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Richard Quinn is an award-winning journalist with 15 years’ experience. He has worked at the Asbury Park Press in New Jersey and The Virginian-Pilot in Norfolk, Va., and currently is managing editor for a leading commercial real estate publication. His freelance work has appeared in The Jewish State, The Hospitalist, The Rheumatologist, ACEP Now, and ENT Today. He lives in New Jersey with his wife and three cats.
Kevin Conrad, MD, MBA, Brings His Passion for Problem Solving to TH’s Editorial Board
Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.
“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”
Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.
And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.
Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?
Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”
Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?
A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.
Q: What about the intensity of hospital medicine appeals to you?
A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.
Q: What was the motivation to write the book and now working on the second?
A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.
Q: So what is hospitalists’ value, and what are they experts in?
A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.
Q: What is your least favorite part of being a hospitalist?
A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.
Q: What’s your favorite part of the job?
A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH
Richard Quinn is a freelance writer in New Jersey.
Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.
“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”
Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.
And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.
Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?
Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”
Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?
A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.
Q: What about the intensity of hospital medicine appeals to you?
A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.
Q: What was the motivation to write the book and now working on the second?
A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.
Q: So what is hospitalists’ value, and what are they experts in?
A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.
Q: What is your least favorite part of being a hospitalist?
A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.
Q: What’s your favorite part of the job?
A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH
Richard Quinn is a freelance writer in New Jersey.
Kevin Conrad, MD, MBA, could always picture being a doctor, given that he enjoyed the sciences and wanted a job where he could work with people. He has more trouble figuring out how people don’t enjoy the detective work that comes with medicine.
“I have a hard time imagining what people do besides people in the sciences,” he says. “In sciences, you deal with facts, you deal with numbers, you deal with data, and you put it together and you come to conclusions. And to me, that seemed like a career pathway as opposed to, say, a field like law or writing or whatnot. I could never wrap my head around what they actually do in a given day.”
Dr. Conrad’s passion for the sciences hasn’t waned yet. He serves as the medical director of community affairs and healthy policy at Ochsner Health Systems of New Orleans, where he focuses on systems improvement. He published his first book this year, Absolute Hospital Medicine Review: An Intensive Question and Answer Guide, and is working on his second tome.
And this year, he was named one of the eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist.
Question: What led you to a more hands-on medical field as opposed to being a basic or translational scientist?
Answer: I had some early exposure to lab work in high school and college and saw what they did and saw how they were sort of confined to labs for long periods of time and said, “No, I think that I would rather be kind of out there, combining science as well as interacting with people in the field.”
Q: When you started residency, was it clear to you that hospital medicine was where you wanted to go, or were you looking at a few different options?
A: Hospital medicine combined my interests in internal medicine, which is sort of a broad overview of all aspects of medicine and healthcare as well as being a little bit more intensive, a little bit more action-oriented. The patients tend to be a little bit more ill, require a little bit more acute attention, and that appealed to me as opposed to my training in internal medicine.
Q: What about the intensity of hospital medicine appeals to you?
A: As opposed to sitting down with a patient in an office setting, I think, in hospital medicine, I like the idea that you’re called from one semi-emergency to another and that you have to think quickly on your feet and move on to the new task. And the new tasks come in rapid sequence: You have one problem that you fix and then you’re called to do another one, and each and every day, it will tend to be sort of a different set of problems.
Q: What was the motivation to write the book and now working on the second?
A: I wanted to share my experience, and I felt I was in a position where I could not only share my personal practice experience as well as sort of collate the other material that has been written and published in hospital medicine. I also think there is a need right now to continue to define what hospital medicine is and show what we’re experts at as well as show our value to the system. We have an ambiguous practice, and people still aren’t quite sure what we do and what we’re expert at. So I think it’s our task to showcase this is what we do well, this is what we do better than other people, and this is our value to the system.
Q: So what is hospitalists’ value, and what are they experts in?
A: We’re experts at systems, hospital systems. … We understand better than anyone what goes on in the hospital, the physicians’ practice, the nursing practice, the administrative practice. … I mean, we’re there. We’re on the floors. No one has a better insight into the function of the hospital than the hospitalists. I think the other unique role we have is we see trends that other specialties don’t. We don’t really own our patients. Our patients come and go, but we tend to have a unique view of the practice of medicine that we see trends maybe before other specialists. … We see some of the failures of other systems.
Q: What is your least favorite part of being a hospitalist?
A: The clerical work. I think I probably speak for most people in that the clerical work is needed. It has become an increasing part of our practice in that now we spend a great deal of our time obviously in front of computers as opposed to at the bedside. The electronic medical record, which is good, which has served us well, becomes a greater and bigger part of our day, and so we find that it is too much a part of my day. I’m not saying it’s not needed because I think it has improved the quality of care we deliver, but it’s not something that you imagine that you should be doing as a physician. You are spending most of your day in front of a computer as opposed to most of the day with patients.
Q: What’s your favorite part of the job?
A: It has changed over my career. I think it probably started out in education. I enjoyed teaching medical students and residents, and certainly, that’s still a part of it, but then I think it has evolved into a little bit more of an academic interest. I just published my first book this past year and am working on my second book, and that has become sort of my bigger focus now. TH
Richard Quinn is a freelance writer in New Jersey.
The State of Hospital Medicine Is Strong
Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.
2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.
One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.
Think again.
“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”
The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.
“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”
Compensation Data
Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.
“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”
Promises like that are getting more expensive to keep.
Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.
Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).
In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.
“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”
To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.
Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.
“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”
Productivity Stalls
While compensation continues to climb, productivity flattened out in this year’s report.
Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.
Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.
“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”
Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.
For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.
“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”
Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.
“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.
The report’s subsections are also critical for comparing one HMG to others, Dr. White says.
“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”
Survey Limitations
Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.
“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.
For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.
“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.
That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.
These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”
Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.
“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.
In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.
“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.
Alternative Payment Models
Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.
“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.
Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.
“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”
In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.
“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”
Richard Quinn is a freelance writer in New Jersey.
Is Burnout a Problem?
Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.
But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”
The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.
Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.
“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.
Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.
“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”
—Richard Quinn
Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.
2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.
One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.
Think again.
“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”
The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.
“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”
Compensation Data
Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.
“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”
Promises like that are getting more expensive to keep.
Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.
Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).
In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.
“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”
To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.
Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.
“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”
Productivity Stalls
While compensation continues to climb, productivity flattened out in this year’s report.
Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.
Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.
“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”
Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.
For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.
“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”
Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.
“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.
The report’s subsections are also critical for comparing one HMG to others, Dr. White says.
“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”
Survey Limitations
Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.
“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.
For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.
“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.
That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.
These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”
Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.
“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.
In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.
“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.
Alternative Payment Models
Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.
“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.
Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.
“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”
In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.
“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”
Richard Quinn is a freelance writer in New Jersey.
Is Burnout a Problem?
Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.
But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”
The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.
Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.
“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.
Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.
“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”
—Richard Quinn
Editor's Note: Listen to Dr. Smith share more of his views on the State of Hospital Medicine report.
2016 is the “Year of the Hospitalist,” a sobriquet meant as a proud nod to the specialty’s maturation as a fixture in hospitals across the country. Hospital medicine is no longer the new kid on the block as it has assumed care for the vast majority of hospitalized patients nationwide.
One could understand then if the ever-rising salaries hospitalists have commanded for 20 years might have finally plateaued, particularly as tightening budgets have C-suite administrators looking to trim costs.
Think again.
“Growth suggests that there is still a huge demand,” says Leslie Flores, MHA, a partner in Nelson Flores Hospital Medicine Consultants and a member of SHM’s Practice Analysis Committee. “The demand for hospitalists still exceeds the supply, and so recruiting hospitalists, particularly to nonurban areas, is really challenging and is requiring more money.”
The SoHM is a biennial partnership between SHM and MGMA that provides HM group leaders and rank-and-file hospitalists a litany of benchmarks for salaries, workloads, and everything that informs those two topics. Call it the specialty’s empirical roadmap.
“Often, compensation information relative to staffing information is proprietary, so hospitalists are in a position where they are dependent upon their hospital stakeholders to have access to this information, but they are also the same stakeholders with whom they negotiate their contracts,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee. “The State of Hospital Medicine report by SHM provides an opportunity for hospitalists to have an independent view of the compensation and workforce distribution factors that can impact negotiations with their hospital stakeholders. It’s a very powerful tool.”
Compensation Data
Rachel Lovins, MD, SFHM, CPE, voraciously reads every SoHM report because she uses its keynote compensation data to benchmark what she should pay her staff.
“I make a promise to my group,” says Dr. Lovins, chief of hospital medicine and vice chair of the Department of Medicine at Middlesex Hospital in Middletown, Conn. “I promise them that we will always be at or above what is standard for our areas. So for me, I have to look every time.”
Promises like that are getting more expensive to keep.
Hospitalists in the East region earn a median compensation of $245,977, up 3.1% from the $238,676 figure reported in 2014. But the East, where the bulk of the country’s population lives and where competition for hospitalists is typically lessened, is by far the lowest-paid region.
Hospitalists in the South continue to earn the most, with a median compensation of $301,833, up a whopping 16.9% from $258,020 from 2013. Hospitalists in the West earned a median of $275,658 (up 10.3% from $249,894), while Midwestern hospitalists saw a median compensation of $285,213 (up 8.9% from $261,868).
In addition to year-over-year growth, HM is also seeing outsized growth as compared with family medicine physicians, according to MGMA data. From 2011 to 2015, family medicine hospitalists saw an average compensation increase of 4.7%, bringing the average salary to $285,213. During the same period, family medicine physicians who are not hospitalists and don’t practice obstetrics saw an average annual compensation increase of only 3%, bringing the average salary to $230,456.
“The hospitalist can save the hospital considerable amounts of money because of their ability to better manage the patient and improve the quality of care at the same time,” says David Gans, MSHA, FACMPE, MGMA’s senior fellow of industry affairs. “Hospitals, they have recognized that, and therefore, there is considerable competition for recruiting and retaining hospitalists.”
To that end, 96.3% of HM groups (HMGs) received financial support in addition to their professional fee revenue. That’s up from 89% of HMGs that relied last year on their host hospitals. The median support is $157,535 per full-time employee (FTE), up just 1%. Correspondingly, SoHM reported 8.5% of HMGs received enough income from professional fee revenue to cover expenses, up from 6% two years ago.
Industry watchers predicted that, in two years, fee revenue would have to rise to offset hospitals’ inability to pay. The early returns seem to show that bearing out.
“We’re pretty close to that breaking point,” Flores says. “When we go around the country and do consulting work, we are hearing many more hospital leaders telling us, ‘We’re concerned about how much money this program is costing us, and we are getting to the point where we can’t afford it.’”
Productivity Stalls
While compensation continues to climb, productivity flattened out in this year’s report.
Median relative value units (RVUs) dipped slightly from the figure reported in 2014, to 4,252 from 4,297. But the tally is still ahead of 2012’s total of 4,159. Median collection-to-work RVUs also ticked down from 2014’s tally, to $50.29 from $51.50 in 2013.
Flores largely attributes the falling metrics of productivity to the evolution of HMGs that have standardized their scheduling to the point that most HMGs now offer vacation time.
“So the number of groups that are working 182 days is fewer, and we see a lot more groups that are working something like 168 days or 172 days,” she says. “And if a hospitalist works fewer shifts, even if they see the same number of patients per shift, they’re going to generate less productivity over the course of the year, so that’s part of it.”
Andrew White, MD, SFHM, director of the HM service at the University of Washington Medical Center in Seattle, says the report’s value is in avoiding a myopic approach to how HMGs operate. For example, RVUs are an important metric of productivity, but not all shifts should be expected to produce the same.
For example, it’d be valuable to use the report to see how hard your nocturnists are working compared with other sites, says Dr. White, also a member of the Practice Analysis Committee.
“The fundamental issue with working at night is that not everybody wants to do it, and so you have to recognize that it’s a pain to do and you have to either pay those people more, have them work less, or acknowledge that they’re going to be less productive,” he says. “We use the survey to assess all three of those things and then can work with our nocturnists to reach an agreement about a fair approach to their job structure that’s actually informed by national benchmarks. That process has helped us to pick, for example, how many nights per year they should work or what their salaries should look like compared to the day hospitalists.”
Dr. White says that because the report is comprehensive and includes broad participation, he’s able to use it as a benchmark to make hiring and service structure decisions.
“It also helps me to keep abreast of some trends that may be occurring in the broader workplace that we aren’t participating in but maybe should be or should be thinking about,” he says.
The report’s subsections are also critical for comparing one HMG to others, Dr. White says.
“Obviously, there is the aggregate data there to look at the average program,” he says. “But really as a hospitalist group leader, you want to know what are other programs like mine doing, and it allows you to drill down into that data.”
Survey Limitations
Any hospitalist worth their weight in scrubs knows that any medical study is only as good as its limitations. And while SoHM is a trove of valuable data information, Flores always cautions against taking data points as gospel.
“People should understand what the numbers are telling us, what goes into those numbers, and take them not with a grain of salt but take them for what they are,” she says.
For example, Flores says, look at productivity metrics per shift. Day shifts have traditionally driven that figure, and those shifts are typically busy. But night shifts have fewer patients and less productivity.
“So as more and more hospitals get 24-hour in-house coverage and have doctors working low-productivity night shifts, that [productivity] number might fall,” she says.
That sort of nuanced analysis of productivity can’t be found anywhere else, says Dr. Lovins.
These are “data that we don’t normally get from our administration,” she says, “information on things like staffing and patient loads, and how much more the director makes than the people that work for the director, and how much more nighttime people make than daytime people make. There is no other way for me to get that information, and it’s very important to make sure that our program is fair.”
Aside from fair, the data points are essential talking points as HMGs negotiate contracts and other arrangements with their administrators.
“It’s a reference point so that everybody feels like we’re using data from a national source that everyone can agree upon as fair,” says Dr. White.
In Dr. White’s case, he doesn’t have many local academic programs to benchmark against. And comparing to private, for-profit hospitals isn’t the proverbial apples-to-apples comparison. Having vetted regional and national figures for comparison is incredibly valuable, particularly since he doesn’t have to compile the data.
“If I had to go call all those group leaders and figure out what they were doing, it would be pretty exhausting,” he says.
Alternative Payment Models
Dr. Smith says that one area where the report will become even more valuable over the next few years is addressing alternative payment models (APMs). In particular, HM leaders say they’re excited about being drivers in one of the largest APMs: the Bundled Payments for Care Improvement (BCPI) initiative. In short, the program covers 48 defined episodes of care, including medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
Dr. Smith thinks it’s still a bit too early to see from the report how APMs have affected compensation.
“We’re still relatively in the early days of bundled-payment models, so in that regard, the State of Hospital Medicine Report still represents very much a starting point with regard to where hospital medicine groups will find themselves as they start to encounter challenges,” he says.
Perhaps more important, Gans doesn’t expect that the maturation of APMs will result in decreased compensation for hospitalists.
“In a hospital environment where the hospital is being reimbursed a set amount for a complete hospital admission and follow-up care and potential readmissions, that is an episodic payment already,” he says. “Consequently, the incentive is there today to better manage the patient and to attain the care coordination and care management necessary for that patient to be discharged and not readmitted.”
In fact, the SHM/MGMA data tell him that the basic economic theory of supply and demand continues to drive hospitalist compensation even 20 years after the field was given its name. He says rising compensation, even as more practices look to hire nurse practitioners or physician assistants as less expensive alternatives, shows no sign of letting up.
“I think demand will continue to be there,” Gans adds. “There may be in the long run some lessening of demand for hospitalists, but I don’t see that for years.”
Richard Quinn is a freelance writer in New Jersey.
Is Burnout a Problem?
Burnout has become a major concern across the healthcare spectrum, particularly in cognitive fields such as hospital medicine where physicians can work long days or weeks with little sleep and a lot of pressure.
But despite hospitalists branching into multiple new arenas over the past decade (surgical co-management and informatics, to name a few), burnout has never registered as a significant problem in SHM’s reports. In fact, the 2016 State of Hospital Medicine Report finds that the median turnover rate for physicians “only continues to decline year after year.”
The biennial report found a turnover rate of 6.9% for responding physicians who serve adults only. That’s down from 8% in 2014 and 14% in 2010.
Turnover rate, however, may not be the best measure of burnout levels, one hospitalist admits.
“It could be tempting to think that a decrease in turnover rates would equal to decreased burnout—it might also be that individuals could get so burnt out everywhere that they no longer see that leaving one hospital medicine group for another is a viable cure,” says G. Randy Smith, MD, MS, FRCP(Edin), SFHM, an assistant professor in the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago and a member of SHM’s Practice Analysis Committee.
Dr. Smith says SHM is actively trying to address burnout outside of the SoHM but that additional questions added to the report in future years could help home in on the phenomenon.
“There are other ways that burnout can manifest,” he adds. “There is concern that it can manifest in decreased patient satisfaction, in more sick leave, diagnostic error, and decreased ability to teach effectively in academic institutions. … Burnout can still very much remain an issue for a hospitalist group even if they see that their turnover rates are level relative to a regional or national average.”
—Richard Quinn
Dr. Geeta Arora Brings Her Passion for Locum Tenens Work to TH’s Editorial Board
If Geeta Arora, MD, were to purchase a personalized license plate, it probably would say something like “B3ACHNUT” or “SURF5UP.” Like many in the profession, she enjoys traveling and helping others. She’s a surfer girl, with a love of the beach and a heart for global medicine. And if given the chance, she says she’d rather be “selling coconuts on a beach” in the Caribbean, Costa Rica, or some other island paradise.
As a locum tenens hospitalist, Dr. Arora is based in New York City, but is licensed to practice in six states. In addition to her board certification in internal medicine, she also is board certified in integrative holistic medicine, something she hopes to expand on in coming years. She’s also active in telemedicine, providing outpatient consulting via phone or video chat with MDLive since 2014.
Dr. Arora, one of eight new members of Team Hospitalist, the volunteer editorial advisory board for The Hospitalist, had published a number of “Letters to the Editor” in SHM’s official newsmagazine prior to her application. The article topics were close to her heart, of course, with headlines reading “How Locums Tenens Can Help Avoid Burnout” and “5 Tips to Finding a Good Locum Tenens Company.” In fact, she recently was one of the interviewees for a TH video focused on working as a locum tenens hospitalist.
Dr. Arora recently stepped away from her busy schedule to chat with The Hospitalist:
Question: Why did you choose a career in medicine?
Answer: I wanted the opportunity to be present with people in some of the most vulnerable times in their lives and be able to help them when they are most vulnerable.
Q: How/when did you decide to become a hospitalist?
A: I decided to become a hospitalist as soon as I graduated residency.
Q: I see you completed undergrad at University of Guelph in Ontario, Canada. Tell us about your medical training. Was there a single moment you knew “I can do this”?
A: I went to medical school [at the Medical University of the Americas] in the Caribbean on an island called Nevis. My residency was at Albany Medical Center in Albany, N.Y. I disliked the politics of residency. I remember thinking, “I can do this,” in my third year of residency when I had just run two codes and was placing lines in a patient in the middle of the night on my own. I was surprised to find myself without any feeling of doubt in my mind as I placed the lines.
Q: What do you like most about working as a hospitalist?
A: I really enjoy the flexibility of my schedule and the large range of disease processes I see in a single day.
Q: What do you dislike most?
A: The immense amount of paperwork and the constant feeling of having administration trying to tell hospitalists how to do their job.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: The most challenging part of patient care, for me, is changing the plan of the previous provider. For example, if the physician that had been seeing the patient prior to me had promised that a CT scan would be repeated, but there is no indication, that often turns into a lengthy discussion with the patient and the patient’s family. And that can sometimes be challenging.
Q: What’s the best advice you ever received?
A: As long as you are doing everything in the best interest of your patient, you are doing the right thing.
Q: What’s the worst advice you ever received?
A: Always practice defensive medicine because, if you don’t, you will get sued.
Q: Have you tried to mentor others? Why or why not?
A: I have mentored several medical students because I feel it is important to give back to the next generation.
Q: What’s the biggest change you’ve seen in HM in your career?
A: More paperwork.
Q: What’s the biggest change you would like to see in HM?
A: Decreasing paperwork.
Q: What aspect of patient care is most rewarding?
A: Connecting with patients.
Q: What is your biggest professional challenge?
A: Leaving a hospital because of poor administrative processes, especially when the hospitalist group is excellent to work with.
Q: What is your biggest professional reward?
A: Being able to work with and learn from other hospitalists.
Q: Outside of patient care, tell us about your career interests.
A: I have a passion for locum tenens hospitalist medicine. I enjoy practicing in different types of communities across the country, and I enjoy teaching others to do the same. I also enjoy consulting hospitals about how to improve their hospitalist systems. Telemedicine platform consultation has also become one of my interests.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: What’s next professionally?
A: I enjoy practicing global medicine. My next destination is Cambodia in October. I’d like to increase the number of global medicine trips I do per year. I also have a very strong interest in integrative holistic medicine and am excited about expanding my practice in the coming year.
Q: What’s the best book you’ve read recently? Why?
A: Fortify Your Life, a book about supplements.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: iPhone and MacBook on a daily basis.
Q: What impact do you feel devices like those just mentioned have had on HM? And medicine in a broader sense?
A: I use them for electronic health records.
Q: What’s your favorite social network? Do you use it at all for work or professional development?
A: Instagram, but not for work.
Richard Quinn is a freelance writer in New Jersey.
If Geeta Arora, MD, were to purchase a personalized license plate, it probably would say something like “B3ACHNUT” or “SURF5UP.” Like many in the profession, she enjoys traveling and helping others. She’s a surfer girl, with a love of the beach and a heart for global medicine. And if given the chance, she says she’d rather be “selling coconuts on a beach” in the Caribbean, Costa Rica, or some other island paradise.
As a locum tenens hospitalist, Dr. Arora is based in New York City, but is licensed to practice in six states. In addition to her board certification in internal medicine, she also is board certified in integrative holistic medicine, something she hopes to expand on in coming years. She’s also active in telemedicine, providing outpatient consulting via phone or video chat with MDLive since 2014.
Dr. Arora, one of eight new members of Team Hospitalist, the volunteer editorial advisory board for The Hospitalist, had published a number of “Letters to the Editor” in SHM’s official newsmagazine prior to her application. The article topics were close to her heart, of course, with headlines reading “How Locums Tenens Can Help Avoid Burnout” and “5 Tips to Finding a Good Locum Tenens Company.” In fact, she recently was one of the interviewees for a TH video focused on working as a locum tenens hospitalist.
Dr. Arora recently stepped away from her busy schedule to chat with The Hospitalist:
Question: Why did you choose a career in medicine?
Answer: I wanted the opportunity to be present with people in some of the most vulnerable times in their lives and be able to help them when they are most vulnerable.
Q: How/when did you decide to become a hospitalist?
A: I decided to become a hospitalist as soon as I graduated residency.
Q: I see you completed undergrad at University of Guelph in Ontario, Canada. Tell us about your medical training. Was there a single moment you knew “I can do this”?
A: I went to medical school [at the Medical University of the Americas] in the Caribbean on an island called Nevis. My residency was at Albany Medical Center in Albany, N.Y. I disliked the politics of residency. I remember thinking, “I can do this,” in my third year of residency when I had just run two codes and was placing lines in a patient in the middle of the night on my own. I was surprised to find myself without any feeling of doubt in my mind as I placed the lines.
Q: What do you like most about working as a hospitalist?
A: I really enjoy the flexibility of my schedule and the large range of disease processes I see in a single day.
Q: What do you dislike most?
A: The immense amount of paperwork and the constant feeling of having administration trying to tell hospitalists how to do their job.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: The most challenging part of patient care, for me, is changing the plan of the previous provider. For example, if the physician that had been seeing the patient prior to me had promised that a CT scan would be repeated, but there is no indication, that often turns into a lengthy discussion with the patient and the patient’s family. And that can sometimes be challenging.
Q: What’s the best advice you ever received?
A: As long as you are doing everything in the best interest of your patient, you are doing the right thing.
Q: What’s the worst advice you ever received?
A: Always practice defensive medicine because, if you don’t, you will get sued.
Q: Have you tried to mentor others? Why or why not?
A: I have mentored several medical students because I feel it is important to give back to the next generation.
Q: What’s the biggest change you’ve seen in HM in your career?
A: More paperwork.
Q: What’s the biggest change you would like to see in HM?
A: Decreasing paperwork.
Q: What aspect of patient care is most rewarding?
A: Connecting with patients.
Q: What is your biggest professional challenge?
A: Leaving a hospital because of poor administrative processes, especially when the hospitalist group is excellent to work with.
Q: What is your biggest professional reward?
A: Being able to work with and learn from other hospitalists.
Q: Outside of patient care, tell us about your career interests.
A: I have a passion for locum tenens hospitalist medicine. I enjoy practicing in different types of communities across the country, and I enjoy teaching others to do the same. I also enjoy consulting hospitals about how to improve their hospitalist systems. Telemedicine platform consultation has also become one of my interests.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: What’s next professionally?
A: I enjoy practicing global medicine. My next destination is Cambodia in October. I’d like to increase the number of global medicine trips I do per year. I also have a very strong interest in integrative holistic medicine and am excited about expanding my practice in the coming year.
Q: What’s the best book you’ve read recently? Why?
A: Fortify Your Life, a book about supplements.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: iPhone and MacBook on a daily basis.
Q: What impact do you feel devices like those just mentioned have had on HM? And medicine in a broader sense?
A: I use them for electronic health records.
Q: What’s your favorite social network? Do you use it at all for work or professional development?
A: Instagram, but not for work.
Richard Quinn is a freelance writer in New Jersey.
If Geeta Arora, MD, were to purchase a personalized license plate, it probably would say something like “B3ACHNUT” or “SURF5UP.” Like many in the profession, she enjoys traveling and helping others. She’s a surfer girl, with a love of the beach and a heart for global medicine. And if given the chance, she says she’d rather be “selling coconuts on a beach” in the Caribbean, Costa Rica, or some other island paradise.
As a locum tenens hospitalist, Dr. Arora is based in New York City, but is licensed to practice in six states. In addition to her board certification in internal medicine, she also is board certified in integrative holistic medicine, something she hopes to expand on in coming years. She’s also active in telemedicine, providing outpatient consulting via phone or video chat with MDLive since 2014.
Dr. Arora, one of eight new members of Team Hospitalist, the volunteer editorial advisory board for The Hospitalist, had published a number of “Letters to the Editor” in SHM’s official newsmagazine prior to her application. The article topics were close to her heart, of course, with headlines reading “How Locums Tenens Can Help Avoid Burnout” and “5 Tips to Finding a Good Locum Tenens Company.” In fact, she recently was one of the interviewees for a TH video focused on working as a locum tenens hospitalist.
Dr. Arora recently stepped away from her busy schedule to chat with The Hospitalist:
Question: Why did you choose a career in medicine?
Answer: I wanted the opportunity to be present with people in some of the most vulnerable times in their lives and be able to help them when they are most vulnerable.
Q: How/when did you decide to become a hospitalist?
A: I decided to become a hospitalist as soon as I graduated residency.
Q: I see you completed undergrad at University of Guelph in Ontario, Canada. Tell us about your medical training. Was there a single moment you knew “I can do this”?
A: I went to medical school [at the Medical University of the Americas] in the Caribbean on an island called Nevis. My residency was at Albany Medical Center in Albany, N.Y. I disliked the politics of residency. I remember thinking, “I can do this,” in my third year of residency when I had just run two codes and was placing lines in a patient in the middle of the night on my own. I was surprised to find myself without any feeling of doubt in my mind as I placed the lines.
Q: What do you like most about working as a hospitalist?
A: I really enjoy the flexibility of my schedule and the large range of disease processes I see in a single day.
Q: What do you dislike most?
A: The immense amount of paperwork and the constant feeling of having administration trying to tell hospitalists how to do their job.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: The most challenging part of patient care, for me, is changing the plan of the previous provider. For example, if the physician that had been seeing the patient prior to me had promised that a CT scan would be repeated, but there is no indication, that often turns into a lengthy discussion with the patient and the patient’s family. And that can sometimes be challenging.
Q: What’s the best advice you ever received?
A: As long as you are doing everything in the best interest of your patient, you are doing the right thing.
Q: What’s the worst advice you ever received?
A: Always practice defensive medicine because, if you don’t, you will get sued.
Q: Have you tried to mentor others? Why or why not?
A: I have mentored several medical students because I feel it is important to give back to the next generation.
Q: What’s the biggest change you’ve seen in HM in your career?
A: More paperwork.
Q: What’s the biggest change you would like to see in HM?
A: Decreasing paperwork.
Q: What aspect of patient care is most rewarding?
A: Connecting with patients.
Q: What is your biggest professional challenge?
A: Leaving a hospital because of poor administrative processes, especially when the hospitalist group is excellent to work with.
Q: What is your biggest professional reward?
A: Being able to work with and learn from other hospitalists.
Q: Outside of patient care, tell us about your career interests.
A: I have a passion for locum tenens hospitalist medicine. I enjoy practicing in different types of communities across the country, and I enjoy teaching others to do the same. I also enjoy consulting hospitals about how to improve their hospitalist systems. Telemedicine platform consultation has also become one of my interests.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: What’s next professionally?
A: I enjoy practicing global medicine. My next destination is Cambodia in October. I’d like to increase the number of global medicine trips I do per year. I also have a very strong interest in integrative holistic medicine and am excited about expanding my practice in the coming year.
Q: What’s the best book you’ve read recently? Why?
A: Fortify Your Life, a book about supplements.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: iPhone and MacBook on a daily basis.
Q: What impact do you feel devices like those just mentioned have had on HM? And medicine in a broader sense?
A: I use them for electronic health records.
Q: What’s your favorite social network? Do you use it at all for work or professional development?
A: Instagram, but not for work.
Richard Quinn is a freelance writer in New Jersey.
Dr. Benjamin Frizner Brings Post-Acute-Care Expertise to TH’s Editorial Board
Going to medical school at Universidad Autónoma de Guadalajara in Guadalajara, Mexico, could have been too much for Benjamin Frizner, MD, FHM.
Medicine is its own new language, as any first-year can tell you. Throw in learning Spanish? And a new culture? One could be forgiven for not excelling.
Dr. Frizner isn’t one of those people.
“The experience changed my life,” he says. “After I survived the first year, I knew I loved medicine.”
After medical school, Dr. Frizner had to complete a Fifth Pathway program, which formerly allowed students who completed four years at a foreign medical school to finish supervised clinical work at a U.S. medical school and become eligible as a U.S. resident.
He learned of hospital medicine during his residency at York Hospital in York, Pa., and, despite others suggesting hospital medicine was “something to do before you really figure out your career,” he enjoyed both working within the hospital walls and having a schedule that allowed 15 shifts a month and commensurate time off.
But as with his shift from undergraduate school in suburban Maryland to medical school in Mexico, Dr. Frizner likes a new challenge. So after a four-year stint as director of the hospitalist program at Saint Agnes Hospital in Baltimore, he took a job in August 2015 as director of the Ventilator Unit at FutureCare Irvington, a post-acute-care center in Baltimore staffed by CEP America.
“Post-acute care has become a new passion and chapter in my career,” he says, adding, “Skilled nursing facilities are extensions of the acute-care hospital and are just as challenging and fulfilling as hospitalist work.”
It’s a perspective Dr. Frizner will bring as one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: I enjoyed math and biology in college. I started out thinking I would be an engineer but fell in love with anatomy. I like solving problems and working with people. Internal medicine/hospital medicine is a perfect match, working to solve a patient’s diagnosis and helping families make difficult decisions about placement and palliative care.
Q: What do you like most about working as a hospitalist?
A: Interacting with all the different specialties, social work, case management, residents, ED docs. I really enjoy the camaraderie.
Q: What do you dislike most?
A: Hospital groups contribute immensely to patient flow, care, quality, process improvement, throughput, but hospitals always advertise the new specialist and never the excellent hospitalist group.
Q: What’s the best advice you ever received?
A: No matter what, do what is best for the patient. Everything else will take care of itself.
Q: What’s the worst advice you ever received?
A: Don’t worry about the contract; you don’t need to really look it over.
Q: What’s the biggest change you’ve seen in HM in your career?
A: The pace of medicine continues to speed up. Residents have to hit the ground running with baseline case-management knowledge.
Q: What’s the biggest change you would like to see in HM?
A: I would like to see more hospitalists ascend into senior leadership in hospitals and healthcare systems.
Q: Why should group leaders continue to see patients?
A: It is important to maintain trust and respect with docs you are leading and managing. When I was a hospitalist director, I made sure I worked nights and weekends so I could understand the workload during those shifts and my team felt I was not just dumping on them.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust with the patient and their family. But it has become second nature to me at this point. The secret is to introduce yourself, tell the patient and family you will take care of them in the hospital, communicate with their outpatient physician and that you are part of a 24-7 team of docs there to take care of the patient.
Q: What aspect of patient care is most rewarding?
A: Helping families navigate end-of-life decisions. It is the most stressful time in a family’s life, and I think it is the most rewarding and honorable part of practicing medicine.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I lead teaching rounds a few months a year when I was a hospitalist director, and I think the most difficult part is getting the residents to understand the workload will be a lot tougher when they get out into the real world. During their third year, residents need to practice efficiency and gauge their work ethic—not the kind of work ethic needed to pass the boards but the kind needed to stay in the ED and help your teammate out until the admissions are caught up or round on a few extra patients when there is a surge in the census.
Q: What is your biggest professional challenge?
A: [Getting others to] stop underestimating my skills and experience as a hospitalist and physician leader. I will complete an MBA through ACPE UMass this December. Learning basic accounting, business law, and finance has helped round out blind spots and build my confidence.
Q: What is your biggest professional reward?
A: Completing quality improvement projects such as increasing DVT prophylaxis, reducing CAUTI, and decreasing throughput times, which all help make the hospital course safer and efficient for the patient.
Q: What SHM event made the most lasting impression on you?
A: Seven years ago, I attended the Level I leadership academy at the Aria hotel in Las Vegas. The meeting opened my eyes to the world of leadership, management, and healthcare economics, which sparked my drive to eventually become a hospitalist director.
Q: What’s the best book you’ve read recently? Why?
A: David and Goliath by Malcolm Gladwell. As a foreign medical graduate, I was told there would be limits to what I could achieve in my career. Mr. Gladwell’s book is filled with stories of people who overcame difficult situations and went on to rise to the top of their fields.
Richard Quinn is a freelance writer in New Jersey.
Going to medical school at Universidad Autónoma de Guadalajara in Guadalajara, Mexico, could have been too much for Benjamin Frizner, MD, FHM.
Medicine is its own new language, as any first-year can tell you. Throw in learning Spanish? And a new culture? One could be forgiven for not excelling.
Dr. Frizner isn’t one of those people.
“The experience changed my life,” he says. “After I survived the first year, I knew I loved medicine.”
After medical school, Dr. Frizner had to complete a Fifth Pathway program, which formerly allowed students who completed four years at a foreign medical school to finish supervised clinical work at a U.S. medical school and become eligible as a U.S. resident.
He learned of hospital medicine during his residency at York Hospital in York, Pa., and, despite others suggesting hospital medicine was “something to do before you really figure out your career,” he enjoyed both working within the hospital walls and having a schedule that allowed 15 shifts a month and commensurate time off.
But as with his shift from undergraduate school in suburban Maryland to medical school in Mexico, Dr. Frizner likes a new challenge. So after a four-year stint as director of the hospitalist program at Saint Agnes Hospital in Baltimore, he took a job in August 2015 as director of the Ventilator Unit at FutureCare Irvington, a post-acute-care center in Baltimore staffed by CEP America.
“Post-acute care has become a new passion and chapter in my career,” he says, adding, “Skilled nursing facilities are extensions of the acute-care hospital and are just as challenging and fulfilling as hospitalist work.”
It’s a perspective Dr. Frizner will bring as one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: I enjoyed math and biology in college. I started out thinking I would be an engineer but fell in love with anatomy. I like solving problems and working with people. Internal medicine/hospital medicine is a perfect match, working to solve a patient’s diagnosis and helping families make difficult decisions about placement and palliative care.
Q: What do you like most about working as a hospitalist?
A: Interacting with all the different specialties, social work, case management, residents, ED docs. I really enjoy the camaraderie.
Q: What do you dislike most?
A: Hospital groups contribute immensely to patient flow, care, quality, process improvement, throughput, but hospitals always advertise the new specialist and never the excellent hospitalist group.
Q: What’s the best advice you ever received?
A: No matter what, do what is best for the patient. Everything else will take care of itself.
Q: What’s the worst advice you ever received?
A: Don’t worry about the contract; you don’t need to really look it over.
Q: What’s the biggest change you’ve seen in HM in your career?
A: The pace of medicine continues to speed up. Residents have to hit the ground running with baseline case-management knowledge.
Q: What’s the biggest change you would like to see in HM?
A: I would like to see more hospitalists ascend into senior leadership in hospitals and healthcare systems.
Q: Why should group leaders continue to see patients?
A: It is important to maintain trust and respect with docs you are leading and managing. When I was a hospitalist director, I made sure I worked nights and weekends so I could understand the workload during those shifts and my team felt I was not just dumping on them.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust with the patient and their family. But it has become second nature to me at this point. The secret is to introduce yourself, tell the patient and family you will take care of them in the hospital, communicate with their outpatient physician and that you are part of a 24-7 team of docs there to take care of the patient.
Q: What aspect of patient care is most rewarding?
A: Helping families navigate end-of-life decisions. It is the most stressful time in a family’s life, and I think it is the most rewarding and honorable part of practicing medicine.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I lead teaching rounds a few months a year when I was a hospitalist director, and I think the most difficult part is getting the residents to understand the workload will be a lot tougher when they get out into the real world. During their third year, residents need to practice efficiency and gauge their work ethic—not the kind of work ethic needed to pass the boards but the kind needed to stay in the ED and help your teammate out until the admissions are caught up or round on a few extra patients when there is a surge in the census.
Q: What is your biggest professional challenge?
A: [Getting others to] stop underestimating my skills and experience as a hospitalist and physician leader. I will complete an MBA through ACPE UMass this December. Learning basic accounting, business law, and finance has helped round out blind spots and build my confidence.
Q: What is your biggest professional reward?
A: Completing quality improvement projects such as increasing DVT prophylaxis, reducing CAUTI, and decreasing throughput times, which all help make the hospital course safer and efficient for the patient.
Q: What SHM event made the most lasting impression on you?
A: Seven years ago, I attended the Level I leadership academy at the Aria hotel in Las Vegas. The meeting opened my eyes to the world of leadership, management, and healthcare economics, which sparked my drive to eventually become a hospitalist director.
Q: What’s the best book you’ve read recently? Why?
A: David and Goliath by Malcolm Gladwell. As a foreign medical graduate, I was told there would be limits to what I could achieve in my career. Mr. Gladwell’s book is filled with stories of people who overcame difficult situations and went on to rise to the top of their fields.
Richard Quinn is a freelance writer in New Jersey.
Going to medical school at Universidad Autónoma de Guadalajara in Guadalajara, Mexico, could have been too much for Benjamin Frizner, MD, FHM.
Medicine is its own new language, as any first-year can tell you. Throw in learning Spanish? And a new culture? One could be forgiven for not excelling.
Dr. Frizner isn’t one of those people.
“The experience changed my life,” he says. “After I survived the first year, I knew I loved medicine.”
After medical school, Dr. Frizner had to complete a Fifth Pathway program, which formerly allowed students who completed four years at a foreign medical school to finish supervised clinical work at a U.S. medical school and become eligible as a U.S. resident.
He learned of hospital medicine during his residency at York Hospital in York, Pa., and, despite others suggesting hospital medicine was “something to do before you really figure out your career,” he enjoyed both working within the hospital walls and having a schedule that allowed 15 shifts a month and commensurate time off.
But as with his shift from undergraduate school in suburban Maryland to medical school in Mexico, Dr. Frizner likes a new challenge. So after a four-year stint as director of the hospitalist program at Saint Agnes Hospital in Baltimore, he took a job in August 2015 as director of the Ventilator Unit at FutureCare Irvington, a post-acute-care center in Baltimore staffed by CEP America.
“Post-acute care has become a new passion and chapter in my career,” he says, adding, “Skilled nursing facilities are extensions of the acute-care hospital and are just as challenging and fulfilling as hospitalist work.”
It’s a perspective Dr. Frizner will bring as one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: I enjoyed math and biology in college. I started out thinking I would be an engineer but fell in love with anatomy. I like solving problems and working with people. Internal medicine/hospital medicine is a perfect match, working to solve a patient’s diagnosis and helping families make difficult decisions about placement and palliative care.
Q: What do you like most about working as a hospitalist?
A: Interacting with all the different specialties, social work, case management, residents, ED docs. I really enjoy the camaraderie.
Q: What do you dislike most?
A: Hospital groups contribute immensely to patient flow, care, quality, process improvement, throughput, but hospitals always advertise the new specialist and never the excellent hospitalist group.
Q: What’s the best advice you ever received?
A: No matter what, do what is best for the patient. Everything else will take care of itself.
Q: What’s the worst advice you ever received?
A: Don’t worry about the contract; you don’t need to really look it over.
Q: What’s the biggest change you’ve seen in HM in your career?
A: The pace of medicine continues to speed up. Residents have to hit the ground running with baseline case-management knowledge.
Q: What’s the biggest change you would like to see in HM?
A: I would like to see more hospitalists ascend into senior leadership in hospitals and healthcare systems.
Q: Why should group leaders continue to see patients?
A: It is important to maintain trust and respect with docs you are leading and managing. When I was a hospitalist director, I made sure I worked nights and weekends so I could understand the workload during those shifts and my team felt I was not just dumping on them.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust with the patient and their family. But it has become second nature to me at this point. The secret is to introduce yourself, tell the patient and family you will take care of them in the hospital, communicate with their outpatient physician and that you are part of a 24-7 team of docs there to take care of the patient.
Q: What aspect of patient care is most rewarding?
A: Helping families navigate end-of-life decisions. It is the most stressful time in a family’s life, and I think it is the most rewarding and honorable part of practicing medicine.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I lead teaching rounds a few months a year when I was a hospitalist director, and I think the most difficult part is getting the residents to understand the workload will be a lot tougher when they get out into the real world. During their third year, residents need to practice efficiency and gauge their work ethic—not the kind of work ethic needed to pass the boards but the kind needed to stay in the ED and help your teammate out until the admissions are caught up or round on a few extra patients when there is a surge in the census.
Q: What is your biggest professional challenge?
A: [Getting others to] stop underestimating my skills and experience as a hospitalist and physician leader. I will complete an MBA through ACPE UMass this December. Learning basic accounting, business law, and finance has helped round out blind spots and build my confidence.
Q: What is your biggest professional reward?
A: Completing quality improvement projects such as increasing DVT prophylaxis, reducing CAUTI, and decreasing throughput times, which all help make the hospital course safer and efficient for the patient.
Q: What SHM event made the most lasting impression on you?
A: Seven years ago, I attended the Level I leadership academy at the Aria hotel in Las Vegas. The meeting opened my eyes to the world of leadership, management, and healthcare economics, which sparked my drive to eventually become a hospitalist director.
Q: What’s the best book you’ve read recently? Why?
A: David and Goliath by Malcolm Gladwell. As a foreign medical graduate, I was told there would be limits to what I could achieve in my career. Mr. Gladwell’s book is filled with stories of people who overcame difficult situations and went on to rise to the top of their fields.
Richard Quinn is a freelance writer in New Jersey.
HM Turns 20: A Look at the Evolution of Hospital Medicine
Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.
When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.
“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”
Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?
“I got the idea that we could do better than that,” Dr. Goldman says.
He was right.
Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.
Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”
The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.
But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.
Until Dr. Wachter and Dr. Goldman.
On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).
A burgeoning specialty was given a name.
Its practitioners were called “hospitalists.”
And the rest, as they say, is history.
The Early Days
The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.
But it wasn’t always this way.
The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.
When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.
“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”
Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.
“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”
In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.
“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”
Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.
At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’
“And someone raised their hand and said, ‘Who’s the doctor?’
“And I said, ‘You mean who’s the intern?’
“They said, ‘No.’
“I said, ‘Or who’s the ward resident?’
“They said, ‘No.’
“And then, ‘Who is the attending?’
“And they said, ‘Yes.’
“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”
Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.
Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”
Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?
“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.
Community Views
Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.
She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.
She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.
So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.
“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”
Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.
“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”
Perfect Timing
The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.
“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”
Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.
“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”
Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”
That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.
Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.
The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”
“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”
Growth Spurt
The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.
“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”
Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.
The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.
“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”
Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.
Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.
“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”
Revenue Rules the Day
Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.
“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.
“That meant more money in their own pockets because the medical group was taking the risk.”
Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.
“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”
And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.
“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”
Tech Effect
In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?
“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.
“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.
“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”
Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).
“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”
So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.
“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”
Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.
He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.
“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”
Teamwork: An HM Tradition
Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).
Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.
Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”
“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”
Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.
“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”
The Post-Acute Space
Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.
Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.
“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”
Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.
“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.
Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.
And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.
“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.
“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”
Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”
Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.
Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.
BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.
“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”
A Score of Success
Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.
To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.
By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.
Again, progress followed quickly.
By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.
In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.
And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.
Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.
Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.
Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.
“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”
The Future
So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.
Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.
“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”
Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.
And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.
“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”
At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.
“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.
“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”
Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.
Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.
Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.
“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH
Richard Quinn is a freelance writer in New Jersey.
References
- Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.
Year of the Hospitalist: Opinions
“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”
—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission
“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”
—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore
“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”
—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago
“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”
—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.
“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”
—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality
“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”
—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.
—Richard Quinn
Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.
When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.
“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”
Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?
“I got the idea that we could do better than that,” Dr. Goldman says.
He was right.
Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.
Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”
The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.
But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.
Until Dr. Wachter and Dr. Goldman.
On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).
A burgeoning specialty was given a name.
Its practitioners were called “hospitalists.”
And the rest, as they say, is history.
The Early Days
The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.
But it wasn’t always this way.
The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.
When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.
“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”
Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.
“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”
In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.
“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”
Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.
At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’
“And someone raised their hand and said, ‘Who’s the doctor?’
“And I said, ‘You mean who’s the intern?’
“They said, ‘No.’
“I said, ‘Or who’s the ward resident?’
“They said, ‘No.’
“And then, ‘Who is the attending?’
“And they said, ‘Yes.’
“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”
Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.
Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”
Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?
“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.
Community Views
Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.
She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.
She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.
So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.
“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”
Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.
“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”
Perfect Timing
The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.
“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”
Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.
“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”
Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”
That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.
Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.
The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”
“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”
Growth Spurt
The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.
“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”
Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.
The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.
“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”
Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.
Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.
“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”
Revenue Rules the Day
Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.
“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.
“That meant more money in their own pockets because the medical group was taking the risk.”
Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.
“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”
And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.
“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”
Tech Effect
In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?
“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.
“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.
“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”
Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).
“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”
So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.
“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”
Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.
He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.
“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”
Teamwork: An HM Tradition
Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).
Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.
Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”
“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”
Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.
“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”
The Post-Acute Space
Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.
Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.
“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”
Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.
“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.
Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.
And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.
“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.
“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”
Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”
Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.
Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.
BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.
“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”
A Score of Success
Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.
To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.
By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.
Again, progress followed quickly.
By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.
In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.
And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.
Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.
Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.
Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.
“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”
The Future
So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.
Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.
“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”
Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.
And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.
“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”
At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.
“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.
“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”
Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.
Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.
Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.
“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH
Richard Quinn is a freelance writer in New Jersey.
References
- Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.
Year of the Hospitalist: Opinions
“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”
—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission
“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”
—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore
“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”
—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago
“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”
—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.
“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”
—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality
“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”
—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.
—Richard Quinn
Editor's Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.
When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.
“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”
Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?
“I got the idea that we could do better than that,” Dr. Goldman says.
He was right.
Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.
Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”
The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.
But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.
Until Dr. Wachter and Dr. Goldman.
On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).
A burgeoning specialty was given a name.
Its practitioners were called “hospitalists.”
And the rest, as they say, is history.
The Early Days
The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.
But it wasn’t always this way.
The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.
When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.
“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”
Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.
“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”
In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.
“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”
Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.
At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’
“And someone raised their hand and said, ‘Who’s the doctor?’
“And I said, ‘You mean who’s the intern?’
“They said, ‘No.’
“I said, ‘Or who’s the ward resident?’
“They said, ‘No.’
“And then, ‘Who is the attending?’
“And they said, ‘Yes.’
“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”
Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.
Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”
Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?
“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.
Community Views
Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.
She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.
She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.
So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.
“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”
Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.
“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”
Perfect Timing
The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.
“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”
Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.
“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”
Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”
That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.
Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.
The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”
“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”
Growth Spurt
The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.
“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”
Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.
The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.
“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”
Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.
Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.
“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”
Revenue Rules the Day
Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.
“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital.
“That meant more money in their own pockets because the medical group was taking the risk.”
Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners.
“They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.”
And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners.
“Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”
Tech Effect
In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM?
“Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes.
“Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.
“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”
Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs).
“EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.”
So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says.
“It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”
Kendall Rogers, MD, CPE, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and chair of SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.
He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.
“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”
Teamwork: An HM Tradition
Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).
Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member.
Dr. Donaldson believes that integrating hospitalists and non-physician providers (NPPs) allows both sets of practitioners to “work at the top of their license.”
“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”
Dr. Donaldson sees SHM’s acceptance of NPs and PAs as a good sign for HM.
“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”
The Post-Acute Space
Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.
Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital.
“We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”
Dr. Gorman, formerly the chief executive of St. Louis–based Advanced ICU Care, which provides intensivists to community hospitals using telemedicine, agrees that for hospitalists to exert even more control over quality of care, they have to team with people outside the hospital.
“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says.
Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge.
And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task.
“There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits.
“The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.”
Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”
Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future.
Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care.
BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge.
“The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon.
“The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”
A Score of Success
Twenty years of unbridled growth is great in any business. Put in perspective, the first iPhone, which redefined personal communication, is just nine years old, and already, stock analysts question whether Apple can grow any bigger or if it’s plateaued.
To be sure, the field of HM and its leaders have accomplished more than even Dr. Wachter and Dr. Goldman envisioned 20 summers ago. Much of it may seem so easily established by now, but when pioneering hospitalists John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997.
By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine.
Again, progress followed quickly.
By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program.
In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.
And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.
Dr. Merlino says it’s not just accomplishments that have set the field apart in its first 20 years. It’s the people.
Take Modern Healthcare’s list of the 50 Most Influential Physician Executives and Leaders of 2016. Third on the list is pediatric hospitalist Patrick Conway, MD, MSc, MHM, deputy administrator for innovation and quality and CMS’s chief medical officer. One spot behind him is Dr. Wachter, who in addition to being an architect of the HM movement was the first hospitalist to serve as chair of the Board of Directors of the American Board of Internal Medicine, which provides certification for the majority of working hospitalists.
Rounding out HM’s presence on the list is Vivek Murthy, MD, MBA, a Boston hospitalist and the current U.S. Surgeon General.
“It does demonstrate the emergence of their leadership,” Dr. Merlino says. “I don’t think yet they’re viewed as being the leaders, but I would add to that I don’t think they have yet the respect they deserve for the work they’re doing. When people who have worked with them can understand the value that they bring to clinical care, they clearly view hospitalists as being critical leaders.”
The Future
So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say.
Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi.
“Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”
Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.
And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty.
“It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”
At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field.
“If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting.
“The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.”
Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.
Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect.
Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea.
“If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.” TH
Richard Quinn is a freelance writer in New Jersey.
References
- Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129(3):197-203.
Year of the Hospitalist: Opinions
“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”
—Mark Chassin, MD, FACP, MPP, MPH, president and chief executive officer of The Joint Commission
“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”
—Peter Pronovost, MD, PhD, FCCM, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore
“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”
—Vineet Arora, MD, MAPP, FHM, associate professor, University of Chicago
“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”
—Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners, Darien, Conn.
“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”
—Patrick Conway, MD, MHM, MSc, CMS’s chief medical officer and deputy administrator for innovation and quality
“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”
—Jill Slater Waldman, MD, SFHM, Team Hospitalist member and medical director of the adult hospital service at Phelps Memorial Hospital, Sleepy Hollow, N.Y.
—Richard Quinn
Pediatric Hospitalist Michael Beck, MD, FAAP, Measures Success By Others’ Success
Young boys sometimes see a firefighter or a police officer in the line of duty and decide that’s what they want to be when they get older. Michael Beck, MD, FAAP, saw his pediatrician that way.
“He was a very humanistic provider and found joy in serving children and their families,” Dr. Beck says. “I saw how a pediatrician could influence others and make the world a better place and still have fun serving a vulnerable patient population.”
His career in pediatric hospital medicine, though?
“It was largely pure luck,” Dr. Beck admits. “When I was seeking my first job, I was offered a position that was 50/50 internal medicine and pediatrics but purely a hospitalist position.”
Dr. Beck has risen through academic hospitalist ranks the past 15 years and now serves as the division chief of pediatric hospital medicine at Penn State Children’s Hospital at Milton S. Hershey (Pa.) Medical Center. He is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What was medical school and residency like for you? Was there a single moment you knew “I can do this”?
Answer: I always have been filled with self-doubt, which is a perpetual motivator for me. I guess I believed I could do hospital-based work when I started knowing the majority of what was going on with patients after hearing residents discuss cases and I knew what the labs, studies, and exam findings were going to be before I saw the patient.
Q: What do you like most about working as a hospitalist?
A: The acuity and pathology of cases. I get to see cases that some people only read about. It is very intellectual challenging, and I get to work with and learn from specialists every day.
Q: What do you dislike most?
A: Some of the cases are devastating to families. It is always important to remind yourself—and the team—that some of the diagnoses we help make affect families and the patient in very profound ways.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: Dr. Barbara Ostrov. I learned what it really means to be a servant-leader. I witnessed her work ethic and saw that a leader of others should lead by example and be willing to work twice what is expected of others. She is always nonjudgmental and professional, yet forthright, when dealing with contentious situations. She trumpets the work of others, not her own, and sees others’ successes as her success. In the end, I believed she worked for me, not the other way around.
Q: Have you tried to mentor others? Why or why not?
A: Yes. As a division chief, I want others to succeed. The best quote I have read was by Richard Branson [CEO of Virgin]: “Train people so that they can leave, but treat them so they want to stay.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: It has moved from a clinical service to a robust area of research and strong researchers.
Q: What’s the biggest change you would like to see in HM?
A: If hospital medicine is positioning itself to be a specialty with fellowship training, with access to knowledge different from PCPs, then I believe we should function like other specialty services with a different skill set. We should own our discharge process and follow-up plans. We should follow up with patients in a discharge clinic setting to review clinical course, health literacy issues, labs, and studies and even order follow-up studies based on incoming results.
Q: For group leaders, why is it important for you to continue seeing patients?
A: As a clinician leader, my charge is to foster teamwork and create a shared vision for improvement and change. This is not possible to do from an office space or conference room separate from where the work gets done.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust and rapport in five to 10 minutes. Caring for a hospitalized patient, when they are surrounded by loved ones, is stressful and anxiety-provoking. Delivering information in a way that is honest and empathetic and timely without the benefit of having a personal historic connection with a patient is always challenging.
Q: What aspect of patient care is most rewarding?
A: Making a diagnosis in a patient that has eluded diagnosis for weeks or months.
Q: What aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Today’s learners have different expectations from mine [in terms] of what they want to get from a career in medicine. While I don’t always agree with them, it is the reality and puts me in a position to discuss and understand the rationale of a changing mindset. As a physician leader, it is important to understand this because it helps me create an environment that fosters successful recruitment and retention.
Q: You mention wanting to tackle the issue of physician burnout? Why is that something important to you?
A: I personally lived through it and felt the effects it had on the relationships I had with family, friends, medical students, residents, and patients. I know what it felt like to be angry, cynical, and distanced from those I cared about and from those whom I was charged with caring for. I never forgot how isolated [you] can feel in an academic center even when surrounded by hundreds. I vowed that if I ever found my way to a leadership position, I would begin by creating an environment that emphasized morale, honesty, integrity, and professionalism. If I succeeded in this, the other organizational missions of education, patient care, quality, and value would follow.
Since 2012, our division has monitored burnout, work-life balance, and, more recently, physician engagement. Although we take care of the sickest children in the region, our group supports each other, recognizing and respectful of the fact that we each have different comfort levels, skill sets, but we also have fun. Patients, nurses, social workers, care coordinators, and clerks see this. Like I teach the residents, you never get a second chance to make a first impression, but you also never get a second chance to make a last one, so make all interactions count. TH
Richard Quinn is a freelance writer in New Jersey.
Young boys sometimes see a firefighter or a police officer in the line of duty and decide that’s what they want to be when they get older. Michael Beck, MD, FAAP, saw his pediatrician that way.
“He was a very humanistic provider and found joy in serving children and their families,” Dr. Beck says. “I saw how a pediatrician could influence others and make the world a better place and still have fun serving a vulnerable patient population.”
His career in pediatric hospital medicine, though?
“It was largely pure luck,” Dr. Beck admits. “When I was seeking my first job, I was offered a position that was 50/50 internal medicine and pediatrics but purely a hospitalist position.”
Dr. Beck has risen through academic hospitalist ranks the past 15 years and now serves as the division chief of pediatric hospital medicine at Penn State Children’s Hospital at Milton S. Hershey (Pa.) Medical Center. He is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What was medical school and residency like for you? Was there a single moment you knew “I can do this”?
Answer: I always have been filled with self-doubt, which is a perpetual motivator for me. I guess I believed I could do hospital-based work when I started knowing the majority of what was going on with patients after hearing residents discuss cases and I knew what the labs, studies, and exam findings were going to be before I saw the patient.
Q: What do you like most about working as a hospitalist?
A: The acuity and pathology of cases. I get to see cases that some people only read about. It is very intellectual challenging, and I get to work with and learn from specialists every day.
Q: What do you dislike most?
A: Some of the cases are devastating to families. It is always important to remind yourself—and the team—that some of the diagnoses we help make affect families and the patient in very profound ways.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: Dr. Barbara Ostrov. I learned what it really means to be a servant-leader. I witnessed her work ethic and saw that a leader of others should lead by example and be willing to work twice what is expected of others. She is always nonjudgmental and professional, yet forthright, when dealing with contentious situations. She trumpets the work of others, not her own, and sees others’ successes as her success. In the end, I believed she worked for me, not the other way around.
Q: Have you tried to mentor others? Why or why not?
A: Yes. As a division chief, I want others to succeed. The best quote I have read was by Richard Branson [CEO of Virgin]: “Train people so that they can leave, but treat them so they want to stay.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: It has moved from a clinical service to a robust area of research and strong researchers.
Q: What’s the biggest change you would like to see in HM?
A: If hospital medicine is positioning itself to be a specialty with fellowship training, with access to knowledge different from PCPs, then I believe we should function like other specialty services with a different skill set. We should own our discharge process and follow-up plans. We should follow up with patients in a discharge clinic setting to review clinical course, health literacy issues, labs, and studies and even order follow-up studies based on incoming results.
Q: For group leaders, why is it important for you to continue seeing patients?
A: As a clinician leader, my charge is to foster teamwork and create a shared vision for improvement and change. This is not possible to do from an office space or conference room separate from where the work gets done.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust and rapport in five to 10 minutes. Caring for a hospitalized patient, when they are surrounded by loved ones, is stressful and anxiety-provoking. Delivering information in a way that is honest and empathetic and timely without the benefit of having a personal historic connection with a patient is always challenging.
Q: What aspect of patient care is most rewarding?
A: Making a diagnosis in a patient that has eluded diagnosis for weeks or months.
Q: What aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Today’s learners have different expectations from mine [in terms] of what they want to get from a career in medicine. While I don’t always agree with them, it is the reality and puts me in a position to discuss and understand the rationale of a changing mindset. As a physician leader, it is important to understand this because it helps me create an environment that fosters successful recruitment and retention.
Q: You mention wanting to tackle the issue of physician burnout? Why is that something important to you?
A: I personally lived through it and felt the effects it had on the relationships I had with family, friends, medical students, residents, and patients. I know what it felt like to be angry, cynical, and distanced from those I cared about and from those whom I was charged with caring for. I never forgot how isolated [you] can feel in an academic center even when surrounded by hundreds. I vowed that if I ever found my way to a leadership position, I would begin by creating an environment that emphasized morale, honesty, integrity, and professionalism. If I succeeded in this, the other organizational missions of education, patient care, quality, and value would follow.
Since 2012, our division has monitored burnout, work-life balance, and, more recently, physician engagement. Although we take care of the sickest children in the region, our group supports each other, recognizing and respectful of the fact that we each have different comfort levels, skill sets, but we also have fun. Patients, nurses, social workers, care coordinators, and clerks see this. Like I teach the residents, you never get a second chance to make a first impression, but you also never get a second chance to make a last one, so make all interactions count. TH
Richard Quinn is a freelance writer in New Jersey.
Young boys sometimes see a firefighter or a police officer in the line of duty and decide that’s what they want to be when they get older. Michael Beck, MD, FAAP, saw his pediatrician that way.
“He was a very humanistic provider and found joy in serving children and their families,” Dr. Beck says. “I saw how a pediatrician could influence others and make the world a better place and still have fun serving a vulnerable patient population.”
His career in pediatric hospital medicine, though?
“It was largely pure luck,” Dr. Beck admits. “When I was seeking my first job, I was offered a position that was 50/50 internal medicine and pediatrics but purely a hospitalist position.”
Dr. Beck has risen through academic hospitalist ranks the past 15 years and now serves as the division chief of pediatric hospital medicine at Penn State Children’s Hospital at Milton S. Hershey (Pa.) Medical Center. He is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What was medical school and residency like for you? Was there a single moment you knew “I can do this”?
Answer: I always have been filled with self-doubt, which is a perpetual motivator for me. I guess I believed I could do hospital-based work when I started knowing the majority of what was going on with patients after hearing residents discuss cases and I knew what the labs, studies, and exam findings were going to be before I saw the patient.
Q: What do you like most about working as a hospitalist?
A: The acuity and pathology of cases. I get to see cases that some people only read about. It is very intellectual challenging, and I get to work with and learn from specialists every day.
Q: What do you dislike most?
A: Some of the cases are devastating to families. It is always important to remind yourself—and the team—that some of the diagnoses we help make affect families and the patient in very profound ways.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: Dr. Barbara Ostrov. I learned what it really means to be a servant-leader. I witnessed her work ethic and saw that a leader of others should lead by example and be willing to work twice what is expected of others. She is always nonjudgmental and professional, yet forthright, when dealing with contentious situations. She trumpets the work of others, not her own, and sees others’ successes as her success. In the end, I believed she worked for me, not the other way around.
Q: Have you tried to mentor others? Why or why not?
A: Yes. As a division chief, I want others to succeed. The best quote I have read was by Richard Branson [CEO of Virgin]: “Train people so that they can leave, but treat them so they want to stay.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: It has moved from a clinical service to a robust area of research and strong researchers.
Q: What’s the biggest change you would like to see in HM?
A: If hospital medicine is positioning itself to be a specialty with fellowship training, with access to knowledge different from PCPs, then I believe we should function like other specialty services with a different skill set. We should own our discharge process and follow-up plans. We should follow up with patients in a discharge clinic setting to review clinical course, health literacy issues, labs, and studies and even order follow-up studies based on incoming results.
Q: For group leaders, why is it important for you to continue seeing patients?
A: As a clinician leader, my charge is to foster teamwork and create a shared vision for improvement and change. This is not possible to do from an office space or conference room separate from where the work gets done.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Establishing trust and rapport in five to 10 minutes. Caring for a hospitalized patient, when they are surrounded by loved ones, is stressful and anxiety-provoking. Delivering information in a way that is honest and empathetic and timely without the benefit of having a personal historic connection with a patient is always challenging.
Q: What aspect of patient care is most rewarding?
A: Making a diagnosis in a patient that has eluded diagnosis for weeks or months.
Q: What aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Today’s learners have different expectations from mine [in terms] of what they want to get from a career in medicine. While I don’t always agree with them, it is the reality and puts me in a position to discuss and understand the rationale of a changing mindset. As a physician leader, it is important to understand this because it helps me create an environment that fosters successful recruitment and retention.
Q: You mention wanting to tackle the issue of physician burnout? Why is that something important to you?
A: I personally lived through it and felt the effects it had on the relationships I had with family, friends, medical students, residents, and patients. I know what it felt like to be angry, cynical, and distanced from those I cared about and from those whom I was charged with caring for. I never forgot how isolated [you] can feel in an academic center even when surrounded by hundreds. I vowed that if I ever found my way to a leadership position, I would begin by creating an environment that emphasized morale, honesty, integrity, and professionalism. If I succeeded in this, the other organizational missions of education, patient care, quality, and value would follow.
Since 2012, our division has monitored burnout, work-life balance, and, more recently, physician engagement. Although we take care of the sickest children in the region, our group supports each other, recognizing and respectful of the fact that we each have different comfort levels, skill sets, but we also have fun. Patients, nurses, social workers, care coordinators, and clerks see this. Like I teach the residents, you never get a second chance to make a first impression, but you also never get a second chance to make a last one, so make all interactions count. TH
Richard Quinn is a freelance writer in New Jersey.
Sarah Stella, MD, Has a Heart for Safety-Net Hospital Medicine
The best advice Sarah Stella, MD, ever received was simple: “You can’t cure everyone, but you can help everyone.” Why has the adage stuck with her?
Because the advice came from her dad, “and he’s been right about a lot of things before,” she says with a smile.
Dr. Stella got into medicine—clearly with her father’s blessing—to satisfy her “intense curiosity about my fellow human beings and to try to ease suffering.” She has risen to be an academic hospitalist at Denver Health and is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training. What did you like most/dislike during the process?
Answer: I attended medical school at Michigan State College of Human Medicine. I appreciated their humanistic approach to medical education. I chose the University of Colorado for my internal medicine residency because I love the sunshine and the mountains and because I thought the large academic program would complement my community-based medical school training. I loved being able to easily access nature on my days off.
Q: What do you like most about working as a hospitalist?
A: Spending time with incredible patients and working to solve difficult problems alongside amazing colleagues. I also love the diversity of the work, being involved in direct patient care, teaching students and residents, being a part of committees, performing quality improvement research. I love the flexibility of the job, which allows me to spend time with my family and travel fairly frequently to far-flung places.
Q: Did you have a mentor during your training or early career?
A: My earliest mentor was my father, also a physician [an oncologist]. Some of my earliest medical memories are of going to the hospital with my dad, who also brought home petri dishes from the lab, which my brother and I then used to perform household science experiments. My dad taught me my first lessons about the scientific method and about the importance of a strong work ethic and mentorship. Since then, I have had many outstanding mentors and role models for various aspects of my training/career. During my time at Denver Health, Drs. Richard K. Albert and Marisha Burden have provided me with invaluable mentorship in my scholarly pursuits.
Q: Have you tried to mentor others? Why or why not?
A: I have really loved mentoring students and residents. It is among the most meaningful experiences of my career. Presently, I am a mentor for undergraduate students from underrepresented minority groups. The maturity, passion, and drive these students possess inspires me.
Q: Why is your mentoring focused on minorities? What is the appeal of that to you?
A: I mentor students and residents from all backgrounds. However, mentoring students from underrepresented minority groups is especially important to me. Ethnic minorities continue to have decreased access to healthcare and disproportionately high morbidity and mortality. In order to improve these disparities, we need to have more healthcare providers from these groups. Yet such students, while they may initially be attracted to a career in medicine, are much less likely to maintain their interest. The reasons for this are complicated but may be explained by differences in access to mentors to help guide and inspire them, write letters, etc.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Developing a rapport with patients. I try to use some techniques from social psychology to help me more easily. The hospital is a particularly depersonalizing place, so trying to see the person behind the patient does help.
Q: What aspect of patient care is most rewarding?
A: Really connecting with patients and seeing them thrive. Working at a safety-net hospital, I have the privilege of caring for some of the most underserved but some of the most gracious and beautiful people.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I do enjoy supervising medical students and residents at all levels and attend frequently on the medical wards. I particularly love teaching medical students because of their enthusiasm and curiosity. I love being reminded of basic pathophysiology by a thoughtfully asked question from a medical student. I am a big advocate of bedside rounding. Finding a way to do this efficiently and while teaching to all the levels on the team is challenging. Also, I still enjoy my own direct patient care activities and feel that they challenge me in a different way and make me a better teacher.
Q: Outside of patient care, tell us about your career interests.
A: My research has focused on understanding problems experienced by patients following hospital discharge and designing systems to help ameliorate them. On an institutional level, I serve on several committees, including the Utilization Review Committee, and a group aiming to improve collaboration between hospitalists and primary care physicians and improve discharge transitions. I have participated in several LEAN events aimed at understanding and improving various systems issues.
Q: When you aren’t working, what is important to you?
A: My family and friends, sunshine, and travel. My husband grew up in Papua, New Guinea, and Australia, and both of his parents are physicians, so he is very understanding and not the least bit grossed out when I regale him with stories involving bodily fluids. We have a beautiful, inquisitive 3-year-old daughter and her furry older sister, Ginger Wasabi Ninja. As the oldest of seven, I also love hanging out with my siblings.
Q: What SHM event has made the most lasting impression on you?
A: I really enjoyed HM16, particularly the keynote address by our U.S. Surgeon General and fellow hospitalist, Vivek Murthy, MD, who discussed the role hospitalists can play in public health. His message that we hospitalists should put as much of an effort into trying to improve health outside the walls of the hospital as we do within the walls really resonated with me and has encouraged me to get more involved in the community. TH
Richard Quinn is a freelance writer in New Jersey.
The best advice Sarah Stella, MD, ever received was simple: “You can’t cure everyone, but you can help everyone.” Why has the adage stuck with her?
Because the advice came from her dad, “and he’s been right about a lot of things before,” she says with a smile.
Dr. Stella got into medicine—clearly with her father’s blessing—to satisfy her “intense curiosity about my fellow human beings and to try to ease suffering.” She has risen to be an academic hospitalist at Denver Health and is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training. What did you like most/dislike during the process?
Answer: I attended medical school at Michigan State College of Human Medicine. I appreciated their humanistic approach to medical education. I chose the University of Colorado for my internal medicine residency because I love the sunshine and the mountains and because I thought the large academic program would complement my community-based medical school training. I loved being able to easily access nature on my days off.
Q: What do you like most about working as a hospitalist?
A: Spending time with incredible patients and working to solve difficult problems alongside amazing colleagues. I also love the diversity of the work, being involved in direct patient care, teaching students and residents, being a part of committees, performing quality improvement research. I love the flexibility of the job, which allows me to spend time with my family and travel fairly frequently to far-flung places.
Q: Did you have a mentor during your training or early career?
A: My earliest mentor was my father, also a physician [an oncologist]. Some of my earliest medical memories are of going to the hospital with my dad, who also brought home petri dishes from the lab, which my brother and I then used to perform household science experiments. My dad taught me my first lessons about the scientific method and about the importance of a strong work ethic and mentorship. Since then, I have had many outstanding mentors and role models for various aspects of my training/career. During my time at Denver Health, Drs. Richard K. Albert and Marisha Burden have provided me with invaluable mentorship in my scholarly pursuits.
Q: Have you tried to mentor others? Why or why not?
A: I have really loved mentoring students and residents. It is among the most meaningful experiences of my career. Presently, I am a mentor for undergraduate students from underrepresented minority groups. The maturity, passion, and drive these students possess inspires me.
Q: Why is your mentoring focused on minorities? What is the appeal of that to you?
A: I mentor students and residents from all backgrounds. However, mentoring students from underrepresented minority groups is especially important to me. Ethnic minorities continue to have decreased access to healthcare and disproportionately high morbidity and mortality. In order to improve these disparities, we need to have more healthcare providers from these groups. Yet such students, while they may initially be attracted to a career in medicine, are much less likely to maintain their interest. The reasons for this are complicated but may be explained by differences in access to mentors to help guide and inspire them, write letters, etc.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Developing a rapport with patients. I try to use some techniques from social psychology to help me more easily. The hospital is a particularly depersonalizing place, so trying to see the person behind the patient does help.
Q: What aspect of patient care is most rewarding?
A: Really connecting with patients and seeing them thrive. Working at a safety-net hospital, I have the privilege of caring for some of the most underserved but some of the most gracious and beautiful people.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I do enjoy supervising medical students and residents at all levels and attend frequently on the medical wards. I particularly love teaching medical students because of their enthusiasm and curiosity. I love being reminded of basic pathophysiology by a thoughtfully asked question from a medical student. I am a big advocate of bedside rounding. Finding a way to do this efficiently and while teaching to all the levels on the team is challenging. Also, I still enjoy my own direct patient care activities and feel that they challenge me in a different way and make me a better teacher.
Q: Outside of patient care, tell us about your career interests.
A: My research has focused on understanding problems experienced by patients following hospital discharge and designing systems to help ameliorate them. On an institutional level, I serve on several committees, including the Utilization Review Committee, and a group aiming to improve collaboration between hospitalists and primary care physicians and improve discharge transitions. I have participated in several LEAN events aimed at understanding and improving various systems issues.
Q: When you aren’t working, what is important to you?
A: My family and friends, sunshine, and travel. My husband grew up in Papua, New Guinea, and Australia, and both of his parents are physicians, so he is very understanding and not the least bit grossed out when I regale him with stories involving bodily fluids. We have a beautiful, inquisitive 3-year-old daughter and her furry older sister, Ginger Wasabi Ninja. As the oldest of seven, I also love hanging out with my siblings.
Q: What SHM event has made the most lasting impression on you?
A: I really enjoyed HM16, particularly the keynote address by our U.S. Surgeon General and fellow hospitalist, Vivek Murthy, MD, who discussed the role hospitalists can play in public health. His message that we hospitalists should put as much of an effort into trying to improve health outside the walls of the hospital as we do within the walls really resonated with me and has encouraged me to get more involved in the community. TH
Richard Quinn is a freelance writer in New Jersey.
The best advice Sarah Stella, MD, ever received was simple: “You can’t cure everyone, but you can help everyone.” Why has the adage stuck with her?
Because the advice came from her dad, “and he’s been right about a lot of things before,” she says with a smile.
Dr. Stella got into medicine—clearly with her father’s blessing—to satisfy her “intense curiosity about my fellow human beings and to try to ease suffering.” She has risen to be an academic hospitalist at Denver Health and is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training. What did you like most/dislike during the process?
Answer: I attended medical school at Michigan State College of Human Medicine. I appreciated their humanistic approach to medical education. I chose the University of Colorado for my internal medicine residency because I love the sunshine and the mountains and because I thought the large academic program would complement my community-based medical school training. I loved being able to easily access nature on my days off.
Q: What do you like most about working as a hospitalist?
A: Spending time with incredible patients and working to solve difficult problems alongside amazing colleagues. I also love the diversity of the work, being involved in direct patient care, teaching students and residents, being a part of committees, performing quality improvement research. I love the flexibility of the job, which allows me to spend time with my family and travel fairly frequently to far-flung places.
Q: Did you have a mentor during your training or early career?
A: My earliest mentor was my father, also a physician [an oncologist]. Some of my earliest medical memories are of going to the hospital with my dad, who also brought home petri dishes from the lab, which my brother and I then used to perform household science experiments. My dad taught me my first lessons about the scientific method and about the importance of a strong work ethic and mentorship. Since then, I have had many outstanding mentors and role models for various aspects of my training/career. During my time at Denver Health, Drs. Richard K. Albert and Marisha Burden have provided me with invaluable mentorship in my scholarly pursuits.
Q: Have you tried to mentor others? Why or why not?
A: I have really loved mentoring students and residents. It is among the most meaningful experiences of my career. Presently, I am a mentor for undergraduate students from underrepresented minority groups. The maturity, passion, and drive these students possess inspires me.
Q: Why is your mentoring focused on minorities? What is the appeal of that to you?
A: I mentor students and residents from all backgrounds. However, mentoring students from underrepresented minority groups is especially important to me. Ethnic minorities continue to have decreased access to healthcare and disproportionately high morbidity and mortality. In order to improve these disparities, we need to have more healthcare providers from these groups. Yet such students, while they may initially be attracted to a career in medicine, are much less likely to maintain their interest. The reasons for this are complicated but may be explained by differences in access to mentors to help guide and inspire them, write letters, etc.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: Developing a rapport with patients. I try to use some techniques from social psychology to help me more easily. The hospital is a particularly depersonalizing place, so trying to see the person behind the patient does help.
Q: What aspect of patient care is most rewarding?
A: Really connecting with patients and seeing them thrive. Working at a safety-net hospital, I have the privilege of caring for some of the most underserved but some of the most gracious and beautiful people.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: I do enjoy supervising medical students and residents at all levels and attend frequently on the medical wards. I particularly love teaching medical students because of their enthusiasm and curiosity. I love being reminded of basic pathophysiology by a thoughtfully asked question from a medical student. I am a big advocate of bedside rounding. Finding a way to do this efficiently and while teaching to all the levels on the team is challenging. Also, I still enjoy my own direct patient care activities and feel that they challenge me in a different way and make me a better teacher.
Q: Outside of patient care, tell us about your career interests.
A: My research has focused on understanding problems experienced by patients following hospital discharge and designing systems to help ameliorate them. On an institutional level, I serve on several committees, including the Utilization Review Committee, and a group aiming to improve collaboration between hospitalists and primary care physicians and improve discharge transitions. I have participated in several LEAN events aimed at understanding and improving various systems issues.
Q: When you aren’t working, what is important to you?
A: My family and friends, sunshine, and travel. My husband grew up in Papua, New Guinea, and Australia, and both of his parents are physicians, so he is very understanding and not the least bit grossed out when I regale him with stories involving bodily fluids. We have a beautiful, inquisitive 3-year-old daughter and her furry older sister, Ginger Wasabi Ninja. As the oldest of seven, I also love hanging out with my siblings.
Q: What SHM event has made the most lasting impression on you?
A: I really enjoyed HM16, particularly the keynote address by our U.S. Surgeon General and fellow hospitalist, Vivek Murthy, MD, who discussed the role hospitalists can play in public health. His message that we hospitalists should put as much of an effort into trying to improve health outside the walls of the hospital as we do within the walls really resonated with me and has encouraged me to get more involved in the community. TH
Richard Quinn is a freelance writer in New Jersey.
Hospitalist Jill Slater Waldman, MD, SFHM, Watched the Field Grow Up But Thinks Peers Deserve More Credit
Jill Slater Waldman, MD, SFHM, loved math and science and working with people, so a career in medicine was always the logical choice. She just didn’t want to leave a hospital, literally. So when she was finishing her internal medicine residency in 1994 at Westchester Medical Center in Valhalla, N.Y., internal medicine (IM) suddenly appealed.
“I started seeking any job that would be ‘all in house,’ with no outpatient or clinic time,” Dr. Waldman says. “I was informed those jobs did not exist, so I joined the faculty of Albert Einstein College of Medicine with a dual appointment in emergency and internal medicine.”
Fast-forward through a few IM positions at New York State hospitals, and she landed the directorship of the adult hospitalist program at Nyack (N.Y.) Hospital. Two years later, she left for her current post, director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y.
A crowded résumé got an extra line this year as Dr. Waldman is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training years.
Answer: I initially matched in anesthesia but within two weeks realized the pre-ops and post-ops were my favorite visits. I went back to complete my IM residency, doing multiple extra months of ICU night float to avoid having to go to continuity of care clinic.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: My mentor was undoubtedly my internship coordinator, who allowed me back to complete my IM training when I realized anesthesia was not for me. He is a special man, incredibly brilliant, and committed to the art and science of medicine. He taught his staff to always act like a physician, always have respect for yourself and the patients, and to take no shortcuts. He is the brightest physician I likely have ever met, and I am lucky to have been hired by him to run his hospital medicine program as a senior attending.
Q: Have you tried to mentor others?
A: I enjoy mentoring junior faculty, house staff, and students. I just returned from a medical mission during which I supervised three fantastic medical students—one of whom was my own daughter.
Q: What do you like most about working as a hospitalist?
A: The variety of patients we get to interact with and the variety of pathology we see.
Q: What do you dislike most?
A: Raw beets and egotistical consultants who treat hospitalists like house staff.
Q: How many Apple products do you interface with in a given week?
A: Two.
Q: What impact do you feel those devices and ones similar to them have had on HM and medicine in a broader sense?
A: I believe they have enabled channels of communication and allowed the public to become more knowledgeable medically.
Q: What’s the best advice you ever received?
A: Do unto others as you wish others to do unto you.
Q: What’s the worst advice you ever received?
A: “There’s no way you can be both a mother and a doctor. Pick one.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: The evolution of HM as a true specialty, requiring a skill set of its own to be a hospitalist.
Q: What’s the biggest change you would like to see in HM?
A: More respect for the field and understanding of our skill set and knowledge base.
Q: As a group leader, why is it important for you to continue seeing patients?
A: As a director, I believe keeping my skill set current is important for myself as well as my partners. I have always said I would never ask them to do something I would not do, so I get to practice what I preach. I also think it enables me to keep perspective when discussing plans with administration or reviewing complaints.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: You are meeting a person on what is likely the worst day of their life. Trying to find the best approach for each individual is still a challenge.
Q: What aspect of patient care is most rewarding?
A: Seeing the relief on a patient’s face when you tell them they will get better and explain their treatment plan.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Teaching in the 21st century is challenging with all the new regulations. We have a family physician residency at our hospital, and the blind dedication we had as residents is just not present in a group of physicians who have grown up with duty hour restrictions and protected time.
Q: What is your biggest professional reward?
A: Our group has virtually no attrition and has been intact for more than five years.
Q: You received your SFHM designation five years ago. What does that public recognition mean to you?
A: It was a mark of respect and recognition for expertise in this new field. A very proud moment.
Q: Where do you see yourself in 10 years?
A: Hopefully, working as a part-time nocturnist two nights per week and caring for some grandbabies and going on medical missions. TH
Richard Quinn is a freelance writer in New Jersey.
Jill Slater Waldman, MD, SFHM, loved math and science and working with people, so a career in medicine was always the logical choice. She just didn’t want to leave a hospital, literally. So when she was finishing her internal medicine residency in 1994 at Westchester Medical Center in Valhalla, N.Y., internal medicine (IM) suddenly appealed.
“I started seeking any job that would be ‘all in house,’ with no outpatient or clinic time,” Dr. Waldman says. “I was informed those jobs did not exist, so I joined the faculty of Albert Einstein College of Medicine with a dual appointment in emergency and internal medicine.”
Fast-forward through a few IM positions at New York State hospitals, and she landed the directorship of the adult hospitalist program at Nyack (N.Y.) Hospital. Two years later, she left for her current post, director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y.
A crowded résumé got an extra line this year as Dr. Waldman is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training years.
Answer: I initially matched in anesthesia but within two weeks realized the pre-ops and post-ops were my favorite visits. I went back to complete my IM residency, doing multiple extra months of ICU night float to avoid having to go to continuity of care clinic.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: My mentor was undoubtedly my internship coordinator, who allowed me back to complete my IM training when I realized anesthesia was not for me. He is a special man, incredibly brilliant, and committed to the art and science of medicine. He taught his staff to always act like a physician, always have respect for yourself and the patients, and to take no shortcuts. He is the brightest physician I likely have ever met, and I am lucky to have been hired by him to run his hospital medicine program as a senior attending.
Q: Have you tried to mentor others?
A: I enjoy mentoring junior faculty, house staff, and students. I just returned from a medical mission during which I supervised three fantastic medical students—one of whom was my own daughter.
Q: What do you like most about working as a hospitalist?
A: The variety of patients we get to interact with and the variety of pathology we see.
Q: What do you dislike most?
A: Raw beets and egotistical consultants who treat hospitalists like house staff.
Q: How many Apple products do you interface with in a given week?
A: Two.
Q: What impact do you feel those devices and ones similar to them have had on HM and medicine in a broader sense?
A: I believe they have enabled channels of communication and allowed the public to become more knowledgeable medically.
Q: What’s the best advice you ever received?
A: Do unto others as you wish others to do unto you.
Q: What’s the worst advice you ever received?
A: “There’s no way you can be both a mother and a doctor. Pick one.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: The evolution of HM as a true specialty, requiring a skill set of its own to be a hospitalist.
Q: What’s the biggest change you would like to see in HM?
A: More respect for the field and understanding of our skill set and knowledge base.
Q: As a group leader, why is it important for you to continue seeing patients?
A: As a director, I believe keeping my skill set current is important for myself as well as my partners. I have always said I would never ask them to do something I would not do, so I get to practice what I preach. I also think it enables me to keep perspective when discussing plans with administration or reviewing complaints.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: You are meeting a person on what is likely the worst day of their life. Trying to find the best approach for each individual is still a challenge.
Q: What aspect of patient care is most rewarding?
A: Seeing the relief on a patient’s face when you tell them they will get better and explain their treatment plan.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Teaching in the 21st century is challenging with all the new regulations. We have a family physician residency at our hospital, and the blind dedication we had as residents is just not present in a group of physicians who have grown up with duty hour restrictions and protected time.
Q: What is your biggest professional reward?
A: Our group has virtually no attrition and has been intact for more than five years.
Q: You received your SFHM designation five years ago. What does that public recognition mean to you?
A: It was a mark of respect and recognition for expertise in this new field. A very proud moment.
Q: Where do you see yourself in 10 years?
A: Hopefully, working as a part-time nocturnist two nights per week and caring for some grandbabies and going on medical missions. TH
Richard Quinn is a freelance writer in New Jersey.
Jill Slater Waldman, MD, SFHM, loved math and science and working with people, so a career in medicine was always the logical choice. She just didn’t want to leave a hospital, literally. So when she was finishing her internal medicine residency in 1994 at Westchester Medical Center in Valhalla, N.Y., internal medicine (IM) suddenly appealed.
“I started seeking any job that would be ‘all in house,’ with no outpatient or clinic time,” Dr. Waldman says. “I was informed those jobs did not exist, so I joined the faculty of Albert Einstein College of Medicine with a dual appointment in emergency and internal medicine.”
Fast-forward through a few IM positions at New York State hospitals, and she landed the directorship of the adult hospitalist program at Nyack (N.Y.) Hospital. Two years later, she left for her current post, director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y.
A crowded résumé got an extra line this year as Dr. Waldman is one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Tell us about your training years.
Answer: I initially matched in anesthesia but within two weeks realized the pre-ops and post-ops were my favorite visits. I went back to complete my IM residency, doing multiple extra months of ICU night float to avoid having to go to continuity of care clinic.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were the most important lessons you learned from him/her?
A: My mentor was undoubtedly my internship coordinator, who allowed me back to complete my IM training when I realized anesthesia was not for me. He is a special man, incredibly brilliant, and committed to the art and science of medicine. He taught his staff to always act like a physician, always have respect for yourself and the patients, and to take no shortcuts. He is the brightest physician I likely have ever met, and I am lucky to have been hired by him to run his hospital medicine program as a senior attending.
Q: Have you tried to mentor others?
A: I enjoy mentoring junior faculty, house staff, and students. I just returned from a medical mission during which I supervised three fantastic medical students—one of whom was my own daughter.
Q: What do you like most about working as a hospitalist?
A: The variety of patients we get to interact with and the variety of pathology we see.
Q: What do you dislike most?
A: Raw beets and egotistical consultants who treat hospitalists like house staff.
Q: How many Apple products do you interface with in a given week?
A: Two.
Q: What impact do you feel those devices and ones similar to them have had on HM and medicine in a broader sense?
A: I believe they have enabled channels of communication and allowed the public to become more knowledgeable medically.
Q: What’s the best advice you ever received?
A: Do unto others as you wish others to do unto you.
Q: What’s the worst advice you ever received?
A: “There’s no way you can be both a mother and a doctor. Pick one.”
Q: What’s the biggest change you’ve seen in HM in your career?
A: The evolution of HM as a true specialty, requiring a skill set of its own to be a hospitalist.
Q: What’s the biggest change you would like to see in HM?
A: More respect for the field and understanding of our skill set and knowledge base.
Q: As a group leader, why is it important for you to continue seeing patients?
A: As a director, I believe keeping my skill set current is important for myself as well as my partners. I have always said I would never ask them to do something I would not do, so I get to practice what I preach. I also think it enables me to keep perspective when discussing plans with administration or reviewing complaints.
Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?
A: You are meeting a person on what is likely the worst day of their life. Trying to find the best approach for each individual is still a challenge.
Q: What aspect of patient care is most rewarding?
A: Seeing the relief on a patient’s face when you tell them they will get better and explain their treatment plan.
Q: Are you on teaching service? If so, what aspect of teaching in the 21st century is most difficult? And what is most enjoyable?
A: Teaching in the 21st century is challenging with all the new regulations. We have a family physician residency at our hospital, and the blind dedication we had as residents is just not present in a group of physicians who have grown up with duty hour restrictions and protected time.
Q: What is your biggest professional reward?
A: Our group has virtually no attrition and has been intact for more than five years.
Q: You received your SFHM designation five years ago. What does that public recognition mean to you?
A: It was a mark of respect and recognition for expertise in this new field. A very proud moment.
Q: Where do you see yourself in 10 years?
A: Hopefully, working as a part-time nocturnist two nights per week and caring for some grandbabies and going on medical missions. TH
Richard Quinn is a freelance writer in New Jersey.
Stella Fitzgibbons, MD, FHM, Relishes the Variety, Interactions of Hospitalist Practice
Stella Fitzgibbons, MD, FHM, was an engineer for several years after college. But there wasn’t enough working with people for her taste. So she moved into internal medicine. But then there was, how to put this, something lacking in office work.
“I realized how bored I was with office practice and how much more interesting were the problems at the hospital than outpatient ones,” Dr. Fitzgibbons says.
So she went to work in hospitals. She hasn’t left.
Dr. Fitzgibbons is a hospitalist and ED practitioner with Mint Physician Staffing, primarily in the Apollo Hospital System in The Woodlands, Texas. And the best part of the job for Dr. Fitzgibbons, one of eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist newsmagazine, is easy to pick.
“Seeing sick people get better,” she says.
Question: Switching careers from engineering to medicine is a big step. What motivated that?
Answer: I wanted to see my efforts helping people I could actually see, and I thought—and still do—that medicine uses my talents better and is far more interesting.
Q: You say office practice became a bit boring. How so? What appealed about the inpatient setting?
A: An internist in the office only sees a tiny fraction of the interesting problems that our field covers. Rheumatoid arthritis is diagnosed by a rheumatologist, who then makes all the decisions. Abdominal pain gets sent to the hospital, where all the diagnostic tests are done.
Fortunately, my multispecialty group arranged for about a quarter of its internists [the youngest quarter in most cases] to manage hospital patients; I figured out pretty quickly that it was only there that I got to see pulmonary hypertension, congestive heart failure, and acute abdomens. Even night call was better at the hospital since office doctors only answered phone calls and never had a chance to do any real evaluation and treatment no matter how sick the caller was.
And a problem at the office was something that made me run behind that odious and impractical appointment schedule; at the hospital I was seeing real illnesses, not people who wanted a prescription med for their sore throat so they wouldn’t be bothered with it on their vacation.
Q: What is your biggest professional challenge?
A: EHRs.
Q: What is your biggest professional reward?
A: When a patient says, “Thanks for taking care of me, doctor.”
Q: What does teaching mean to you, and how has it been gratifying in your career?
A: Teaching means paying it forward, in gratitude to those who taught me, with the reward of seeing light bulbs go off behind the eyes of students and younger doctors who are eager to learn.
Q: When you aren’t working, what is important to you?
A: Family and music and church.
Q: Faith is obviously important to you. How does that help your work as a care provider?
A: I don’t think anybody goes around being religious all the time. But it sometimes makes all the difference knowing that a higher power is looking out for me and the patients.
Q: You’ve described mentoring as fun for you. What exactly do you mean by fun?
A: Mentoring is what we do. Patients, nurses—anybody we work with—need explanations and clarifications. About the third day of med school, docs in training realize that anybody who can help us understand and retain the huge stream of information directed at us is performing a necessary service. Throughout the training period, residents teach students, fellows teach residents, and attending faculty teach everybody. Doctors in training are bright people who want to learn both the facts and how to deal with patients’ side of things, and feeding their desires is very enjoyable.
Q: You’d like to see more physicians than MBAs in decision-making positions. Why? What real changes do you think that would effectuate?
A: Physicians and nurses were administrators for decades before insurance company penny-pinching and government regulations led hospitals to hire “bean counters” to replace them. It is a tremendous change for the worse, to have people making decisions for patients whose primary consideration is the bottom line.
Q: What’s next professionally?
A: Small-volume ERs, where I don’t have to do discharge planning while being harassed by insurance company reps.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: If you weren’t a doctor, what would you be doing right now?
A: Law enforcement.
Q: Devices like iPhones and tablets can take away from patient face time. But they can also be valuable. How do you balance that? How do you encourage younger docs to do so, particularly when they’re much more used to having smartphones glued to their hands?
A: I use my iPhone when I’m with patients … but only when they can see the reason I need it to help them, such as looking up the side effects of a medication. Electronic health records can work on an iPad, but I hesitate to use them unless the patient knows just what I am doing, such as looking up results of a lab test that concerns them. Taking a computer on wheels into a patient’s room means that I spend part of the visit looking at a screen instead of at the patient, and I prefer to avoid it if at all possible.
Q: What’s the best book you’ve read recently? Why?
A: The House of Silk by Anthony Horowitz. Great continuation of the Holmes stories, with a seamless link to [Sir Arthur] Conan Doyle’s style.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: Three.
Q: What’s your favorite social network? Do you use it all for work or professional development?
A: Facebook. Heck no, it’s just fun.
Q: What’s next in your Netflix queue?
A: Last two episodes of Game of Thrones season 5.
Richard Quinn is a freelance writer in New Jersey.
Stella Fitzgibbons, MD, FHM, was an engineer for several years after college. But there wasn’t enough working with people for her taste. So she moved into internal medicine. But then there was, how to put this, something lacking in office work.
“I realized how bored I was with office practice and how much more interesting were the problems at the hospital than outpatient ones,” Dr. Fitzgibbons says.
So she went to work in hospitals. She hasn’t left.
Dr. Fitzgibbons is a hospitalist and ED practitioner with Mint Physician Staffing, primarily in the Apollo Hospital System in The Woodlands, Texas. And the best part of the job for Dr. Fitzgibbons, one of eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist newsmagazine, is easy to pick.
“Seeing sick people get better,” she says.
Question: Switching careers from engineering to medicine is a big step. What motivated that?
Answer: I wanted to see my efforts helping people I could actually see, and I thought—and still do—that medicine uses my talents better and is far more interesting.
Q: You say office practice became a bit boring. How so? What appealed about the inpatient setting?
A: An internist in the office only sees a tiny fraction of the interesting problems that our field covers. Rheumatoid arthritis is diagnosed by a rheumatologist, who then makes all the decisions. Abdominal pain gets sent to the hospital, where all the diagnostic tests are done.
Fortunately, my multispecialty group arranged for about a quarter of its internists [the youngest quarter in most cases] to manage hospital patients; I figured out pretty quickly that it was only there that I got to see pulmonary hypertension, congestive heart failure, and acute abdomens. Even night call was better at the hospital since office doctors only answered phone calls and never had a chance to do any real evaluation and treatment no matter how sick the caller was.
And a problem at the office was something that made me run behind that odious and impractical appointment schedule; at the hospital I was seeing real illnesses, not people who wanted a prescription med for their sore throat so they wouldn’t be bothered with it on their vacation.
Q: What is your biggest professional challenge?
A: EHRs.
Q: What is your biggest professional reward?
A: When a patient says, “Thanks for taking care of me, doctor.”
Q: What does teaching mean to you, and how has it been gratifying in your career?
A: Teaching means paying it forward, in gratitude to those who taught me, with the reward of seeing light bulbs go off behind the eyes of students and younger doctors who are eager to learn.
Q: When you aren’t working, what is important to you?
A: Family and music and church.
Q: Faith is obviously important to you. How does that help your work as a care provider?
A: I don’t think anybody goes around being religious all the time. But it sometimes makes all the difference knowing that a higher power is looking out for me and the patients.
Q: You’ve described mentoring as fun for you. What exactly do you mean by fun?
A: Mentoring is what we do. Patients, nurses—anybody we work with—need explanations and clarifications. About the third day of med school, docs in training realize that anybody who can help us understand and retain the huge stream of information directed at us is performing a necessary service. Throughout the training period, residents teach students, fellows teach residents, and attending faculty teach everybody. Doctors in training are bright people who want to learn both the facts and how to deal with patients’ side of things, and feeding their desires is very enjoyable.
Q: You’d like to see more physicians than MBAs in decision-making positions. Why? What real changes do you think that would effectuate?
A: Physicians and nurses were administrators for decades before insurance company penny-pinching and government regulations led hospitals to hire “bean counters” to replace them. It is a tremendous change for the worse, to have people making decisions for patients whose primary consideration is the bottom line.
Q: What’s next professionally?
A: Small-volume ERs, where I don’t have to do discharge planning while being harassed by insurance company reps.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: If you weren’t a doctor, what would you be doing right now?
A: Law enforcement.
Q: Devices like iPhones and tablets can take away from patient face time. But they can also be valuable. How do you balance that? How do you encourage younger docs to do so, particularly when they’re much more used to having smartphones glued to their hands?
A: I use my iPhone when I’m with patients … but only when they can see the reason I need it to help them, such as looking up the side effects of a medication. Electronic health records can work on an iPad, but I hesitate to use them unless the patient knows just what I am doing, such as looking up results of a lab test that concerns them. Taking a computer on wheels into a patient’s room means that I spend part of the visit looking at a screen instead of at the patient, and I prefer to avoid it if at all possible.
Q: What’s the best book you’ve read recently? Why?
A: The House of Silk by Anthony Horowitz. Great continuation of the Holmes stories, with a seamless link to [Sir Arthur] Conan Doyle’s style.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: Three.
Q: What’s your favorite social network? Do you use it all for work or professional development?
A: Facebook. Heck no, it’s just fun.
Q: What’s next in your Netflix queue?
A: Last two episodes of Game of Thrones season 5.
Richard Quinn is a freelance writer in New Jersey.
Stella Fitzgibbons, MD, FHM, was an engineer for several years after college. But there wasn’t enough working with people for her taste. So she moved into internal medicine. But then there was, how to put this, something lacking in office work.
“I realized how bored I was with office practice and how much more interesting were the problems at the hospital than outpatient ones,” Dr. Fitzgibbons says.
So she went to work in hospitals. She hasn’t left.
Dr. Fitzgibbons is a hospitalist and ED practitioner with Mint Physician Staffing, primarily in the Apollo Hospital System in The Woodlands, Texas. And the best part of the job for Dr. Fitzgibbons, one of eight new members of Team Hospitalist, the volunteer editorial advisory board of The Hospitalist newsmagazine, is easy to pick.
“Seeing sick people get better,” she says.
Question: Switching careers from engineering to medicine is a big step. What motivated that?
Answer: I wanted to see my efforts helping people I could actually see, and I thought—and still do—that medicine uses my talents better and is far more interesting.
Q: You say office practice became a bit boring. How so? What appealed about the inpatient setting?
A: An internist in the office only sees a tiny fraction of the interesting problems that our field covers. Rheumatoid arthritis is diagnosed by a rheumatologist, who then makes all the decisions. Abdominal pain gets sent to the hospital, where all the diagnostic tests are done.
Fortunately, my multispecialty group arranged for about a quarter of its internists [the youngest quarter in most cases] to manage hospital patients; I figured out pretty quickly that it was only there that I got to see pulmonary hypertension, congestive heart failure, and acute abdomens. Even night call was better at the hospital since office doctors only answered phone calls and never had a chance to do any real evaluation and treatment no matter how sick the caller was.
And a problem at the office was something that made me run behind that odious and impractical appointment schedule; at the hospital I was seeing real illnesses, not people who wanted a prescription med for their sore throat so they wouldn’t be bothered with it on their vacation.
Q: What is your biggest professional challenge?
A: EHRs.
Q: What is your biggest professional reward?
A: When a patient says, “Thanks for taking care of me, doctor.”
Q: What does teaching mean to you, and how has it been gratifying in your career?
A: Teaching means paying it forward, in gratitude to those who taught me, with the reward of seeing light bulbs go off behind the eyes of students and younger doctors who are eager to learn.
Q: When you aren’t working, what is important to you?
A: Family and music and church.
Q: Faith is obviously important to you. How does that help your work as a care provider?
A: I don’t think anybody goes around being religious all the time. But it sometimes makes all the difference knowing that a higher power is looking out for me and the patients.
Q: You’ve described mentoring as fun for you. What exactly do you mean by fun?
A: Mentoring is what we do. Patients, nurses—anybody we work with—need explanations and clarifications. About the third day of med school, docs in training realize that anybody who can help us understand and retain the huge stream of information directed at us is performing a necessary service. Throughout the training period, residents teach students, fellows teach residents, and attending faculty teach everybody. Doctors in training are bright people who want to learn both the facts and how to deal with patients’ side of things, and feeding their desires is very enjoyable.
Q: You’d like to see more physicians than MBAs in decision-making positions. Why? What real changes do you think that would effectuate?
A: Physicians and nurses were administrators for decades before insurance company penny-pinching and government regulations led hospitals to hire “bean counters” to replace them. It is a tremendous change for the worse, to have people making decisions for patients whose primary consideration is the bottom line.
Q: What’s next professionally?
A: Small-volume ERs, where I don’t have to do discharge planning while being harassed by insurance company reps.
Q: Where do you see yourself in 10 years?
A: Retired.
Q: If you weren’t a doctor, what would you be doing right now?
A: Law enforcement.
Q: Devices like iPhones and tablets can take away from patient face time. But they can also be valuable. How do you balance that? How do you encourage younger docs to do so, particularly when they’re much more used to having smartphones glued to their hands?
A: I use my iPhone when I’m with patients … but only when they can see the reason I need it to help them, such as looking up the side effects of a medication. Electronic health records can work on an iPad, but I hesitate to use them unless the patient knows just what I am doing, such as looking up results of a lab test that concerns them. Taking a computer on wheels into a patient’s room means that I spend part of the visit looking at a screen instead of at the patient, and I prefer to avoid it if at all possible.
Q: What’s the best book you’ve read recently? Why?
A: The House of Silk by Anthony Horowitz. Great continuation of the Holmes stories, with a seamless link to [Sir Arthur] Conan Doyle’s style.
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: Three.
Q: What’s your favorite social network? Do you use it all for work or professional development?
A: Facebook. Heck no, it’s just fun.
Q: What’s next in your Netflix queue?
A: Last two episodes of Game of Thrones season 5.
Richard Quinn is a freelance writer in New Jersey.
Is Email an Endangered Species?
And yet despite the seemingly definitive place email communication holds for hospitalists—for messages to one another, missives to hospital administrators, instructions to patients, and myriad other uses—there are those who often wonder if email is outmoded. In a world bent on text messaging, Facebook, Twitter, Skype, Vine, Periscope, and Google Talk (not to mention dozens of lesser-known services and a seemingly endless string of startups aiming to be the proverbial next big thing), is email old-fashioned or ineffective?
In a word, no.
But that doesn’t mean email is the only communication method in a hospitalist’s toolbox or the best one for every situation. Physicians and communication experts interviewed by The Hospitalist agree that email has a function and isn’t going anywhere anytime soon. However, that function is dependent on trust, urgency, formality, and relationships.
“It has a place in communication, especially for busy hospitals, but the key is to figure out what is that place,” says Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, who has spoken at SHM annual meetings on how hospitalists communicate. “All of the information that is coming to you is in a push-pull model … There is information that you want pushed to you because it’s important and you want to see it. And then there is information that you want to pull because perhaps you know it relates to a patient in front of you … Where does email fit into it?”
Communications consultant A.J. Moore, associate professor of communication at Rider University in Lawrenceville, N.J., put it even more bluntly when assuring that email isn’t going anywhere.
“Research shows, and I know I do it myself, the first thing I do in the morning when I pick up my phone is check my email,” he says. “People often check their email before they check the weather, before they check social media.
“Sure, there are other places to go, there’s other ways of communicating. But I still think that email is the center point. It’s the starting line for your communication.”
A Modus for the Medium
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, appreciates the academic discussion over the future of email, but he also knows he uses it every day. To him, there are several factors that go into choosing which medium he uses for a particular message.
“It depends on the situation and the message you are sending,” says Dr. Jacobs, associate professor in the Department of Pediatrics at the University of New Mexico School of Medicine. “If I’m friends with the pediatric nephrologist, I may text him a quick question about a [glomerular filtration rate] or a clinical question. But if I’m not on those terms with another subspecialist, I wouldn’t do that.
“There’s definitely a relationship aspect that is relevant.”
Another factor in choosing to send an email versus a text message versus a tweet is timing. In the days when email was the only alternative to in-person communication or a phone call, the electronic message was the fastest way to reach a person. It was the best way to hold a synchronous conversation. But in today’s era of smartphones, tablets, and even wristwatches that have instant access, email is no longer the fastest option. In fact, email today is best tailored to asynchronous conversations, Dr. Arora says.
“Texting is really more invasive. It’s more demanding of the recipient’s time in an immediate sort of way,” Dr. Jacobs says. “With email, you’re basically saying, ‘Please take a look at this at your convenience, and when you can, write me back.’ In contrast, when people send text messages, they’re typically expecting a response in minutes. This may seem logical and trivial, but it can also be disruptive. Since some texts are urgent, all texts must at least initially be treated as such.”
The urgency that comes with a text message or a direct message on Facebook or Twitter is the flip side of the formality that comes with an email, says Moore.
“Email has more of a professional connotation to it than a Facebook message,” Moore says. “Even if I work with somebody, even if I’m Facebook friends with somebody and that person is one door away from me, if it is a work conversation, I am going to send them an email.”
Formality is the delineation between social media and what Moore half-jokingly calls “professional media.” And while in some ways technology gaps can often be a generational difference, Moore doesn’t see email usage through that prism and certainly not when he’s interacting with the young adults in his classes.
“I look at myself as a professor, and I have that formal relationship with younger people being students. They could find me on social media. There’s nothing preventing them,” he says. “But still they reach out to me via email, and I communicate with them via email.”
That being said, a generational gap does exist that can cause older physicians to refrain from embracing newer technologies that could be effective alternatives to email, says Howard Landa, chief medical information officer of the Alameda Health System in Oakland, Calif., and vice chairman of the board of advisors for the Association of Medical Directors of Information Systems. Many communication tools (Shortmail, Fridge, Apple Mail) either were discontinued, wrapped into larger technologies, or never became mainstream enough to be worthwhile. So the idea that some technologies won’t catch on discourages some from using anything but email.
“The younger we are, the easier the changes are and the more receptive we are to change,” Landa says. “We have seen a lot of flash-in-the-pan technology, snake oil, new ideas that go crazy for [a while]. They get to the top in the hype cycle, they drop to the bottom of the pit in the depression, and then they never move.
“With the older physicians, I think there is a reluctance to try something just because it’s new, whereas with the younger docs, there is every week a new technology that I want to try because I am willing to go through 20 of them before I find one that works. They have more energy and are more open to it.”
Security Is Job One
The safety of email is a major reason that many continually question its fate. In a broad sense, that is the natural question when a technology is new, says Ben Compaine, director of the fellows program at the Columbia University Institute for Tele-Information and a lecturer in the D’Amore-McKim School of Business at Northeastern University in Boston.
“There are always people who will find something to fear,” Compaine says. “Like when ATMs came along, there was stuff being written about safety concerns: ‘People will go to an ATM, and someone just holds them up and gets their money.’ It’s happened, but given the hundreds of millions of transactions that go on, you don’t throw out the baby with the bathwater.”
Dr. Arora cautions that the difference for hospitalists is that when a safety mistake is made with email, it can constitute a violation of the Health Insurance Portability and Accountability Act (HIPAA). And while those mistakes can happen innocently enough on social media or via text messaging, she says email issues are the most common.
“I’ve seen HIPAA violations where a patient would send an email to a doctor and the doctor would reply all to all of the [hospitalists] in their group saying, ‘Can anyone help me answer this question?’” she says. “So the forward email and forward and reply all are the most dangerous features because you have to know what you are forwarding and would that person want it shared with everybody.”
Landa believes that part of the problem with the efficacy of email is that it’s become so fast and so easy that people don’t take their time thinking about the impact of each email. Dr. Arora agrees and suggests hospitalists think carefully about what is in an email, particularly when it involves patient information.
“Share the minimum necessary information with a minimum number of people to try to accomplish what you are trying to do,” she adds. “That way, you are not clogging the inbox of everybody involved.”
Another potential pitfall to the efficacy of email is the “lost in translation” phenomenon, Landa says.
“How many times have you written am email and someone misinterpreted sarcasm or a joke or a particular word or a phrase and got upset because of what they thought you were saying?” he says. “I think that when you talk about the synchronous and rapid-fire style of the forms of communication, I think you elevate the risk by an order of magnitude. That’s the reason we have developed all the emoticons and all the visual references that are out there—to make sure that people don’t misinterpret what we’re saying.”
What’s Old Is New
So if hospitalists and communications experts believe email retains a place in the way information is conveyed, why is the question of its impending death a continuing parlor game for some?
“Because there’s always something new,” Moore says. “Because Messenger on Facebook looks a little bit flashier than email. Because now we have Periscope. Now we have Twitter. Now we have different types of platforms that message within each other. They all look flashier.”
But, in essence, each is simply a somewhat more modernized version, more bells and whistles, Moore says. He likes to compare it to the U.S. Postal Service. As technology progressed and communication became more real-time in ways well beyond telephone conversations, many pundits forecasted the end of what is derisively called snail mail, itself an admission of the speed and efficacy of electronic mail.
“You could make the analogy between the death of email and the death of the U.S. mail,” Moore says. “Ten years ago, people were writing this article about the death of the U.S. mail. And it certainly changed. Yes, there are less letters and less traffic and less parcels that the post office sends. But it’s still there. It’s not going away; it’s just adapting in a certain way.
“If you want to pinpoint a time that there is ‘the death of email,’ I think the death of the U.S. mail comes before it.” TH
Richard Quinn is a freelance writer in New Jersey.
Email should not replace face-to-face conversation, other workplace interactions
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, deals with the intersection of HM and technology for a living, particularly email. But perhaps email’s greatest use to him? A reminder that for all it is, it isn’t a face-to-face conversation.
“I more and more am reminding myself: Pick up the phone. Walk down to their office. Go to the coffee cart and see who shows up there so you can actually have a conversation,” he says. “I really enjoy those interactions.
“[Email] is an absolutely vital form of communication, but it’s just one of many and has obvious limitations.”
In the years-long discussion over whether email is antiquated in the face of instant-messaging services and other mobile applications, Dr. Jacobs clearly sides with those who see a future for email. It’s just too ubiquitous in hospitalist workflow at this point.
But the debate is a clarion call that hospitalists should take some time to focus on the clearest interpersonal interactions they can. It’s a message echoed by hospitalist pioneer Robert Wachter, MD, MHM, who used his annual closing lecture at HM15 in National Harbor, Md., last year to note that the advent of communicative technology has reduced the role of face-to-face meetings among hospital staff from different specialties.
For his part, Dr. Jacobs tries to focus as much as possible on making sure that email is just one piece of his communications spectrum.
“We rely too much on technology,” he says. “We’ve seen that with computerized physician order entries [CPOE]. For some reason, people put an order into a computer and they assume that it gets communicated effectively to everybody that needs to get that message.
“I think it’s the same with emailing or text messaging. You assume it gets there. People sometimes forget … a common-sense approach. Why don’t you follow up on that email? Why don’t you talk to the nurse, as well? Make sure that there is no misunderstanding. That’s where the errors are really going to hurt us … when we stop doing those other things to follow up on the messages.” TH
Richard Quinn is a freelance writer in New Jersey.
And yet despite the seemingly definitive place email communication holds for hospitalists—for messages to one another, missives to hospital administrators, instructions to patients, and myriad other uses—there are those who often wonder if email is outmoded. In a world bent on text messaging, Facebook, Twitter, Skype, Vine, Periscope, and Google Talk (not to mention dozens of lesser-known services and a seemingly endless string of startups aiming to be the proverbial next big thing), is email old-fashioned or ineffective?
In a word, no.
But that doesn’t mean email is the only communication method in a hospitalist’s toolbox or the best one for every situation. Physicians and communication experts interviewed by The Hospitalist agree that email has a function and isn’t going anywhere anytime soon. However, that function is dependent on trust, urgency, formality, and relationships.
“It has a place in communication, especially for busy hospitals, but the key is to figure out what is that place,” says Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, who has spoken at SHM annual meetings on how hospitalists communicate. “All of the information that is coming to you is in a push-pull model … There is information that you want pushed to you because it’s important and you want to see it. And then there is information that you want to pull because perhaps you know it relates to a patient in front of you … Where does email fit into it?”
Communications consultant A.J. Moore, associate professor of communication at Rider University in Lawrenceville, N.J., put it even more bluntly when assuring that email isn’t going anywhere.
“Research shows, and I know I do it myself, the first thing I do in the morning when I pick up my phone is check my email,” he says. “People often check their email before they check the weather, before they check social media.
“Sure, there are other places to go, there’s other ways of communicating. But I still think that email is the center point. It’s the starting line for your communication.”
A Modus for the Medium
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, appreciates the academic discussion over the future of email, but he also knows he uses it every day. To him, there are several factors that go into choosing which medium he uses for a particular message.
“It depends on the situation and the message you are sending,” says Dr. Jacobs, associate professor in the Department of Pediatrics at the University of New Mexico School of Medicine. “If I’m friends with the pediatric nephrologist, I may text him a quick question about a [glomerular filtration rate] or a clinical question. But if I’m not on those terms with another subspecialist, I wouldn’t do that.
“There’s definitely a relationship aspect that is relevant.”
Another factor in choosing to send an email versus a text message versus a tweet is timing. In the days when email was the only alternative to in-person communication or a phone call, the electronic message was the fastest way to reach a person. It was the best way to hold a synchronous conversation. But in today’s era of smartphones, tablets, and even wristwatches that have instant access, email is no longer the fastest option. In fact, email today is best tailored to asynchronous conversations, Dr. Arora says.
“Texting is really more invasive. It’s more demanding of the recipient’s time in an immediate sort of way,” Dr. Jacobs says. “With email, you’re basically saying, ‘Please take a look at this at your convenience, and when you can, write me back.’ In contrast, when people send text messages, they’re typically expecting a response in minutes. This may seem logical and trivial, but it can also be disruptive. Since some texts are urgent, all texts must at least initially be treated as such.”
The urgency that comes with a text message or a direct message on Facebook or Twitter is the flip side of the formality that comes with an email, says Moore.
“Email has more of a professional connotation to it than a Facebook message,” Moore says. “Even if I work with somebody, even if I’m Facebook friends with somebody and that person is one door away from me, if it is a work conversation, I am going to send them an email.”
Formality is the delineation between social media and what Moore half-jokingly calls “professional media.” And while in some ways technology gaps can often be a generational difference, Moore doesn’t see email usage through that prism and certainly not when he’s interacting with the young adults in his classes.
“I look at myself as a professor, and I have that formal relationship with younger people being students. They could find me on social media. There’s nothing preventing them,” he says. “But still they reach out to me via email, and I communicate with them via email.”
That being said, a generational gap does exist that can cause older physicians to refrain from embracing newer technologies that could be effective alternatives to email, says Howard Landa, chief medical information officer of the Alameda Health System in Oakland, Calif., and vice chairman of the board of advisors for the Association of Medical Directors of Information Systems. Many communication tools (Shortmail, Fridge, Apple Mail) either were discontinued, wrapped into larger technologies, or never became mainstream enough to be worthwhile. So the idea that some technologies won’t catch on discourages some from using anything but email.
“The younger we are, the easier the changes are and the more receptive we are to change,” Landa says. “We have seen a lot of flash-in-the-pan technology, snake oil, new ideas that go crazy for [a while]. They get to the top in the hype cycle, they drop to the bottom of the pit in the depression, and then they never move.
“With the older physicians, I think there is a reluctance to try something just because it’s new, whereas with the younger docs, there is every week a new technology that I want to try because I am willing to go through 20 of them before I find one that works. They have more energy and are more open to it.”
Security Is Job One
The safety of email is a major reason that many continually question its fate. In a broad sense, that is the natural question when a technology is new, says Ben Compaine, director of the fellows program at the Columbia University Institute for Tele-Information and a lecturer in the D’Amore-McKim School of Business at Northeastern University in Boston.
“There are always people who will find something to fear,” Compaine says. “Like when ATMs came along, there was stuff being written about safety concerns: ‘People will go to an ATM, and someone just holds them up and gets their money.’ It’s happened, but given the hundreds of millions of transactions that go on, you don’t throw out the baby with the bathwater.”
Dr. Arora cautions that the difference for hospitalists is that when a safety mistake is made with email, it can constitute a violation of the Health Insurance Portability and Accountability Act (HIPAA). And while those mistakes can happen innocently enough on social media or via text messaging, she says email issues are the most common.
“I’ve seen HIPAA violations where a patient would send an email to a doctor and the doctor would reply all to all of the [hospitalists] in their group saying, ‘Can anyone help me answer this question?’” she says. “So the forward email and forward and reply all are the most dangerous features because you have to know what you are forwarding and would that person want it shared with everybody.”
Landa believes that part of the problem with the efficacy of email is that it’s become so fast and so easy that people don’t take their time thinking about the impact of each email. Dr. Arora agrees and suggests hospitalists think carefully about what is in an email, particularly when it involves patient information.
“Share the minimum necessary information with a minimum number of people to try to accomplish what you are trying to do,” she adds. “That way, you are not clogging the inbox of everybody involved.”
Another potential pitfall to the efficacy of email is the “lost in translation” phenomenon, Landa says.
“How many times have you written am email and someone misinterpreted sarcasm or a joke or a particular word or a phrase and got upset because of what they thought you were saying?” he says. “I think that when you talk about the synchronous and rapid-fire style of the forms of communication, I think you elevate the risk by an order of magnitude. That’s the reason we have developed all the emoticons and all the visual references that are out there—to make sure that people don’t misinterpret what we’re saying.”
What’s Old Is New
So if hospitalists and communications experts believe email retains a place in the way information is conveyed, why is the question of its impending death a continuing parlor game for some?
“Because there’s always something new,” Moore says. “Because Messenger on Facebook looks a little bit flashier than email. Because now we have Periscope. Now we have Twitter. Now we have different types of platforms that message within each other. They all look flashier.”
But, in essence, each is simply a somewhat more modernized version, more bells and whistles, Moore says. He likes to compare it to the U.S. Postal Service. As technology progressed and communication became more real-time in ways well beyond telephone conversations, many pundits forecasted the end of what is derisively called snail mail, itself an admission of the speed and efficacy of electronic mail.
“You could make the analogy between the death of email and the death of the U.S. mail,” Moore says. “Ten years ago, people were writing this article about the death of the U.S. mail. And it certainly changed. Yes, there are less letters and less traffic and less parcels that the post office sends. But it’s still there. It’s not going away; it’s just adapting in a certain way.
“If you want to pinpoint a time that there is ‘the death of email,’ I think the death of the U.S. mail comes before it.” TH
Richard Quinn is a freelance writer in New Jersey.
Email should not replace face-to-face conversation, other workplace interactions
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, deals with the intersection of HM and technology for a living, particularly email. But perhaps email’s greatest use to him? A reminder that for all it is, it isn’t a face-to-face conversation.
“I more and more am reminding myself: Pick up the phone. Walk down to their office. Go to the coffee cart and see who shows up there so you can actually have a conversation,” he says. “I really enjoy those interactions.
“[Email] is an absolutely vital form of communication, but it’s just one of many and has obvious limitations.”
In the years-long discussion over whether email is antiquated in the face of instant-messaging services and other mobile applications, Dr. Jacobs clearly sides with those who see a future for email. It’s just too ubiquitous in hospitalist workflow at this point.
But the debate is a clarion call that hospitalists should take some time to focus on the clearest interpersonal interactions they can. It’s a message echoed by hospitalist pioneer Robert Wachter, MD, MHM, who used his annual closing lecture at HM15 in National Harbor, Md., last year to note that the advent of communicative technology has reduced the role of face-to-face meetings among hospital staff from different specialties.
For his part, Dr. Jacobs tries to focus as much as possible on making sure that email is just one piece of his communications spectrum.
“We rely too much on technology,” he says. “We’ve seen that with computerized physician order entries [CPOE]. For some reason, people put an order into a computer and they assume that it gets communicated effectively to everybody that needs to get that message.
“I think it’s the same with emailing or text messaging. You assume it gets there. People sometimes forget … a common-sense approach. Why don’t you follow up on that email? Why don’t you talk to the nurse, as well? Make sure that there is no misunderstanding. That’s where the errors are really going to hurt us … when we stop doing those other things to follow up on the messages.” TH
Richard Quinn is a freelance writer in New Jersey.
And yet despite the seemingly definitive place email communication holds for hospitalists—for messages to one another, missives to hospital administrators, instructions to patients, and myriad other uses—there are those who often wonder if email is outmoded. In a world bent on text messaging, Facebook, Twitter, Skype, Vine, Periscope, and Google Talk (not to mention dozens of lesser-known services and a seemingly endless string of startups aiming to be the proverbial next big thing), is email old-fashioned or ineffective?
In a word, no.
But that doesn’t mean email is the only communication method in a hospitalist’s toolbox or the best one for every situation. Physicians and communication experts interviewed by The Hospitalist agree that email has a function and isn’t going anywhere anytime soon. However, that function is dependent on trust, urgency, formality, and relationships.
“It has a place in communication, especially for busy hospitals, but the key is to figure out what is that place,” says Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, who has spoken at SHM annual meetings on how hospitalists communicate. “All of the information that is coming to you is in a push-pull model … There is information that you want pushed to you because it’s important and you want to see it. And then there is information that you want to pull because perhaps you know it relates to a patient in front of you … Where does email fit into it?”
Communications consultant A.J. Moore, associate professor of communication at Rider University in Lawrenceville, N.J., put it even more bluntly when assuring that email isn’t going anywhere.
“Research shows, and I know I do it myself, the first thing I do in the morning when I pick up my phone is check my email,” he says. “People often check their email before they check the weather, before they check social media.
“Sure, there are other places to go, there’s other ways of communicating. But I still think that email is the center point. It’s the starting line for your communication.”
A Modus for the Medium
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, appreciates the academic discussion over the future of email, but he also knows he uses it every day. To him, there are several factors that go into choosing which medium he uses for a particular message.
“It depends on the situation and the message you are sending,” says Dr. Jacobs, associate professor in the Department of Pediatrics at the University of New Mexico School of Medicine. “If I’m friends with the pediatric nephrologist, I may text him a quick question about a [glomerular filtration rate] or a clinical question. But if I’m not on those terms with another subspecialist, I wouldn’t do that.
“There’s definitely a relationship aspect that is relevant.”
Another factor in choosing to send an email versus a text message versus a tweet is timing. In the days when email was the only alternative to in-person communication or a phone call, the electronic message was the fastest way to reach a person. It was the best way to hold a synchronous conversation. But in today’s era of smartphones, tablets, and even wristwatches that have instant access, email is no longer the fastest option. In fact, email today is best tailored to asynchronous conversations, Dr. Arora says.
“Texting is really more invasive. It’s more demanding of the recipient’s time in an immediate sort of way,” Dr. Jacobs says. “With email, you’re basically saying, ‘Please take a look at this at your convenience, and when you can, write me back.’ In contrast, when people send text messages, they’re typically expecting a response in minutes. This may seem logical and trivial, but it can also be disruptive. Since some texts are urgent, all texts must at least initially be treated as such.”
The urgency that comes with a text message or a direct message on Facebook or Twitter is the flip side of the formality that comes with an email, says Moore.
“Email has more of a professional connotation to it than a Facebook message,” Moore says. “Even if I work with somebody, even if I’m Facebook friends with somebody and that person is one door away from me, if it is a work conversation, I am going to send them an email.”
Formality is the delineation between social media and what Moore half-jokingly calls “professional media.” And while in some ways technology gaps can often be a generational difference, Moore doesn’t see email usage through that prism and certainly not when he’s interacting with the young adults in his classes.
“I look at myself as a professor, and I have that formal relationship with younger people being students. They could find me on social media. There’s nothing preventing them,” he says. “But still they reach out to me via email, and I communicate with them via email.”
That being said, a generational gap does exist that can cause older physicians to refrain from embracing newer technologies that could be effective alternatives to email, says Howard Landa, chief medical information officer of the Alameda Health System in Oakland, Calif., and vice chairman of the board of advisors for the Association of Medical Directors of Information Systems. Many communication tools (Shortmail, Fridge, Apple Mail) either were discontinued, wrapped into larger technologies, or never became mainstream enough to be worthwhile. So the idea that some technologies won’t catch on discourages some from using anything but email.
“The younger we are, the easier the changes are and the more receptive we are to change,” Landa says. “We have seen a lot of flash-in-the-pan technology, snake oil, new ideas that go crazy for [a while]. They get to the top in the hype cycle, they drop to the bottom of the pit in the depression, and then they never move.
“With the older physicians, I think there is a reluctance to try something just because it’s new, whereas with the younger docs, there is every week a new technology that I want to try because I am willing to go through 20 of them before I find one that works. They have more energy and are more open to it.”
Security Is Job One
The safety of email is a major reason that many continually question its fate. In a broad sense, that is the natural question when a technology is new, says Ben Compaine, director of the fellows program at the Columbia University Institute for Tele-Information and a lecturer in the D’Amore-McKim School of Business at Northeastern University in Boston.
“There are always people who will find something to fear,” Compaine says. “Like when ATMs came along, there was stuff being written about safety concerns: ‘People will go to an ATM, and someone just holds them up and gets their money.’ It’s happened, but given the hundreds of millions of transactions that go on, you don’t throw out the baby with the bathwater.”
Dr. Arora cautions that the difference for hospitalists is that when a safety mistake is made with email, it can constitute a violation of the Health Insurance Portability and Accountability Act (HIPAA). And while those mistakes can happen innocently enough on social media or via text messaging, she says email issues are the most common.
“I’ve seen HIPAA violations where a patient would send an email to a doctor and the doctor would reply all to all of the [hospitalists] in their group saying, ‘Can anyone help me answer this question?’” she says. “So the forward email and forward and reply all are the most dangerous features because you have to know what you are forwarding and would that person want it shared with everybody.”
Landa believes that part of the problem with the efficacy of email is that it’s become so fast and so easy that people don’t take their time thinking about the impact of each email. Dr. Arora agrees and suggests hospitalists think carefully about what is in an email, particularly when it involves patient information.
“Share the minimum necessary information with a minimum number of people to try to accomplish what you are trying to do,” she adds. “That way, you are not clogging the inbox of everybody involved.”
Another potential pitfall to the efficacy of email is the “lost in translation” phenomenon, Landa says.
“How many times have you written am email and someone misinterpreted sarcasm or a joke or a particular word or a phrase and got upset because of what they thought you were saying?” he says. “I think that when you talk about the synchronous and rapid-fire style of the forms of communication, I think you elevate the risk by an order of magnitude. That’s the reason we have developed all the emoticons and all the visual references that are out there—to make sure that people don’t misinterpret what we’re saying.”
What’s Old Is New
So if hospitalists and communications experts believe email retains a place in the way information is conveyed, why is the question of its impending death a continuing parlor game for some?
“Because there’s always something new,” Moore says. “Because Messenger on Facebook looks a little bit flashier than email. Because now we have Periscope. Now we have Twitter. Now we have different types of platforms that message within each other. They all look flashier.”
But, in essence, each is simply a somewhat more modernized version, more bells and whistles, Moore says. He likes to compare it to the U.S. Postal Service. As technology progressed and communication became more real-time in ways well beyond telephone conversations, many pundits forecasted the end of what is derisively called snail mail, itself an admission of the speed and efficacy of electronic mail.
“You could make the analogy between the death of email and the death of the U.S. mail,” Moore says. “Ten years ago, people were writing this article about the death of the U.S. mail. And it certainly changed. Yes, there are less letters and less traffic and less parcels that the post office sends. But it’s still there. It’s not going away; it’s just adapting in a certain way.
“If you want to pinpoint a time that there is ‘the death of email,’ I think the death of the U.S. mail comes before it.” TH
Richard Quinn is a freelance writer in New Jersey.
Email should not replace face-to-face conversation, other workplace interactions
Hospitalist Aaron Jacobs, MD, associate chief medical information officer at University of New Mexico Hospital in Albuquerque, deals with the intersection of HM and technology for a living, particularly email. But perhaps email’s greatest use to him? A reminder that for all it is, it isn’t a face-to-face conversation.
“I more and more am reminding myself: Pick up the phone. Walk down to their office. Go to the coffee cart and see who shows up there so you can actually have a conversation,” he says. “I really enjoy those interactions.
“[Email] is an absolutely vital form of communication, but it’s just one of many and has obvious limitations.”
In the years-long discussion over whether email is antiquated in the face of instant-messaging services and other mobile applications, Dr. Jacobs clearly sides with those who see a future for email. It’s just too ubiquitous in hospitalist workflow at this point.
But the debate is a clarion call that hospitalists should take some time to focus on the clearest interpersonal interactions they can. It’s a message echoed by hospitalist pioneer Robert Wachter, MD, MHM, who used his annual closing lecture at HM15 in National Harbor, Md., last year to note that the advent of communicative technology has reduced the role of face-to-face meetings among hospital staff from different specialties.
For his part, Dr. Jacobs tries to focus as much as possible on making sure that email is just one piece of his communications spectrum.
“We rely too much on technology,” he says. “We’ve seen that with computerized physician order entries [CPOE]. For some reason, people put an order into a computer and they assume that it gets communicated effectively to everybody that needs to get that message.
“I think it’s the same with emailing or text messaging. You assume it gets there. People sometimes forget … a common-sense approach. Why don’t you follow up on that email? Why don’t you talk to the nurse, as well? Make sure that there is no misunderstanding. That’s where the errors are really going to hurt us … when we stop doing those other things to follow up on the messages.” TH
Richard Quinn is a freelance writer in New Jersey.
