which he nominated former Sen. Tom Daschle (D-S.D.) to be his secretary of Health and Human Services and appointed him director of a new White House Office on Health Reform.

What this aggressive pursuit of healthcare change means for hospital medicine is still unclear, say health policy experts and hospitalists, because the Obama administration’s plan isn’t concrete and will change as it moves through Congress and the forums of public debate. Even so, some experts think an Obama healthcare overhaul would mean more revenue and information technology advancements for hospitals as well as significantly more patients as millions of newly insured Americans flood a system beset by a dwindling number of primary-care physicians.

For hospitalists and other physicians, the Obama plan could mean:

• Access to more information on what therapies work best for patients.
• A focus on preventative care.
• Greater emphasis on care-management programs and medical homes, especially for people with chronic conditions.

“He will lay out a bold vision on what he wants to do over time, and then he will enact it in several steps,” says Karen Davis, PhD, president of the Commonwealth Fund, a private healthcare research organization. “He’s certainly said it won’t be business as usual.”

Key Healthcare Officials in President Obama’s Administration

TOM DASCHLE

The secretary of Health and Human Services and director of a new White House Office on Health Reform is a former Democratic congressman and senator from South Dakota. He co-authored a book with Jeanne Lambrew this year, “Critical: What We Can Do About the Health-Care Crisis.” Obama has called the book “groundbreaking.” Prior to joining the Obama team, Daschle, 61, was a public policy adviser at Alston & Bird, a legal and lobbying firm. He remains a distinguished senior fellow at the Center for American Progress, where he’s pursued his interest in healthcare policy.

JEANNE LAMBREW

The deputy director of a new White House Office on Health Reform is an associate professor at the Lyndon B. Johnson School of Public Affairs at the University of Texas in Austin, and a senior fellow at the Center for American Progress. A co-author of the book Critical: What We Can Do About the Health-Care Crisis, Lambrew was a health policy advisor to President Clinton during his second term and helped establish the State Children’s Health Insurance Program.

PETER ORSZAG

The director of the Office of Management and Budget is a Princeton University graduate who has a Ph.D. from the London School of Economics. Prior to joining the Obama administration, Orszag, 39, directed the Con-gressional Budget Office and shifted a large part of its focus to healthcare issues. Orszag says the top fiscal threat facing the nation is escalating healthcare spending.

Sources: Obama-Biden transition Web site, www.change.gov; Center for American Progress; Congressional Quarterly

Right to Work

Obama says he will work immediately to expand eligibility for the State Children’s Health Insurance Program (SCHIP) and, in light of the recession, direct more federal money to states’ Medicaid programs, says Joseph Newhouse, PhD, a professor of health policy at Harvard University. Indeed, in the months before she was named deputy director of the White House’s new office on health reform, Jeanne Lambrew urged Congress to pass legislation that would boost federal funding for Medicaid and SCHIP.

Within the first few months of his administration, Obama also plans to push for investment in health information technology as a way to modernize the healthcare system and spur the economy, says Judy Feder, PhD, a professor and former dean of Georgetown University’s Public Policy Institute and a two-time Democratic congressional candidate who campaigned on a healthcare platform almost identical to the president’s.

Obama says he would like to direct $10 billion a year over the next five years to help the nation’s hospitals and healthcare providers install electronic billing and medical record systems.

“Somebody’s got to help set those up. We’ve got to buy computer systems and so forth. That’s an immediate boost to the economy…but it’s also laying the groundwork for reducing our healthcare costs over the long term,” Obama said in November upon naming Peter Orszag, an economist who regards rising healthcare spending as the nation’s top fiscal threat, director of the Office of Management and Budget.

Hospitals and hospitalists can benefit from IT advancements, but the technology should be slowly phased in to give users time to adjust, which may run counter to the quick economic stimulus Obama is trying to achieve, says David Meltzer, M.D., Ph.D., a professor in the department of medicine at the University of Chicago who has conducted considerable research in hospital medicine.

“The point is, health IT takes years to implement,” Dr. Meltzer says. “Just giving grants to buy and set up the equipment isn’t enough. You also want to give grants to prepare people on how to use it effectively.”

Dr. Meltzer is encouraged by Obama’s plan to create an independent, government-funded board charged with scientifically comparing the effectiveness of pharmaceutical drugs, medical devices, and procedures, and presenting the results to the medical community. He foresees hospitalists gaining opportunities to participate in clinical research as well as enroll patients in clinical trials.

“Over the long run, we’ll probably end up with therapies that will be better for patients and will control costs,” Dr. Meltzer says. “We spend a lot of money on things that don’t work or don’t work very well.”

Calling a comparative-effectiveness board “absolutely essential,” the Common-wealth Fund’s Davis says the U.S. has fallen far behind other countries in reviewing and rating therapies. Part of the reason is a fear that comparative effectiveness would stymie innovation and prevent doctors and patients from pursuing their choice of treatments, Dr. Meltzer says.

Opponents point to the book “Critical: What We Can Do About the Healthcare Crisis,” which Daschle and Lambrew co-wrote last year. In the book, Daschle advocates creating a federal health board outside the influence of Congress that would decide which procedures and therapies should be covered under public and private insurance plans. Obama has yet to support such a concept.

“There is that danger, but we live in an even more dangerous health system now,” says Dr. Meltzer, who predicts comparative-effectiveness legislation will advance this year. “I will be shocked and profoundly disappointed if we don’t see the legislation.”

Dr. Meltzer and other experts are less certain as to when Obama will move on other parts of his proposal, although Feder believes the president will try to create a national health-plan option and establish a national health insurance exchange, a kind of one-stop shop offering consumers health plans that would meet a minimum level of benefits, sometime in the next four years.

The national health-plan benefits could be similar to what federal employees receive, namely guaranteed health coverage and long-term care benefits, a wide variety of health plans to choose from, and insurability for pre-existing conditions. Private insurers would have to sell policies to everyone, regardless of pre-existing health conditions, and consumers who are unable to afford the premiums would be eligible for tax credits. The president’s plan stops short of requiring all Americans to have health insurance.

System Overload?

With more Americans insured, hospitals’ revenues will increase, according to Davis. Hospital patient loads—and hospitalists’ workloads—would increase, says Iris Mangulabnan, MD, a hospitalist at Covenant HealthCare in Saginaw, Mich.

“In the global scheme of things, if (Obama) is going to have insurance for about 45 million more patients, you’re going to see hospitals crammed with more people,” Dr. Mangulabnan says.

Adam Singer, MD, CEO of IPC: The Hospitalist Company, a national physician group practice based in California, says Obama’s plan has the potential to “overwhelm” the U.S. healthcare system. “Who’s going to take care of all these people?” he says.

Obama’s healthcare plan highlights preventive-care and disease management programs as ways to keep people out of hospitals and save money, but Dr. Mangulabnan says research has shown such initiatives aren’t always effective. “They hold a lot of conceptual promise, but I’m reminded of that fast-food commercial—you know, ‘Where’s the beef?’ ” Dr. Singer says.

Both doctors question how Obama’s healthcare plan, which would cost an estimated $75 billion a year when fully implemented, would be paid for. During his campaign, Obama talked about letting tax cuts expire for people making more than $250,000 a year and using that money for healthcare. But the economic crisis has forced the president to reconsider ending the tax cuts.

Cost is just one obstacle to Obama’s plan. Experts say the list also includes health insurers, pharmaceutical and medical product companies, doctors, congressional Republicans, an agenda full of other pressing problems, and change.

“It’s very difficult for a multitrillion-dollar industry to see the ground shift beneath it. It’s the known versus the unknown,” Davis says. “But I don’t see the economy as an obstacle. If anything, it increases the chance that healthcare will be addressed, because more people are being affected by problems in the system. The main thing that’s driving all of this is a feeling that it’s time.” TH

Lisa M. Ryan is a freelance writer based in New Jersey.

The global economy is on life support, unemployment is marching upward, wars rage on in Iraq and Afghanistan, and the federal deficit is approaching $1 trillion. By necessity, President Obama will push campaign promises to lower healthcare costs and provide affordable, accessible health insurance to all Americans to the end of his “to do” list, right?

Not necessarily.

“If we want to overcome our economic challenges, we must also finally address our healthcare challenge,” Obama said in a Dec. 11, 2008, speech in which he nominated former Sen. Tom Daschle (D-S.D.) to be his secretary of Health and Human Services and appointed him director of a new White House Office on Health Reform.

What this aggressive pursuit of healthcare change means for hospital medicine is still unclear, say health policy experts and hospitalists, because the Obama administration’s plan isn’t concrete and will change as it moves through Congress and the forums of public debate. Even so, some experts think an Obama healthcare overhaul would mean more revenue and information technology advancements for hospitals as well as significantly more patients as millions of newly insured Americans flood a system beset by a dwindling number of primary-care physicians.

For hospitalists and other physicians, the Obama plan could mean:

• Access to more information on what therapies work best for patients.
• A focus on preventative care.
• Greater emphasis on care-management programs and medical homes, especially for people with chronic conditions.

“He will lay out a bold vision on what he wants to do over time, and then he will enact it in several steps,” says Karen Davis, PhD, president of the Commonwealth Fund, a private healthcare research organization. “He’s certainly said it won’t be business as usual.”

Key Healthcare Officials in President Obama’s Administration

TOM DASCHLE

The secretary of Health and Human Services and director of a new White House Office on Health Reform is a former Democratic congressman and senator from South Dakota. He co-authored a book with Jeanne Lambrew this year, “Critical: What We Can Do About the Health-Care Crisis.” Obama has called the book “groundbreaking.” Prior to joining the Obama team, Daschle, 61, was a public policy adviser at Alston & Bird, a legal and lobbying firm. He remains a distinguished senior fellow at the Center for American Progress, where he’s pursued his interest in healthcare policy.

JEANNE LAMBREW

The deputy director of a new White House Office on Health Reform is an associate professor at the Lyndon B. Johnson School of Public Affairs at the University of Texas in Austin, and a senior fellow at the Center for American Progress. A co-author of the book Critical: What We Can Do About the Health-Care Crisis, Lambrew was a health policy advisor to President Clinton during his second term and helped establish the State Children’s Health Insurance Program.

PETER ORSZAG

The director of the Office of Management and Budget is a Princeton University graduate who has a Ph.D. from the London School of Economics. Prior to joining the Obama administration, Orszag, 39, directed the Con-gressional Budget Office and shifted a large part of its focus to healthcare issues. Orszag says the top fiscal threat facing the nation is escalating healthcare spending.

Sources: Obama-Biden transition Web site, www.change.gov; Center for American Progress; Congressional Quarterly

Right to Work

Obama says he will work immediately to expand eligibility for the State Children’s Health Insurance Program (SCHIP) and, in light of the recession, direct more federal money to states’ Medicaid programs, says Joseph Newhouse, PhD, a professor of health policy at Harvard University. Indeed, in the months before she was named deputy director of the White House’s new office on health reform, Jeanne Lambrew urged Congress to pass legislation that would boost federal funding for Medicaid and SCHIP.

Within the first few months of his administration, Obama also plans to push for investment in health information technology as a way to modernize the healthcare system and spur the economy, says Judy Feder, PhD, a professor and former dean of Georgetown University’s Public Policy Institute and a two-time Democratic congressional candidate who campaigned on a healthcare platform almost identical to the president’s.

Obama says he would like to direct $10 billion a year over the next five years to help the nation’s hospitals and healthcare providers install electronic billing and medical record systems.

“Somebody’s got to help set those up. We’ve got to buy computer systems and so forth. That’s an immediate boost to the economy…but it’s also laying the groundwork for reducing our healthcare costs over the long term,” Obama said in November upon naming Peter Orszag, an economist who regards rising healthcare spending as the nation’s top fiscal threat, director of the Office of Management and Budget.

Hospitals and hospitalists can benefit from IT advancements, but the technology should be slowly phased in to give users time to adjust, which may run counter to the quick economic stimulus Obama is trying to achieve, says David Meltzer, M.D., Ph.D., a professor in the department of medicine at the University of Chicago who has conducted considerable research in hospital medicine.

“The point is, health IT takes years to implement,” Dr. Meltzer says. “Just giving grants to buy and set up the equipment isn’t enough. You also want to give grants to prepare people on how to use it effectively.”

Dr. Meltzer is encouraged by Obama’s plan to create an independent, government-funded board charged with scientifically comparing the effectiveness of pharmaceutical drugs, medical devices, and procedures, and presenting the results to the medical community. He foresees hospitalists gaining opportunities to participate in clinical research as well as enroll patients in clinical trials.

“Over the long run, we’ll probably end up with therapies that will be better for patients and will control costs,” Dr. Meltzer says. “We spend a lot of money on things that don’t work or don’t work very well.”

Calling a comparative-effectiveness board “absolutely essential,” the Common-wealth Fund’s Davis says the U.S. has fallen far behind other countries in reviewing and rating therapies. Part of the reason is a fear that comparative effectiveness would stymie innovation and prevent doctors and patients from pursuing their choice of treatments, Dr. Meltzer says.

Opponents point to the book “Critical: What We Can Do About the Healthcare Crisis,” which Daschle and Lambrew co-wrote last year. In the book, Daschle advocates creating a federal health board outside the influence of Congress that would decide which procedures and therapies should be covered under public and private insurance plans. Obama has yet to support such a concept.

“There is that danger, but we live in an even more dangerous health system now,” says Dr. Meltzer, who predicts comparative-effectiveness legislation will advance this year. “I will be shocked and profoundly disappointed if we don’t see the legislation.”

Dr. Meltzer and other experts are less certain as to when Obama will move on other parts of his proposal, although Feder believes the president will try to create a national health-plan option and establish a national health insurance exchange, a kind of one-stop shop offering consumers health plans that would meet a minimum level of benefits, sometime in the next four years.

The national health-plan benefits could be similar to what federal employees receive, namely guaranteed health coverage and long-term care benefits, a wide variety of health plans to choose from, and insurability for pre-existing conditions. Private insurers would have to sell policies to everyone, regardless of pre-existing health conditions, and consumers who are unable to afford the premiums would be eligible for tax credits. The president’s plan stops short of requiring all Americans to have health insurance.

System Overload?

With more Americans insured, hospitals’ revenues will increase, according to Davis. Hospital patient loads—and hospitalists’ workloads—would increase, says Iris Mangulabnan, MD, a hospitalist at Covenant HealthCare in Saginaw, Mich.

“In the global scheme of things, if (Obama) is going to have insurance for about 45 million more patients, you’re going to see hospitals crammed with more people,” Dr. Mangulabnan says.

Adam Singer, MD, CEO of IPC: The Hospitalist Company, a national physician group practice based in California, says Obama’s plan has the potential to “overwhelm” the U.S. healthcare system. “Who’s going to take care of all these people?” he says.

Obama’s healthcare plan highlights preventive-care and disease management programs as ways to keep people out of hospitals and save money, but Dr. Mangulabnan says research has shown such initiatives aren’t always effective. “They hold a lot of conceptual promise, but I’m reminded of that fast-food commercial—you know, ‘Where’s the beef?’ ” Dr. Singer says.

Both doctors question how Obama’s healthcare plan, which would cost an estimated $75 billion a year when fully implemented, would be paid for. During his campaign, Obama talked about letting tax cuts expire for people making more than $250,000 a year and using that money for healthcare. But the economic crisis has forced the president to reconsider ending the tax cuts.

Cost is just one obstacle to Obama’s plan. Experts say the list also includes health insurers, pharmaceutical and medical product companies, doctors, congressional Republicans, an agenda full of other pressing problems, and change.

“It’s very difficult for a multitrillion-dollar industry to see the ground shift beneath it. It’s the known versus the unknown,” Davis says. “But I don’t see the economy as an obstacle. If anything, it increases the chance that healthcare will be addressed, because more people are being affected by problems in the system. The main thing that’s driving all of this is a feeling that it’s time.” TH

Lisa M. Ryan is a freelance writer based in New Jersey.

The global economy is on life support, unemployment is marching upward, wars rage on in Iraq and Afghanistan, and the federal deficit is approaching $1 trillion. By necessity, President Obama will push campaign promises to lower healthcare costs and provide affordable, accessible health insurance to all Americans to the end of his “to do” list, right?

Not necessarily.

“If we want to overcome our economic challenges, we must also finally address our healthcare challenge,” Obama said in a Dec. 11, 2008, speech in which he nominated former Sen. Tom Daschle (D-S.D.) to be his secretary of Health and Human Services and appointed him director of a new White House Office on Health Reform.

What this aggressive pursuit of healthcare change means for hospital medicine is still unclear, say health policy experts and hospitalists, because the Obama administration’s plan isn’t concrete and will change as it moves through Congress and the forums of public debate. Even so, some experts think an Obama healthcare overhaul would mean more revenue and information technology advancements for hospitals as well as significantly more patients as millions of newly insured Americans flood a system beset by a dwindling number of primary-care physicians.

For hospitalists and other physicians, the Obama plan could mean:

• Access to more information on what therapies work best for patients.
• A focus on preventative care.
• Greater emphasis on care-management programs and medical homes, especially for people with chronic conditions.

“He will lay out a bold vision on what he wants to do over time, and then he will enact it in several steps,” says Karen Davis, PhD, president of the Commonwealth Fund, a private healthcare research organization. “He’s certainly said it won’t be business as usual.”

Key Healthcare Officials in President Obama’s Administration

TOM DASCHLE

The secretary of Health and Human Services and director of a new White House Office on Health Reform is a former Democratic congressman and senator from South Dakota. He co-authored a book with Jeanne Lambrew this year, “Critical: What We Can Do About the Health-Care Crisis.” Obama has called the book “groundbreaking.” Prior to joining the Obama team, Daschle, 61, was a public policy adviser at Alston & Bird, a legal and lobbying firm. He remains a distinguished senior fellow at the Center for American Progress, where he’s pursued his interest in healthcare policy.

JEANNE LAMBREW

The deputy director of a new White House Office on Health Reform is an associate professor at the Lyndon B. Johnson School of Public Affairs at the University of Texas in Austin, and a senior fellow at the Center for American Progress. A co-author of the book Critical: What We Can Do About the Health-Care Crisis, Lambrew was a health policy advisor to President Clinton during his second term and helped establish the State Children’s Health Insurance Program.

PETER ORSZAG

The director of the Office of Management and Budget is a Princeton University graduate who has a Ph.D. from the London School of Economics. Prior to joining the Obama administration, Orszag, 39, directed the Con-gressional Budget Office and shifted a large part of its focus to healthcare issues. Orszag says the top fiscal threat facing the nation is escalating healthcare spending.

Sources: Obama-Biden transition Web site, www.change.gov; Center for American Progress; Congressional Quarterly

Right to Work

Obama says he will work immediately to expand eligibility for the State Children’s Health Insurance Program (SCHIP) and, in light of the recession, direct more federal money to states’ Medicaid programs, says Joseph Newhouse, PhD, a professor of health policy at Harvard University. Indeed, in the months before she was named deputy director of the White House’s new office on health reform, Jeanne Lambrew urged Congress to pass legislation that would boost federal funding for Medicaid and SCHIP.

Within the first few months of his administration, Obama also plans to push for investment in health information technology as a way to modernize the healthcare system and spur the economy, says Judy Feder, PhD, a professor and former dean of Georgetown University’s Public Policy Institute and a two-time Democratic congressional candidate who campaigned on a healthcare platform almost identical to the president’s.

Obama says he would like to direct $10 billion a year over the next five years to help the nation’s hospitals and healthcare providers install electronic billing and medical record systems.

“Somebody’s got to help set those up. We’ve got to buy computer systems and so forth. That’s an immediate boost to the economy…but it’s also laying the groundwork for reducing our healthcare costs over the long term,” Obama said in November upon naming Peter Orszag, an economist who regards rising healthcare spending as the nation’s top fiscal threat, director of the Office of Management and Budget.

Hospitals and hospitalists can benefit from IT advancements, but the technology should be slowly phased in to give users time to adjust, which may run counter to the quick economic stimulus Obama is trying to achieve, says David Meltzer, M.D., Ph.D., a professor in the department of medicine at the University of Chicago who has conducted considerable research in hospital medicine.

“The point is, health IT takes years to implement,” Dr. Meltzer says. “Just giving grants to buy and set up the equipment isn’t enough. You also want to give grants to prepare people on how to use it effectively.”

Dr. Meltzer is encouraged by Obama’s plan to create an independent, government-funded board charged with scientifically comparing the effectiveness of pharmaceutical drugs, medical devices, and procedures, and presenting the results to the medical community. He foresees hospitalists gaining opportunities to participate in clinical research as well as enroll patients in clinical trials.

“Over the long run, we’ll probably end up with therapies that will be better for patients and will control costs,” Dr. Meltzer says. “We spend a lot of money on things that don’t work or don’t work very well.”

Calling a comparative-effectiveness board “absolutely essential,” the Common-wealth Fund’s Davis says the U.S. has fallen far behind other countries in reviewing and rating therapies. Part of the reason is a fear that comparative effectiveness would stymie innovation and prevent doctors and patients from pursuing their choice of treatments, Dr. Meltzer says.

Opponents point to the book “Critical: What We Can Do About the Healthcare Crisis,” which Daschle and Lambrew co-wrote last year. In the book, Daschle advocates creating a federal health board outside the influence of Congress that would decide which procedures and therapies should be covered under public and private insurance plans. Obama has yet to support such a concept.

“There is that danger, but we live in an even more dangerous health system now,” says Dr. Meltzer, who predicts comparative-effectiveness legislation will advance this year. “I will be shocked and profoundly disappointed if we don’t see the legislation.”

Dr. Meltzer and other experts are less certain as to when Obama will move on other parts of his proposal, although Feder believes the president will try to create a national health-plan option and establish a national health insurance exchange, a kind of one-stop shop offering consumers health plans that would meet a minimum level of benefits, sometime in the next four years.

The national health-plan benefits could be similar to what federal employees receive, namely guaranteed health coverage and long-term care benefits, a wide variety of health plans to choose from, and insurability for pre-existing conditions. Private insurers would have to sell policies to everyone, regardless of pre-existing health conditions, and consumers who are unable to afford the premiums would be eligible for tax credits. The president’s plan stops short of requiring all Americans to have health insurance.

System Overload?

With more Americans insured, hospitals’ revenues will increase, according to Davis. Hospital patient loads—and hospitalists’ workloads—would increase, says Iris Mangulabnan, MD, a hospitalist at Covenant HealthCare in Saginaw, Mich.

“In the global scheme of things, if (Obama) is going to have insurance for about 45 million more patients, you’re going to see hospitals crammed with more people,” Dr. Mangulabnan says.

Adam Singer, MD, CEO of IPC: The Hospitalist Company, a national physician group practice based in California, says Obama’s plan has the potential to “overwhelm” the U.S. healthcare system. “Who’s going to take care of all these people?” he says.

Obama’s healthcare plan highlights preventive-care and disease management programs as ways to keep people out of hospitals and save money, but Dr. Mangulabnan says research has shown such initiatives aren’t always effective. “They hold a lot of conceptual promise, but I’m reminded of that fast-food commercial—you know, ‘Where’s the beef?’ ” Dr. Singer says.

Both doctors question how Obama’s healthcare plan, which would cost an estimated $75 billion a year when fully implemented, would be paid for. During his campaign, Obama talked about letting tax cuts expire for people making more than $250,000 a year and using that money for healthcare. But the economic crisis has forced the president to reconsider ending the tax cuts.

Cost is just one obstacle to Obama’s plan. Experts say the list also includes health insurers, pharmaceutical and medical product companies, doctors, congressional Republicans, an agenda full of other pressing problems, and change.

“It’s very difficult for a multitrillion-dollar industry to see the ground shift beneath it. It’s the known versus the unknown,” Davis says. “But I don’t see the economy as an obstacle. If anything, it increases the chance that healthcare will be addressed, because more people are being affected by problems in the system. The main thing that’s driving all of this is a feeling that it’s time.” TH

Lisa M. Ryan is a freelance writer based in New Jersey.