Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.¹ More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.

Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.

Reference

1. Reese P, Smith D. Million-dollar hospital bills rise sharply in Northern California. Sacramento Bee website. Available at: http://www.sacbee.com/2012/03/11/4328036/million-dollar-hospital-bills.html. Accessed March 29, 2012.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.

L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.¹ Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.

Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.²

A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.

“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.

References

1. Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
2. Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.

An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.

One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.¹ The data were inconclusive on the impact of reporting on heart failure.

The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.

Reference

1. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31(3):585-592.

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.

In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.

In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.

SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:

• Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
• Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
• PCPs should be more involved in the inpatient care of the complex medically ill; and
• There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.

As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:

• Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
• Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
• Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
• Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.

SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.

Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.

While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.

Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at [email protected].

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).

We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.

Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.

The Accountability Imperative

If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”

Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.¹ The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.

The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.

Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1

Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.

Accountability and Autonomy

Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.

Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.² He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”

Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.

Failure to Perform Not an Option

It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.

Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”

Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.

Dr. Frost is president of SHM.

References

1. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361;14:1401-1406.
2. Reinertsen J. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to [email protected].

As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to [email protected].

As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to [email protected].

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

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

.

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

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

.

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

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

.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.