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Physicians Exercise Their Entrepreneurial Skills, Creativity to Pursue Passions Beyond Clinical Medicine
After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.
Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.
Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."
A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.
"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.
Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.
For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."
The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.
Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.
"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.
–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.
"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."
The Writer
Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.
"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."
She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.
Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.
"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."
The Entrepreneur
Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.
"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."
—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.
Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.
Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.
To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.
"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."
His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.
The Director
Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.
"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."
Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.
–Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston
Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.
As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.
Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.
"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."
In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."
Susan Kreimer is a freelance writer in New York.
After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.
Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.
Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."
A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.
"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.
Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.
For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."
The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.
Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.
"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.
–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.
"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."
The Writer
Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.
"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."
She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.
Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.
"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."
The Entrepreneur
Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.
"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."
—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.
Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.
Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.
To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.
"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."
His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.
The Director
Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.
"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."
Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.
–Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston
Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.
As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.
Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.
"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."
In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."
Susan Kreimer is a freelance writer in New York.
After years of juggling more than one career, Kulleni Gebreyes, MD, MBA, had a tough decision to make. "I'm a little bit of a glutton for punishment," she admits with a chuckle. While overseeing quality improvement (QI) for a healthcare foundation, she had negotiated to take off every other Friday and work several ED shifts per month on weekends at two local hospitals.
Then, in January 2012, Dr. Gebreyes began a new full-time position as a director at PricewaterhouseCoopers in McLean, Va. It became too time-consuming and exhausting to treat patients and consult in healthcare industries, says the mother of two children, who are 7 and 4.
Dr. Gebreyes is among a growing number of physicians who, after a number of years, opt to give up clinical medicine for nonclinical roles in healthcare or other industries altogether. "You are ready for transition when the new choice excites and energizes you," she explains, "and not necessarily when your first choice disappoints you."
A career shift offers new opportunities for broadening one's horizons while often striking a better work-life balance. Many clinicians make the transition slowly and wisely, and some take an expected financial hit as they carve out an entrepreneurial and creative path.
"Modern medicine is very difficult. You can burn out if you're not careful," says Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston.
Stepping off the merry-go-round can help you regroup. Fortunately, he adds, hospitalists can exercise more flexibility in scheduling than physicians in different specialties. Some hospitalists prefer to work nights and weekends in order to free up weekdays for other activities. Others decrease their clinical shifts and devote more time to teaching, research, or administration.
For those who decide to leave medicine completely, "hospitalists definitely have people skills day to day in their jobs that are applicable in multiple other careers," says Dr. Hale, a Team Hospitalist member. "Becoming a physician requires so much dedication and hard work, so you will succeed in whatever career you choose."
The Society of Physician Entrepreneurs (www.sopenet.org) is expanding by about 150 to 200 new members each month. Founded in 2008 and officially launched in January 2011, the society has more than 4,700 members globally. The interdisciplinary network includes physicians and innovators in other professions—from law to information technology to product development.
Its purpose is to "bring all the stakeholders together in one virtual space to collaborate," says co-founder and president Arlen Meyers, MD, MBA, professor in the departments of otolaryngology, dentistry, and engineering at the University of Colorado Denver, where he directs the graduate program in bio-innovation and entrepreneurship.
"The opportunities for physician entrepreneurs include working with industry, consulting, creating their own company, and much more," Dr. Meyers says. "As domain experts, physicians are in a unique position to add value to the innovation chain.
–Maren Grainger-Monsen, MD, filmmaker-in-residence and director of the bioethics and film program, Stanford Center for Biomedical Ethics, Stanford, Calif.
"However, to leave practice and be successful at something nonclinical requires education, experience, and networks," he says. "Doing what you did successfully in your last career won't be a guarantee of success in your next career, so you have to be willing to pay your dues and accept the risk."
The Writer
Deborah Shlian, MD, MBA, a former family medicine physician and managed-care executive in California, has evolved into a medical management consultant and an author of both fiction and nonfiction titles. Dr. Shlian, who now lives in Boca Raton, Fla., had always wanted to write. Her father, an internist, encouraged the pursuit of medicine, so she followed in his footsteps.
"I wanted to emulate what he did," she says. Over time, she realized that "doctors have a lot of skills that are applicable to other endeavors."
She and her husband, Joel Shlian, MD, MBA, also a former family medicine physician, fully gave up clinical practice about 10 years ago after doing it part time for a decade. The Shlians met as students at the University of Maryland School of Medicine in 1970. Initially, their new business concentrated on physician executive recruitment. As clients requested other services, the Shlians helped identify nonphysician managers as well. Clients included established, as well as start-up health plans, academic institutions, utilization review, and healthcare consulting companies.
Given the accelerated changes in healthcare delivery, earning a graduate education in business is not a quick and easy avenue to another career. "An MBA should never be viewed as the means to 'get out of medical practice,'" Dr. Shlian says in her new book, "Lessons Learned: Stories from Women in Medical Management," released this month by the American College of Physician Executives.
"In fact, I would submit that if you really hate clinical medicine, medical management is not for you," she says. "It can be every bit as demanding and frustrating as clinical practice."
The Entrepreneur
Jeffrey N. Hausfeld, MD, MBA, FACS, completed an MBA program on evenings and weekends. After graduation in 2005, he gave up his 24-year practice of otolaryngology and facial plastic surgery. He continued his education by obtaining a graduate certificate in leadership coaching and organizational development. Then he became involved in the first of several business ventures, capitalizing on his clinical experience.
"Doctors don't have a trusted partner to do their debt collections," says Dr. Hausfeld, co-founder and treasurer of the Society of Physician Entrepreneurs. His own negative experiences with debt-collection agencies contributed to his "understanding the obstacles and objections to create this kind of an entity."
—Kulleni Gebreyes, MD, MBA, director of healthcare consulting, PricewaterhouseCoopers, McLean, Va.
Hence the emergence of FMS Financial Solutions, based in Greenbelt, Md. "This seemed to be a very natural fit for me," says Dr. Hausfeld, who is the managing director. By collecting money owed to physicians, hospitals, and surgical centers, he has increased the revenues of his business fourfold since 2006. The company has 24 full- and part-time workers.
Meanwhile, his son, Joshua, who joined him in the healthcare MBA program at Johns Hopkins University in Baltimore and now works for an investment banking firm that provides real estate loans for senior housing, introduced Dr. Hausfeld to a group of Midwest-based assisted-living-facility developers. Four years ago, they struck a deal to provide private equity funding and create Memory Care Communities of Illinois, with Dr. Hausfeld serving as president. The 24-hour residential facilities are home to patients with Alzheimer's disease and dementia.
To some degree, he misses practicing medicine, but Dr. Hausfeld is enthusiastic about making a difference in even more people's lives than he did as a physician and surgeon.
"I've done 10,000 ear, nose, and throat operations. If I did 1,000 more, how much would I be changing the world?" Dr. Hausfeld says. Ultimately, "you find a way to leave a bigger footprint."
His entrepreneurial spirit has led to other consulting roles. For instance, he is trying to help two startup companies—one in the medical device arena, the other in information technology—grow by leaps and bounds.
The Director
Maren Grainger-Monsen, MD, has made her mark as an award-winning physician filmmaker. She is filmmaker-in-residence and director of the bioethics and film program at the Stanford Center for Biomedical Ethics in Palo Alto, Calif. She studied at the London Film School and received her medical training at the University of Washington in Seattle and Stanford University School of Medicine.
"I have really enjoyed using all of my medical background and knowledge and applying it toward film," Dr. Grainger-Monsen says of her position at Stanford, which she has held since 1998. "It's very grounding. It gives you a purpose."
Her one-hour documentary "Rare," which features a family with a very uncommon genetic disease, aired last August on PBS. Another film, "The Revolutionary Optimists," follows a group of aspiring youngsters in the slums of Calcutta, India, who battle poverty and transform their neighborhoods from the inside out. One-hour and 80-minute versions of the film are slated to air on the PBS series "Independent Lens" as part of the Women and Girls Lead Global partnership.
–Dan Hale, MD, FAAP, a pediatric hospitalist in the Floating Hospital for Children at Tufts Medical Center in Boston
Dr. Grainger-Monsen co-produced and co-directed both films with Nicole Newnham, an independent documentary filmmaker who is in residence at Stanford's bioethics and film program.
As an undergraduate art history major, Dr. Grainger-Monsen became interested in social and ethical issues in medicine. Later, films shown in medical school struck a chord with her. She was amazed at how images could resonate with viewers and trigger animated debate. During the summer between her first and second years of medical school, she was inspired to study film at New York University.
Dr. Grainger-Monsen eventually trained in emergency medicine at Stanford and completed a fellowship in palliative care at Stanford-affiliated Palo Alto Veterans Administration Hospital. For years, she split her career between working in community ER clinics and producing films. Her films are large-scale projects that may take five years or longer to make, and she raises all the funds to bring them to fruition.
"I really do find documentary filmmaking tremendously gratifying," Dr. Grainger-Monsen says of the chance "to talk with all different kinds of people in all different situations and walk in their shoes, with them, for a time. That is what I'm trying to share with the audience."
In creating character-driven documentaries, she aims to spark discussions about important issues in contemporary medicine. "I hope my films can help increase understanding and empathy," she says, "and result in improvements to the delivery of healthcare and reduction of disparities on multiple levels."
Susan Kreimer is a freelance writer in New York.
John Nelson: Fixing Complaints Between Primary-Care Physicians, Hospitalists Not Always Easy
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1
The absence of research studies doesn’t stop a lot of people, including me, from expressing their opinions. Numerous articles and opinion pieces are available on the Internet. They generally summarize that despite having the same goal of safe and efficient patient care, PCPs and hospitalists often see direct admissions a little differently.
An Internet search of ”direct admission + hospitalist” turns up the practice website for a hospitalist group. I found several such sites that do accept direct admissions. Presumably, those hospitalist groups that refuse to accept direct admissions don’t advertise that on their website so don’t turn up in a search. This one is typical:
Hospitalists are also available to facilitate direct admissions to Beth Israel Deaconess Hospital-Needham, so that patients can avoid a trip through the emergency department. Please note that it is Beth Israel Deaconess Hospital-Needham policy that the patient needs to have been seen by the primary-care provider or specialist physician within the previous 24 hours to qualify for direct admission status.
Mass General Hospital for Children in Boston has posted a very detailed approach to direct admissions2 allowing them only from some PCP groups (presumably those in their system), and only when the patient has been seen in the office on the day of admission. And the hospitalist program at Johns Hopkins Hospital in Baltimore advertises its “VIP Direct-Admitting Service.”3
Recommendations
I’ve come to the following conclusions that I think most groups could follow, though I realize thoughtful people can see this differently.
- Most hospitalist groups should not have a policy of refusing all direct admissions. They should thoughtfully listen every time a doctor calls asking to refer a patient directly from an office setting. And, at least some of the time, they should say yes.
- You should more liberally accept direct admissions from PCPs you work with regularly. The better you know the PCP (i.e. have cared for many of that doctor’s patients), the more you can judge the risk the patient will arrive in a condition other than described.
- Requiring that the patient be in the office at the time of the decision to accept the direct admission, or within the preceding 12 or 24 hours, is a good idea.
- Work with your hospital to improve the speed of testing like blood work and X-rays done “on the floor” on new admissions so they’re resulted as quickly as in the ED. Consider notifying in advance the relevant department that you’ll likely be ordering a stat study as soon as the patient arrives. This is sort of like calling a restaurant to get in line for a table before you arrive.
- The hospitalist should have the final say regarding whether a patient is appropriate for direct admission, or whether it is best to stop in the ED first. That is the case for all the practices I mentioned above. But don’t let this insulate you from the very real frustration suffered by PCPs and patients, should you unfairly refuse to allow it.
I don’t have any idea what might be an appropriate portion of direct admissions for a typical hospitalist practice; it’s probably no more than 1% or 2%. But I don’t think it should be zero.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
- Kulkarni N, Williams M. Is it safe to be direct? Agency for Healthcare Research and Quality website. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=178. Accessed Feb. 2, 2013.
- MassGeneral Hospital for Children. Direct admit policy. MassGeneral Hospital for Children website. Available at: http://www.massgeneral.org/children/professionals/direct_admit_policy.aspx. Accessed Feb. 2, 2013.
- Johns Hopkins Medicine. Hospitalists Introduce VIP Direct-Admitting Service. Johns Hopkins Medicine website. Available at: http://www.hopkinsmedicine.org/gim/news/2010_News_Items/6-17-10.html. Accessed Feb. 2, 2013.
Better Thinking by Hospitalists Key to Improving Healthcare Industry
Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.
Clearly, something is not working.
This is a time when hospitalists should start thinking about dropping some of our Pulaskis.
Handy, Useful, Versatile, Reliable
A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.
Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”1 He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.
During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.
Seize the Day
There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.
But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.
And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.
Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
Reference
Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.
Clearly, something is not working.
This is a time when hospitalists should start thinking about dropping some of our Pulaskis.
Handy, Useful, Versatile, Reliable
A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.
Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”1 He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.
During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.
Seize the Day
There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.
But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.
And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.
Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
Reference
Old habits are hard to break. We all get used to doing things in certain ways, and the longer we do it, it becomes increasingly difficult to do them differently. We clearly are clinging to old habits in the healthcare industry, despite compelling evidence that we need to figure out better ways of doing business. Our industry has been in a crisis for a very long time—rising costs, drastic reimbursement reductions from payors, and continually escalating risks and medical errors.
Clearly, something is not working.
This is a time when hospitalists should start thinking about dropping some of our Pulaskis.
Handy, Useful, Versatile, Reliable
A Pulaski is a versatile tool that combines an axe and an adze; it’s most commonly used in firefighting, but it is also used in trail-blazing, gardening, and woodworking (see right). The Pulaski was invented by Ed Pulaski, a forest ranger in the 1910s who almost died in a forest fire after being trapped in an old mine tunnel. After he barely survived, he invented the Pulaski as a means to reduce the risk of future firefighters being trapped in his same situation. For more than 100 years, this tool has come in handy in countless situations. It is versatile, irreplaceable, reliable—a must-have. Unless you don’t need it. And then it becomes a 22-pound handicap.
Donald Berwick, MD, MPP, spoke about the Pulaski 13 years ago in a powerful speech to the National Forum on Quality Improvement in Health Care; his presentation was titled “Escape Fire.”1 He described the Mann Gulch fire of 1949, which took the lives of 13 young men when the fire did not behave as expected. The men were forced to outrun this fire, up a hill at a 76% slope, with the fire racing at them at 7 miles per hour, at an air temperature of 100 degrees. Only two firefighters survived. Those who perished tried to run up the hill with all of their gear, including their Pulaski, which served, at the time, only to slow them down. One survivor was lucky; he managed to get to the top of hill before the fire engulfed him. The other survivor, Wagner Dodge, was heroic. He realized the situation was hopeless and created a radical, innovative, and immediate solution to the problem at hand: He not only dropped his 22-pound handicap, but he also stopped running up the hill, stood still, and lit his own escape fire to avoid the larger fire at hand. The rest of the pack clung to the only option they could conceive of, which was outrunning the beast, despite the fact that it was traveling twice as fast as they were.
During his speech, Dr. Berwick also spoke of some of his personal experiences within U.S. hospitals that were filled with fear, uncertainty, and at times downright outrage; of misunderstandings, despicable care transitions, and daily medical errors or near misses. About how he and his wife struggled for security, appropriate treatments, and more answers than questions. He spoke of being in some of the best hospitals in the nation, and of being more organized and informed than most patients. Most patients would not possibly fare as well as the Berwicks, being under- or uninsured, of low health literacy, undereducated, or uninformed. It is incomprehensible that we have created a system that is so complicated and difficult to navigate that even the best and the brightest cannot traverse it unscathed. So it seems that sometimes the key to doing something better (or surviving, in the case of the Mann Gulch fire) is not knowing what new tools to adopt, but instead knowing what tools to get rid of.
Seize the Day
There is a dog park near my house that we take our dog to whenever we get a chance. There is a dog that frequents the park, a brown Labrador by the name of Gracie. Gracie’s favorite activity is fetching tennis balls; she dutifully catches the ball (usually in midair) and brings it back to her owner. When she gets back to her owner, she stands in front of him waiting for her order: “Drop it, Gracie.” As soon as Gracie hears the order, she drops the ball immediately. But she won’t drop the ball until ordered to do so—even though, by keeping the ball, she is that much further away from her next favorite activity. It seems like, to do the best for herself, she should come back and drop the ball, which would bring her that much closer to the one thing she loves best.
But she doesn’t. She waits dutifully for someone else to tell her when to drop the ball.
And interestingly, Gracie will not just drop it for anyone. When others at the park want to play with Gracie, and follow the lead of Gracie’s owner, and say “Drop it, Gracie,” she will look at the visitor, and then at her owner, looking for the approval that it really is in fact OK for her to drop it. Even after an approving look, she will hesitatingly drop the ball, and only after the stranger is a safe distance away, in case she needs to retrieve it sooner than later.
Many of us in the healthcare industry often wait for someone else to tell us when to start doing new things, but rarely do we expect, do we hear, or do we initiate the order to stop doing something. We need to think deeply about all the things we do that are useless Pulaskis, and about how to radically change the industry in which we work. Because this inching along is not going fast enough, and there is little evidence that we have made much progress in the last decade. So if you find yourself lugging around a Pulaski (or two), don’t just think about how to drop it, or when to drop it, or whether to drop it on certain days of the week. Just drop it, Gracie.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
Reference
Choosing Wisely Campaign Initiatives Grounded in Tenets of Hospital Medicine
The Choosing Wisely campaign is focused on better decision-making, improved quality, and decreased healthcare costs. Such focus on efficiency and cost-effectiveness also was part of the initial motivation for developing hospital medicine, says one of HM’s pioneering doctors.
Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.
“It’s the right time, the right message, and the right messenger,” says Dr. Wachter, who also chairs the American Board of Internal Medicine and sits on the board of the ABIM Foundation. “We’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was, because ultimately it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.”
Dr. Wachter expects the medical community to hear “similar kinds of drumbeats about waste” from every corner of healthcare. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign,” he says, “and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.
The Choosing Wisely campaign is focused on better decision-making, improved quality, and decreased healthcare costs. Such focus on efficiency and cost-effectiveness also was part of the initial motivation for developing hospital medicine, says one of HM’s pioneering doctors.
Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.
“It’s the right time, the right message, and the right messenger,” says Dr. Wachter, who also chairs the American Board of Internal Medicine and sits on the board of the ABIM Foundation. “We’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was, because ultimately it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.”
Dr. Wachter expects the medical community to hear “similar kinds of drumbeats about waste” from every corner of healthcare. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign,” he says, “and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.
The Choosing Wisely campaign is focused on better decision-making, improved quality, and decreased healthcare costs. Such focus on efficiency and cost-effectiveness also was part of the initial motivation for developing hospital medicine, says one of HM’s pioneering doctors.
Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.
“It’s the right time, the right message, and the right messenger,” says Dr. Wachter, who also chairs the American Board of Internal Medicine and sits on the board of the ABIM Foundation. “We’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was, because ultimately it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.”
Dr. Wachter expects the medical community to hear “similar kinds of drumbeats about waste” from every corner of healthcare. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign,” he says, “and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.
Hospital Medicine Leaders Set to Converge for HM13
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Ten Clinical Decisions to Eliminate Wasteful Healthcare Spending
Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?
If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.
SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.
Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”
SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.
“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.
Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.
“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.
Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.
“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”
Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.
Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”
A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).
“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”
Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”
Larry Beresford is a freelance writer in Oakland, Calif.
Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?
If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.
SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.
Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”
SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.
“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.
Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.
“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.
Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.
“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”
Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.
Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”
A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).
“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”
Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”
Larry Beresford is a freelance writer in Oakland, Calif.
Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?
If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.
SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.
Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”
SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.
“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.
Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.
“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.
Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.
“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”
Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.
Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”
A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).
“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”
Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”
Larry Beresford is a freelance writer in Oakland, Calif.
Week On, Week Off Schedules Make Balancing Work-Life Demands Tough for Some Hospitalists
Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.
Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”
Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”
Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.
Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”
Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”
Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.
Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”
Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”
Experts Debate Pros and Cons of Seven Days On, Seven Days Off Work Schedule
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
Former Hospitalist Gets Satisfaction Helping Physicians Launch Nonclinical Careers
Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).
Question: What type of business do you operate?
Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.
Q: Why did you give up the practice of medicine?
A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.
In short, I was deeply restless, in my early 40s, and ready for a change.
Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?
A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.
Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.
Q: Can you name some pros and cons for physicians interested in a career change?
A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.
The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.
Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).
Question: What type of business do you operate?
Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.
Q: Why did you give up the practice of medicine?
A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.
In short, I was deeply restless, in my early 40s, and ready for a change.
Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?
A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.
Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.
Q: Can you name some pros and cons for physicians interested in a career change?
A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.
The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.
Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).
Question: What type of business do you operate?
Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.
Q: Why did you give up the practice of medicine?
A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.
In short, I was deeply restless, in my early 40s, and ready for a change.
Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?
A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.
Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.
Q: Can you name some pros and cons for physicians interested in a career change?
A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.
The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.
ONLINE EXCLUSIVE: Should HM groups protect themselves against extreme moonlighters?
Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?
“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.
In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.
“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.
To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.
Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.
“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH
Richard Quinn is a freelance writer in New Jersey.
Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?
“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.
In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.
“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.
To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.
Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.
“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH
Richard Quinn is a freelance writer in New Jersey.
Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?
“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.
In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.
“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.
To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.
Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.
“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH
Richard Quinn is a freelance writer in New Jersey.