“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

Clinical question: What are the updated recommendations for treating first unprovoked seizure in adults?

Background: Approximately 150,000 adults present with an unprovoked first seizure in the U.S. annually, and these events are associated with physical and psychological trauma. Prior guidelines discussed evaluation of unprovoked first seizures in adults but did not address management. This publication aims to analyze existing evidence regarding prognosis and therapy with antiepileptic drugs (AEDs).

Study design: Evidence-based appraisal of a systematic review.

Setting: Literature published from 1966 to 2013 on MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

Synopsis: Ten prognostic studies describing risk of recurrence were found. Generalized tonic-clonic seizures were the major seizure type. Cumulative incidence of recurrent seizure increased over time, with the majority occurring within the first two years, regardless of treatment with AED; however, there were treatment differences among these studies and wide variation in recurrence rates.

Recurrence risk was lower with AED therapy, though patients were not randomized. Increased risk of recurrence was associated with prior brain lesion causing the seizure, EEG with epileptiform abnormalities, imaging abnormality, and nocturnal seizure.

Five studies were reviewed for prognosis following immediate AED therapy. Immediate AED treatment reduced risk of recurrence by 35% over the first two years. Among studies, “immediate” ranged from within one week to up to three months. Two studies described long-term prognosis, concluding that immediate AED treatment was unlikely to improve the chance of sustained seizure remission.

Five studies were used to describe adverse events in patients treated with AED. Adverse event incidence varied from 7% to 31%, and the incidents that occurred were largely mild and were reversible.

Bottom line: In adults presenting with unprovoked first seizure, the risk of recurrence is highest in the first two years and can be reduced with immediate AED therapy, though AED therapy was not shown to improve long-term prognosis.

Citation: Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-1713.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.¹ The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.

In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.² Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.

References

1. Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
2. Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)

The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.

When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.

I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.

Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.

What Can Be Done?

Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.

Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.

A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.

Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.

Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.

Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)

Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.

Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.

Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.

Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

On the last day of 2014, a provision of the Affordable Care Act (ACA) that increased payments to some physicians providing primary care services to the country’s poorest patients expired. The Medicaid payment parity program, under section 1202 of the ACA, increased to Medicare levels Medicaid reimbursement for primary care services rendered by internists, pediatricians, family medicine physicians, some subspecialists, and hospitalists in all states in 2013 and 2014.

A bill introduced in 2015, the Ensuring Access to Primary Care for Women and Children Act—sponsored by Sherrod Brown (D-Ohio) and Patty Murray, (D-W. Va.) in the Senate and Kathy Castor (D-Fla.) in the House—seeks to extend the parity program another two years and expand it to other providers, like obstetricians and nurse practitioners.

The parity program was intended to improve access to healthcare for the millions of Americans newly eligible for Medicaid under the ACA. Currently, one in five Americans is on Medicaid.

Fewer physicians in the U.S. participate in Medicaid than in Medicare or private insurance, and low reimbursement rates are sometimes cited as a cause.1,2 In 2012, fee-for-service Medicaid reimbursement for primary care averaged just 59% of Medicare fee levels nationally, but during the years of increased payment, eligible physicians saw a 73% boost in reimbursement for Medicaid primary care services.^1,2

The new bill is similar to one introduced unsuccessfully last year in the Senate, which sought to avoid a lapse in the program. Initially beset by delays, some experts say the program did not last long enough to gather sufficient data or to demonstrate its effectiveness. Others say the short duration of the program prevented new providers from accepting Medicaid patients.³

An extension “would give people the chance to get more data and show the payment increase resulted in a more cost-effective healthcare system,” says Ron Greeno, MD, FCCP, MHM, an SHM board member, chair of SHM’s Public Policy Committee, and chief strategy officer at IPC Healthcare. “Ideally, there would be permanent parity.”

From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable? At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?

–Dr. Greeno

In February, Dan Polsky, PhD, the Robert D. Eilers professor in healthcare management and economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues published a study in the New England Journal of Medicine that showed an increase in primary care appointments for new Medicaid patients correlating with the temporary increase in reimbursement.⁴

“We saw a 10% increase in the number of providers willing to see new Medicaid patients,” Dr. Polsky says. “It was an economic behavior test to see how physicians respond to changes in payment rates, because in a lot of states, policy makers are being asked to extend parity, and the typical comment was: ‘We don’t know if it works; it’s not cheap.’”

Indeed, the Congressional Budget Office estimated that the two-year pay increase would cost between $11 and $12 billion.¹

“We came up with evidence it works,” Dr. Polsky says.

However, further measures of the parity program’s success remain a challenge, according to the author of a Kaiser Family Foundation brief, because it’s difficult to separate it from other elements of the healthcare law. Studies have also conflicted with regard to the ability of payment boosts to improve access, and the reimbursement increase may not be compatible with a shift away from the fee-for-service model.¹

Yet, experts like Dr. Polsky say that to encourage greater participation in Medicaid, some type of parity is needed. “If we’re going to maintain better provider availability, I think you would need something like this,” he says.

For hospitalists, the two-year boost meant the ability to provide better care for hospitalized patients, Dr. Greeno says. Anecdotally, hospitalists reported that it was easier to discharge Medicaid patients to primary care follow-up in the community, he says, and better pay meant better staffing ratios were possible.

As of Jan. 1, 2015, 16 states and the District of Columbia reported that they will continue to reimburse Medicaid primary care services at Medicare levels.² Dr. Greeno says the disparity between states that reimburse at higher rates for Medicaid and those that won’t could start changing the macroeconomics of medical practice, similar to the situation that occurred when states differentially imposed caps on malpractice liability.

A May 2015 Health Affairs policy brief indicates that, despite the House and Senate bill, Congress is unlikely to act soon on increasing Medicaid reimbursement rates again. Dr. Greeno believes this a mistake.

“From a healthcare policy standpoint, it seems intellectually inconsistent, and from a public health standpoint, is it really justifiable?” he asks. “At the end of the day, the fundamental question is, do we really want to have two classes of access to American healthcare?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Paradise J. Henry J. Kaiser Family Foundation. The Kaiser Commission on Medicaid and the Uninsured. Medicaid moving forward. March 9, 2015. Accessed July 7, 2015.
2. Tollen L. Medicaid primary care parity. May 11, 2015. Health Affairs online. Accessed July 7, 2015.
3. Medicaid and CHIP Payment and Access Commission (MACPAC). March 2015 report to Congress on Medicaid and CHIP, chapter 8: an update on the Medicaid primary care payment increase. Accessed July 7, 2015.
4. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Engl J Med. 2015;372:537-545. doi: 10.1056/NEJMsa1413299.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Society of Hospital Medicine members have a real impact.

A paper published in the Journal of Hospital Medicine in April by Ann Sheehy, MD, MS, and colleagues was recently cited in Sen. Ben Cardin’s (D-Md.) amendment to the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015.^1,2 The act aims to improve the accuracy and transparency of recovery audits (RA), which were the subject of testimony given by Dr. Sheehy—a hospitalist at the University of Wisconsin-Madison—by invitation before Congress twice in 2014.

Formally called recovery audit contractors, or RACS, RAs evaluate whether hospitals were overpaid for hospitalizations improperly deemed inpatient rather than outpatient via observation status. In the study cited before the Senate Finance Committee, Dr. Sheehy’s group found a three-fold increase in RA overpayment determinations from 2010 to 2013; concurrently, the number of decisions overturned in favor of cited hospitals, either in discussion or appeal, doubled, going from 36% in 2010 to nearly 70% in 2013.

RAs share a percentage of the money they recover for the Centers for Medicare and Medicaid Services, even when decisions are appealed and won by hospitals. As Dr. Sheehy testified last year: “Unfortunately, these contingency incentives favor aggressive auditing, without transparency, accountability, or repercussions for cases that should never have been audited.”

The bill passed the Senate on June 5, 2015.

References

1. Sheehy AM, Locke C, Engel JZ, et al. Recovery audit contractor audits and appeals at three academic medical centers. J Hosp Med. 2015;10(4):212-219. doi: 10.1002/jhm.2332.
2. United States Senate Committee on Finance. Master Amendments of the Audit and Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015. Accessed July 7, 2015.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.

When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.

The Unique Paths of Hospitalist Careers

But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.

That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.

Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.

They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.

That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA’s Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.

—Larry Wellikson, MD, MHM

Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.

I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.

Podcast: A Format That Works for Hospitalists

Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.

And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.

In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”

Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.

How to Listen and Share

I hope you’ll join their ranks today. Here’s how:

• Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
• iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
• And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.

This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.

Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.

As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.

Larry Wellikson is CEO of the Society of Hospital Medicine.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.

Nearly 20 years ago, Bob Wachter, MD, coined the term “hospitalist,” defining a new specialty caring for the hospitalized medical patient. Since that time, we’ve seen rapid growth in the numbers of physicians who identify themselves as hospitalists, dominated by training in internal medicine and, to a lesser extent, family practice and pediatrics.

But, what about other specialty hospitalists, trained in the medicine or surgical specialties? How much of a presence do they have in our institutions today and in which specialties? To help us better understand this, a new question in 2014 State of Hospital Medicine survey asked whether specialty hospitalists practice in your hospital or health system.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years.

—Carolyn Sites, DO, FHM

Results show the top three specialty hospitalists to be critical care, at (35.4%), followed by general surgery/trauma (16.6%) and neurology (15.7%), based on the responses of survey participants representing hospital medicine groups (HMGs) that care for adults only. Other specialties included obstetrics (OB), psychiatry, GI, cardiology, and orthopedics (see Figure 1).

Perhaps not too surprising, the greatest number of specialty hospitalists are found in university and academic settings. These are our primary training centers, offering fellowship programs and further subspecialization programs. Much like in our own field of hospital medicine, some academic centers have created one-year fellowships for those interested in specific hospital specialty fields, such as OB hospitalist.

For reasons that are less clear, the survey also shows percentages are highest in the western U.S. and lowest in the East.

Critical care hospitalists, also known as intensivists, dominate the spectrum, being present in academic and nonacademic centers, regardless of the employment model of the medical hospitalists at those facilities. This is not unexpected, given the Leapfrog Group’s endorsement of ICU physician staffing with intensivists.

What’s driving the other specialty hospitalist fields? I suspect the reasons are similar to those of our own specialty. OB and neuro hospitalists at my health system cite the challenges of managing outpatient and inpatient practices, the higher inpatient acuity and focused skill set that are required, immediate availability demands, and work-life balance as key factors. Further drivers include external quality/safety governing agencies or groups, such as the Leapfrog example above, or The Joint Commission’s requirements for certification as a Comprehensive Stroke Center with neurointensive care units.

Much like our own field’s exponential growth, we are likely to see further expansion of specialty hospitalists over the next several years. It will be interesting to watch how much and how fast this occurs, and what impact and influence these groups will bring to the care of the hospitalized patient. I’m already looking forward to next year’s SOHM report to see those results.

Dr. Sites is regional medical director of hospital medicine at Providence Health Systems in Oregon and a member of the SHM Practice Analysis Committee.

Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.

“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.

“And I am never, ever bored.”

And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.

Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future.

–Dr. Zipper

Question: Why did you choose a career in medicine?

Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!

Q: How/when did you decide to become a hospitalist?

A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!

Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”

A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.

Q: What do you like most about working as a hospitalist?

A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.

Q: What do you dislike most?

A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.

Q: What’s the best advice you ever received?

A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.

Q: Did you have a mentor during training or early career?

A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.

Q: What’s the biggest change you would like to see in HM?

A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.

Q: As a leader, why is it important for you to continue seeing patients?

A: I think that being able to see things from a variety of perspectives is very important.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.

Q: What aspect of patient care is most rewarding?

A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.

Q: What is your biggest professional challenge?

A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.

Q: What is your biggest professional reward?

A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.

Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?

A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.

Q: What’s next professionally?

A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.

Q: If you weren’t a doctor, what would you be doing right now?

A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.

Q: When you aren’t working, what is important to you?

A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.

Q: What’s the best book you’ve read recently?

A: Being Mortal by Atul Gawande.

Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.

“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.

“And I am never, ever bored.”

And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.

Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future.

–Dr. Zipper

Question: Why did you choose a career in medicine?

Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!

Q: How/when did you decide to become a hospitalist?

A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!

Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”

A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.

Q: What do you like most about working as a hospitalist?

A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.

Q: What do you dislike most?

A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.

Q: What’s the best advice you ever received?

A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.

Q: Did you have a mentor during training or early career?

A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.

Q: What’s the biggest change you would like to see in HM?

A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.

Q: As a leader, why is it important for you to continue seeing patients?

A: I think that being able to see things from a variety of perspectives is very important.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.

Q: What aspect of patient care is most rewarding?

A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.

Q: What is your biggest professional challenge?

A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.

Q: What is your biggest professional reward?

A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.

Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?

A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.

Q: What’s next professionally?

A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.

Q: If you weren’t a doctor, what would you be doing right now?

A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.

Q: When you aren’t working, what is important to you?

A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.

Q: What’s the best book you’ve read recently?

A: Being Mortal by Atul Gawande.

Any hospitalist working for the largest HM group (HMG) in the country has one heck of a top-down perspective. And if you’re Robert Zipper, MD, MMM, SFHM, a regional chief medical officer (CMO) overseeing 25 hospitalist programs in the Pacific Northwest and Northern California for Sound Physicians, you love it.

“In my role, I really like working with younger leaders and those that are the future of the specialty,” he says, “but mostly I like knowing that I am supporting people that are doing incredible work, day in and day out.

“And I am never, ever bored.”

And, while never unengaged in his day-to-day job, Dr. Zipper has also been an active member of SHM. A former member of the Hospital Quality and Patient Safety (HQPS) Committee, Dr. Zipper currently chairs the Leadership Committee. The latest line on his resume is his role as one of seven new members of Team Hospitalist, the volunteer editorial advisory board of SHM’s official newsmagazine.

Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future.

–Dr. Zipper

Question: Why did you choose a career in medicine?

Answer: Both of my parents were psychotherapists, and I knew that I wanted to do something in healthcare…but not that!

Q: How/when did you decide to become a hospitalist?

A: I always liked inpatient medicine. I did 50/50 inpatient and outpatient for my first three years out of training, and the hospitalist part of that crumbled. That led to the opportunity to do pure hospital medicine in the same community in 2002, and I took it!

Q: Tell me a little more about medical school, residency, etc. Was there a single moment you knew “I can do this?”

A: I chose a single large institution because I wanted to know the people I worked with, as healthcare is all about relationships. In medical school, I didn’t spend more than two months at any given hospital doing rotations, and that didn’t seem like the best way to learn. It wasn’t like the real world. I never had self doubt that I would finish what I had started, partly because I had to work so hard to get into medical school in the first place.

Q: What do you like most about working as a hospitalist?

A: I enjoy the high acuity, but miss the longer-term relationships of outpatient care.

Q: What do you dislike most?

A: My role as regional CMO for a large management company never ends. I’m never “done with my shift,” so to speak. I love my job but would love more family time, too.

Q: What’s the best advice you ever received?

A: I was applying for medical school in the late 1990s, and I worked as a tech in an emergency department in Michigan. Many physicians at that time were jaded, feeling that the golden era of being a doctor had come and gone. The best advice I ever received was to ignore their negativity and to make my own future. This came from an emergency medicine resident named Paul Blackburn, who later went on to be the ED residency director at University of Arizona.

Q: Did you have a mentor during training or early career?

A: Not really, though I thought about oncology, and one of my oncology attendings played a special role for me. I ultimately chose not to do that specialty because I couldn’t deal with the high mortality—I took the grim reality that so many patients face home with me.

Q: What’s the biggest change you’ve seen in HM in your career?

A: Where to start? HM used to be a “thing,” requiring a lot of explanation. Now we have a peer-reviewed journal, and some of the best internists and family physicians in the U.S. choose hospital medicine as a career. Patients are more accepting.

Q: What’s the biggest change you would like to see in HM?

A: This may sound odd, but I would like compensation to stabilize. It will happen, but the continuous upward climb, while benefitting physicians on one hand, also serves to destabilize programs and create difficult financial situations for hospitals, particularly smaller hospitals that are at risk of closing nowadays.

Q: As a leader, why is it important for you to continue seeing patients?

A: I think that being able to see things from a variety of perspectives is very important.

Q: As a hospitalist, seeing most of your patients for the very first time, what aspect of patient care is most challenging?

A: Time management on a hospitalist’s first day is a challenge, as it always takes more time to really understand a patient and their course. Patients generally don’t like being asked the same questions repetitively.

Q: What aspect of patient care is most rewarding?

A: The human connection and feeling that you’ve played an important part in a patient’s and their family’s lives.

Q: What is your biggest professional challenge?

A: The very rapid pace of change when working with several hospitals and systems that each have their own set of strengths and challenges.

Q: What is your biggest professional reward?

A: Feeling like a part of something really meaningful. I am proud of being a leader in my organization, and I have never felt that way in any other job.

Q: What did it mean to you to be elected a Senior Fellow in Hospital Medicine?

A: I was elected SFHM in the first cohort, and I was not sure what to make of it. It has become something that is more meaningful over time as it is more widely recognized.

Q: What’s next professionally?

A: Transitional care. We are working hard to improve care in the post-acute period. The variability there is incredible, and where there is variability, there is waste. Making it work as a business, though, is another matter.

Q: If you weren’t a doctor, what would you be doing right now?

A: Probably either in information technology in some fashion—I built my first PC back when the 386 processor was king—or in music. I’ve played drums for a long time and still do whenever I get the chance.

Q: When you aren’t working, what is important to you?

A: Given that I travel quite a bit, I like to spend time with my family. We live in Bend, Ore., which offers great outdoor activities like mountain biking and skiing. We like to stay active as a family.

Q: What’s the best book you’ve read recently?

A: Being Mortal by Atul Gawande.

Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?

Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.

Study design: Prospective, multicenter study.

Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.

Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.

Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.

Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.

Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.

Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.

Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.

Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?

Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.

Study design: Prospective, multicenter study.

Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.

Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.

Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.

Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.

Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.

Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.

Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.

Clinical question: What are the risk factors for development of a recurrent infection in cirrhotic patients hospitalized with an initial infection?

Background: Infections are a major cause of morbidity and mortality in patients with cirrhosis. Prior retrospective data suggest that proton pump inhibitors (PPIs) increase the risk of infections in cirrhotic patients, while beta blockers do not. This study sought to prospectively evaluate risk factors for recurrent infections in hospitalized patients with cirrhosis.

Study design: Prospective, multicenter study.

Setting: Twelve North American hospitalists enrolled in the North American Consortium for the Study of End-Stage Liver Disease.

Synopsis: Researchers enrolled 188 hospitalized cirrhotic patients who had or developed an infection during their hospitalization. Patients were followed for six months to determine risk of development of subsequent infection and to identify independent risk factors associated with recurrent infections.

Forty-five percent of patients developed a subsequent infection, 74% of which occurred in a different location than the primary infection. This risk was independent of liver disease severity.

Age (OR 1.06; CI 1.02-1.11), PPI use (OR 2.72; CI 1.30-5.71), and spontaneous bacterial peritonitis (SBP) prophylaxis (OR 3.66; CI 1.60-8.37) were found to be independent predictors of recurrent infections. Beta blocker use did not differ between those who developed an infection and those who did not. An initial infection of SBP (compared to other infection sites) was protective (OR 0.37; CI 0.15-0.91) against subsequent infection.

Notably, study size was small, and 18% of patients were lost to follow-up. Further studies are needed to determine effective strategies to prevent recurrent infections in cirrhotics.

Bottom line: Cirrhotic patients hospitalized with an infection are at high risk of recurrent infections, and the long-term use of SBP prophylaxis and PPIs independently increase this risk.

Citation: O’Leary JG, Reddy KR, Wong F, et al. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clinical Gastro Hepatol. 2015;13(4):753-759.