The FDA's approval of a new oral anticoagulant—the first in 56 years—has sparked conversation in internal-medicine circles, prompting the industry to wonder: Will the new drug unseat warfarin as the go-to therapy?

Warfarin is among the most common prescriptions written by hospitalists, but that is in part due to its status as the lone option for the prevention of strokes and embolisms in atrial fibrillation (AF) patients. But on Oct. 19, the FDA approved dabigatran etexilate (Pradaxa) for AF patients. Several other similar medications are under development.

An FDA announcement on the approval notes that in a trial of 18,000 patients, those taking dabigatran etexilate had fewer strokes than those who took warfarin. The study (N Engl J Med. 361;12:1139-1151) reported primary outcome rates were 1.69% per year in the warfarin group, compared with 1.53% per year in the group that received 110mg of dabigatran (P<0.001).

Marketers for the new drug have suggested that while physicians often are slow to accept new therapies, the elimination of blood monitoring that often increases length of stay could nudge hospitalists to adopt the treatment more quickly.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee and a bleeding-risk research follower, is not so sure. He says that until there is clinical evidence, it will be difficult to tout any potential long-term benefits of the new therapy.

"It's not time to have a funeral for warfarin," Dr. Pfeifer says.

He adds that dabigatran's initial trials have not showed him such a compelling efficacy that he would consider removing current warfarin patients from their therapy. He also says that the cost of the new medication—at least double that of warfarin, with no generics available—will be a stumbling block and could prevent it from hospital formularies.

"Even with all these alternative anticoagulants out there, there is still no doubt that warfarin will be a mainstay therapy," Dr. Pfeifer says. "There is a reason these drugs are around a long time. …They are effective and they are cheap."

The FDA's approval of a new oral anticoagulant—the first in 56 years—has sparked conversation in internal-medicine circles, prompting the industry to wonder: Will the new drug unseat warfarin as the go-to therapy?

Warfarin is among the most common prescriptions written by hospitalists, but that is in part due to its status as the lone option for the prevention of strokes and embolisms in atrial fibrillation (AF) patients. But on Oct. 19, the FDA approved dabigatran etexilate (Pradaxa) for AF patients. Several other similar medications are under development.

An FDA announcement on the approval notes that in a trial of 18,000 patients, those taking dabigatran etexilate had fewer strokes than those who took warfarin. The study (N Engl J Med. 361;12:1139-1151) reported primary outcome rates were 1.69% per year in the warfarin group, compared with 1.53% per year in the group that received 110mg of dabigatran (P<0.001).

Marketers for the new drug have suggested that while physicians often are slow to accept new therapies, the elimination of blood monitoring that often increases length of stay could nudge hospitalists to adopt the treatment more quickly.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee and a bleeding-risk research follower, is not so sure. He says that until there is clinical evidence, it will be difficult to tout any potential long-term benefits of the new therapy.

"It's not time to have a funeral for warfarin," Dr. Pfeifer says.

He adds that dabigatran's initial trials have not showed him such a compelling efficacy that he would consider removing current warfarin patients from their therapy. He also says that the cost of the new medication—at least double that of warfarin, with no generics available—will be a stumbling block and could prevent it from hospital formularies.

"Even with all these alternative anticoagulants out there, there is still no doubt that warfarin will be a mainstay therapy," Dr. Pfeifer says. "There is a reason these drugs are around a long time. …They are effective and they are cheap."

The FDA's approval of a new oral anticoagulant—the first in 56 years—has sparked conversation in internal-medicine circles, prompting the industry to wonder: Will the new drug unseat warfarin as the go-to therapy?

Warfarin is among the most common prescriptions written by hospitalists, but that is in part due to its status as the lone option for the prevention of strokes and embolisms in atrial fibrillation (AF) patients. But on Oct. 19, the FDA approved dabigatran etexilate (Pradaxa) for AF patients. Several other similar medications are under development.

An FDA announcement on the approval notes that in a trial of 18,000 patients, those taking dabigatran etexilate had fewer strokes than those who took warfarin. The study (N Engl J Med. 361;12:1139-1151) reported primary outcome rates were 1.69% per year in the warfarin group, compared with 1.53% per year in the group that received 110mg of dabigatran (P<0.001).

Marketers for the new drug have suggested that while physicians often are slow to accept new therapies, the elimination of blood monitoring that often increases length of stay could nudge hospitalists to adopt the treatment more quickly.

Kurt Pfeifer, MD, FACP, program director of the Internal Medicine Residency program at Medical College in Milwaukee and a bleeding-risk research follower, is not so sure. He says that until there is clinical evidence, it will be difficult to tout any potential long-term benefits of the new therapy.

"It's not time to have a funeral for warfarin," Dr. Pfeifer says.

He adds that dabigatran's initial trials have not showed him such a compelling efficacy that he would consider removing current warfarin patients from their therapy. He also says that the cost of the new medication—at least double that of warfarin, with no generics available—will be a stumbling block and could prevent it from hospital formularies.

"Even with all these alternative anticoagulants out there, there is still no doubt that warfarin will be a mainstay therapy," Dr. Pfeifer says. "There is a reason these drugs are around a long time. …They are effective and they are cheap."

Pediatric Research in Inpatient Settings (PRIS), a network of pediatric hospitalists practicing at 150 academic and community hospitals, recently landed two federal stimulus grants totaling $12 million, far outstripping past support for research in the field, according to PRIS executive council chair Raj Srivastava, MD, MPH.

"Our mandate is to get federal dollars for multisite, transformative, clinical research for pediatric hospital medicine," says Dr. Srivastava, a pediatric hospitalist at Primary Children's Medical Center in Salt Lake City. "If we are going to be a real specialty, we have to conduct research to define best evidence and best practice: how to translate the evidence out into the field."

PRIS was formed in 2002 with sponsorship from SHM, the American Academy of Pediatrics, and the Academic Pediatric Association. Reorganized last year with a new executive council of active researchers, PRIS convened a strategic planning roundtable to reinvigorate the research agenda. In March, the Child Health Corporation of America, a business alliance of CEOs from 42 nonprofit children’s hospitals, awarded PRIS $1.4 million to support its infrastructure needs and a process that would prioritize research based on prevalence, cost, and variation in practice.

The federal stimulus monies, a pair of three-year grants awarded in September, will fund pediatric inpatient comparative effectiveness research. One of the grants, for $9 million, will support work to link clinical and administrative databases at six children’s hospitals. The second grant, worth $3 million, will be used to study the effectiveness of a resident handoff "bundle" of QI processes designed to enhance communication and improve signouts and transitions of care.

Dr. Srivastava says that, with the infrastructure now in place, more grant support will become possible. Adult hospitalists could use the PRIS experience as a model for building their own multisite research networks, he adds. “This kind of research matters because it is what we are all being asked to do in healthcare anyway,” he says.

Pediatric Research in Inpatient Settings (PRIS), a network of pediatric hospitalists practicing at 150 academic and community hospitals, recently landed two federal stimulus grants totaling $12 million, far outstripping past support for research in the field, according to PRIS executive council chair Raj Srivastava, MD, MPH.

"Our mandate is to get federal dollars for multisite, transformative, clinical research for pediatric hospital medicine," says Dr. Srivastava, a pediatric hospitalist at Primary Children's Medical Center in Salt Lake City. "If we are going to be a real specialty, we have to conduct research to define best evidence and best practice: how to translate the evidence out into the field."

PRIS was formed in 2002 with sponsorship from SHM, the American Academy of Pediatrics, and the Academic Pediatric Association. Reorganized last year with a new executive council of active researchers, PRIS convened a strategic planning roundtable to reinvigorate the research agenda. In March, the Child Health Corporation of America, a business alliance of CEOs from 42 nonprofit children’s hospitals, awarded PRIS $1.4 million to support its infrastructure needs and a process that would prioritize research based on prevalence, cost, and variation in practice.

The federal stimulus monies, a pair of three-year grants awarded in September, will fund pediatric inpatient comparative effectiveness research. One of the grants, for $9 million, will support work to link clinical and administrative databases at six children’s hospitals. The second grant, worth $3 million, will be used to study the effectiveness of a resident handoff "bundle" of QI processes designed to enhance communication and improve signouts and transitions of care.

Dr. Srivastava says that, with the infrastructure now in place, more grant support will become possible. Adult hospitalists could use the PRIS experience as a model for building their own multisite research networks, he adds. “This kind of research matters because it is what we are all being asked to do in healthcare anyway,” he says.

Pediatric Research in Inpatient Settings (PRIS), a network of pediatric hospitalists practicing at 150 academic and community hospitals, recently landed two federal stimulus grants totaling $12 million, far outstripping past support for research in the field, according to PRIS executive council chair Raj Srivastava, MD, MPH.

"Our mandate is to get federal dollars for multisite, transformative, clinical research for pediatric hospital medicine," says Dr. Srivastava, a pediatric hospitalist at Primary Children's Medical Center in Salt Lake City. "If we are going to be a real specialty, we have to conduct research to define best evidence and best practice: how to translate the evidence out into the field."

PRIS was formed in 2002 with sponsorship from SHM, the American Academy of Pediatrics, and the Academic Pediatric Association. Reorganized last year with a new executive council of active researchers, PRIS convened a strategic planning roundtable to reinvigorate the research agenda. In March, the Child Health Corporation of America, a business alliance of CEOs from 42 nonprofit children’s hospitals, awarded PRIS $1.4 million to support its infrastructure needs and a process that would prioritize research based on prevalence, cost, and variation in practice.

The federal stimulus monies, a pair of three-year grants awarded in September, will fund pediatric inpatient comparative effectiveness research. One of the grants, for $9 million, will support work to link clinical and administrative databases at six children’s hospitals. The second grant, worth $3 million, will be used to study the effectiveness of a resident handoff "bundle" of QI processes designed to enhance communication and improve signouts and transitions of care.

Dr. Srivastava says that, with the infrastructure now in place, more grant support will become possible. Adult hospitalists could use the PRIS experience as a model for building their own multisite research networks, he adds. “This kind of research matters because it is what we are all being asked to do in healthcare anyway,” he says.

Hospitalists who encounter the occasional late-stage colorectal cancer patient might be perplexed as to why the patient refuses to remove food from their in-room refrigerator and often are wearing mittens. But it would be immediately clear to them once they knew that the patient was on oxaliplatin—a less-than-decade-old medication delivered via the chemotherapy regimen known as FOLFOX—and that a common side effect is neuropathy resulting in extreme sensitivity to cold.

Why wouldn’t hospitalists know this? Because, according to a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, oncologists traditionally have tried to holistically manage the care of cancer patients. In today’s age of new treatments and increased inpatient care for patients with aggressive cancers, though, Jason Konner, MD, says it’s time for hospitalists to take a greater role in the management of cancer patients.

The upshot: Dr. Konner envisions a new breed of oncologist-hospitalists. (Check out this in-depth look at specialty physicians adopting the HM model of care.)

“Universally, the hospitalist is going to have to be part of a team with the oncologist,” says Dr. Konner, assistant professor with the Gynecological Medical Oncology Service and Developmental Therapeutic Services. “We’re going to complement each other. There are definitely things that we can do that they can’t and definitely things they can do that we can’t. Right now, it’s just being part of the team to address the diverse medical complications of cancer. But I think that increasingly, [hospitalists] are going to be the primary caregivers, sometimes solely the caregivers, of patients with cancer complications.”

The concept, which was raised during an “Oncology for the Hospitalist” presentation at the fifth annual Mid-Atlantic Hospital Medicine Symposium at Mount Sinai School of Medicine in New York City, is not new, but it is particularly relevant as cancer mortality and incidence rates continue to drop. Dr. Konner counters that while improved screening techniques—mammographies and prostate-specific antigen (PSA) tests, to note a pair—have reduced incidences, the majority of “aggressive cancers and cancers that kill people” still require intensive inpatient care.

To wit, a pilot program at Mount Sinai several years ago dedicated a hospitalist to the oncology service in the hopes of developing a staffer with a new expertise. The brief program, which yielded little data because of its small sample size, was aimed at determining the efficacy of an oncology hospitalist.

Richard Quinn is a freelance writer based in New Jersey.

Hospitalists who encounter the occasional late-stage colorectal cancer patient might be perplexed as to why the patient refuses to remove food from their in-room refrigerator and often are wearing mittens. But it would be immediately clear to them once they knew that the patient was on oxaliplatin—a less-than-decade-old medication delivered via the chemotherapy regimen known as FOLFOX—and that a common side effect is neuropathy resulting in extreme sensitivity to cold.

Why wouldn’t hospitalists know this? Because, according to a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, oncologists traditionally have tried to holistically manage the care of cancer patients. In today’s age of new treatments and increased inpatient care for patients with aggressive cancers, though, Jason Konner, MD, says it’s time for hospitalists to take a greater role in the management of cancer patients.

The upshot: Dr. Konner envisions a new breed of oncologist-hospitalists. (Check out this in-depth look at specialty physicians adopting the HM model of care.)

“Universally, the hospitalist is going to have to be part of a team with the oncologist,” says Dr. Konner, assistant professor with the Gynecological Medical Oncology Service and Developmental Therapeutic Services. “We’re going to complement each other. There are definitely things that we can do that they can’t and definitely things they can do that we can’t. Right now, it’s just being part of the team to address the diverse medical complications of cancer. But I think that increasingly, [hospitalists] are going to be the primary caregivers, sometimes solely the caregivers, of patients with cancer complications.”

The concept, which was raised during an “Oncology for the Hospitalist” presentation at the fifth annual Mid-Atlantic Hospital Medicine Symposium at Mount Sinai School of Medicine in New York City, is not new, but it is particularly relevant as cancer mortality and incidence rates continue to drop. Dr. Konner counters that while improved screening techniques—mammographies and prostate-specific antigen (PSA) tests, to note a pair—have reduced incidences, the majority of “aggressive cancers and cancers that kill people” still require intensive inpatient care.

To wit, a pilot program at Mount Sinai several years ago dedicated a hospitalist to the oncology service in the hopes of developing a staffer with a new expertise. The brief program, which yielded little data because of its small sample size, was aimed at determining the efficacy of an oncology hospitalist.

Richard Quinn is a freelance writer based in New Jersey.

Hospitalists who encounter the occasional late-stage colorectal cancer patient might be perplexed as to why the patient refuses to remove food from their in-room refrigerator and often are wearing mittens. But it would be immediately clear to them once they knew that the patient was on oxaliplatin—a less-than-decade-old medication delivered via the chemotherapy regimen known as FOLFOX—and that a common side effect is neuropathy resulting in extreme sensitivity to cold.

Why wouldn’t hospitalists know this? Because, according to a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, oncologists traditionally have tried to holistically manage the care of cancer patients. In today’s age of new treatments and increased inpatient care for patients with aggressive cancers, though, Jason Konner, MD, says it’s time for hospitalists to take a greater role in the management of cancer patients.

The upshot: Dr. Konner envisions a new breed of oncologist-hospitalists. (Check out this in-depth look at specialty physicians adopting the HM model of care.)

“Universally, the hospitalist is going to have to be part of a team with the oncologist,” says Dr. Konner, assistant professor with the Gynecological Medical Oncology Service and Developmental Therapeutic Services. “We’re going to complement each other. There are definitely things that we can do that they can’t and definitely things they can do that we can’t. Right now, it’s just being part of the team to address the diverse medical complications of cancer. But I think that increasingly, [hospitalists] are going to be the primary caregivers, sometimes solely the caregivers, of patients with cancer complications.”

The concept, which was raised during an “Oncology for the Hospitalist” presentation at the fifth annual Mid-Atlantic Hospital Medicine Symposium at Mount Sinai School of Medicine in New York City, is not new, but it is particularly relevant as cancer mortality and incidence rates continue to drop. Dr. Konner counters that while improved screening techniques—mammographies and prostate-specific antigen (PSA) tests, to note a pair—have reduced incidences, the majority of “aggressive cancers and cancers that kill people” still require intensive inpatient care.

To wit, a pilot program at Mount Sinai several years ago dedicated a hospitalist to the oncology service in the hopes of developing a staffer with a new expertise. The brief program, which yielded little data because of its small sample size, was aimed at determining the efficacy of an oncology hospitalist.

Richard Quinn is a freelance writer based in New Jersey.

Hospitalist Jeffrey Schnipper, MD, MPH, FHM, estimated last year that a full third of his current patient census was either diabetic or hypoglycemic, a figure that might seem out of place for someone who isn’t a diabetologist.

Last week, Dr. Schnipper's estimation made perfect sense with the release of a new report from the Centers for Disease Control and Prevention (CDC) that forecasts a near-doubling of diabetic incidences in the next 40 years.

"I won't be surprised when there's a day where half of my patients have diabetes or hypoglycemia," says Dr. Schnipper, director of clinical research and associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston. "We all have to become experts in how to comanage these patients."

The CDC data, published in Population Health Metrics on Oct. 22, state that "annual diagnosed diabetes incidence [new cases] will increase from about 8 cases per 1,000 in 2008 to about 15 in 2050" (doi: 10.1186/1478-7954-8-29). The authors note that intervention can reduce that prevalence, but won't eliminate it.

Dr. Schnipper says the exponential growth of diabetes incidence will not directly correlate to growth in patient counts, as many diabetics will be able to control their disease without admission to the hospital. However, he says, a large percentage of new cases are likely to end up as hospitalized patients heaped on HM groups' already full plates.

He suggests one response to the looming surge in diabetics might be to administer an A1c test to nearly all of your admitted patients to determine blood-glucose levels, or develop new protocols for how, who, and when to screen for diabetes.

One obvious patient group to be concerned about is the obese population, which Dr. Schnipper says is a direct cause of the diabetic incidence increase. "What we're seeing is an epidemic of obesity causing an epidemic of diabetes," he adds. "We already need to know how to manage these patients."

Hospitalist Jeffrey Schnipper, MD, MPH, FHM, estimated last year that a full third of his current patient census was either diabetic or hypoglycemic, a figure that might seem out of place for someone who isn’t a diabetologist.

Last week, Dr. Schnipper's estimation made perfect sense with the release of a new report from the Centers for Disease Control and Prevention (CDC) that forecasts a near-doubling of diabetic incidences in the next 40 years.

"I won't be surprised when there's a day where half of my patients have diabetes or hypoglycemia," says Dr. Schnipper, director of clinical research and associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston. "We all have to become experts in how to comanage these patients."

The CDC data, published in Population Health Metrics on Oct. 22, state that "annual diagnosed diabetes incidence [new cases] will increase from about 8 cases per 1,000 in 2008 to about 15 in 2050" (doi: 10.1186/1478-7954-8-29). The authors note that intervention can reduce that prevalence, but won't eliminate it.

Dr. Schnipper says the exponential growth of diabetes incidence will not directly correlate to growth in patient counts, as many diabetics will be able to control their disease without admission to the hospital. However, he says, a large percentage of new cases are likely to end up as hospitalized patients heaped on HM groups' already full plates.

He suggests one response to the looming surge in diabetics might be to administer an A1c test to nearly all of your admitted patients to determine blood-glucose levels, or develop new protocols for how, who, and when to screen for diabetes.

One obvious patient group to be concerned about is the obese population, which Dr. Schnipper says is a direct cause of the diabetic incidence increase. "What we're seeing is an epidemic of obesity causing an epidemic of diabetes," he adds. "We already need to know how to manage these patients."

Hospitalist Jeffrey Schnipper, MD, MPH, FHM, estimated last year that a full third of his current patient census was either diabetic or hypoglycemic, a figure that might seem out of place for someone who isn’t a diabetologist.

Last week, Dr. Schnipper's estimation made perfect sense with the release of a new report from the Centers for Disease Control and Prevention (CDC) that forecasts a near-doubling of diabetic incidences in the next 40 years.

"I won't be surprised when there's a day where half of my patients have diabetes or hypoglycemia," says Dr. Schnipper, director of clinical research and associate physician in the general medicine division at Brigham and Women's Hospitalist Service in Boston. "We all have to become experts in how to comanage these patients."

The CDC data, published in Population Health Metrics on Oct. 22, state that "annual diagnosed diabetes incidence [new cases] will increase from about 8 cases per 1,000 in 2008 to about 15 in 2050" (doi: 10.1186/1478-7954-8-29). The authors note that intervention can reduce that prevalence, but won't eliminate it.

Dr. Schnipper says the exponential growth of diabetes incidence will not directly correlate to growth in patient counts, as many diabetics will be able to control their disease without admission to the hospital. However, he says, a large percentage of new cases are likely to end up as hospitalized patients heaped on HM groups' already full plates.

He suggests one response to the looming surge in diabetics might be to administer an A1c test to nearly all of your admitted patients to determine blood-glucose levels, or develop new protocols for how, who, and when to screen for diabetes.

One obvious patient group to be concerned about is the obese population, which Dr. Schnipper says is a direct cause of the diabetic incidence increase. "What we're seeing is an epidemic of obesity causing an epidemic of diabetes," he adds. "We already need to know how to manage these patients."

Clinical question: Are beta-blockers safe to use in patients with chest pain and recent cocaine use?

Background: Beta-blockers are known to improve outcomes after myocardial infarction, yet are contraindicated in chest pain associated with recent cocaine use. Recommendations against beta-blocker use in the setting of cocaine-induced chest pain are based on case reports, small human experiments, and the theoretical concern that beta-blockers may potentiate cocaine toxicity by creating unopposed alpha-adrenergic stimulation. Clinical outcomes of beta-blocker use in patients with cocaine use and chest pain are unknown.

Study design: Retrospective cohort study.

Setting: San Francisco General Hospital, San Francisco.

Synopsis: Three hundred thirty-one patients with chest pain and positive urine toxicologic screening for cocaine were admitted during the study period. One hundred fifty-one (46%) received a beta-blocker in the ED, per the discretion of the treating physicians. There were no differences in ECG abnormalities, troponin levels, length of stay, intubation, ventricular arrhythmias, use of vasopressors, or death in those patients who did and who did not receive a beta-blocker. Over a median follow-up of 972 days, patients who had been discharged on a beta-blocker did have a significant reduction in cardiovascular death (hazard ratio 0.29, 95% CI, 0.09-0.98, P=0.047).

Because this was an observational study and post-discharge data were limited only to vital status, definitive conclusions regarding the safety of beta-blockers in cocaine-associated chest pain cannot be made. The authors acknowledge that more rigorous study is indicated given the potential benefit of beta-blockers in this population.

Bottom line: Use of beta-blockers in patients with chest pain and positive urine drug screen for cocaine is not associated with immediate adverse outcomes and might actually reduce cardiovascular mortality over time.

Citation: Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879.

Reviewed for TH eWire by Kelly Cunningham MD, Joshua LaBrin, MD, Amanda Salanitro, MD, MSPH, Kelly Sopko, MD, Shelley Ellis, MD, MPH, and Elizabeth Rice MD, Section of Hospital Medicine, Vanderbilt University.

For more physician reviews of literature, visit our website.

Clinical question: Are beta-blockers safe to use in patients with chest pain and recent cocaine use?

Background: Beta-blockers are known to improve outcomes after myocardial infarction, yet are contraindicated in chest pain associated with recent cocaine use. Recommendations against beta-blocker use in the setting of cocaine-induced chest pain are based on case reports, small human experiments, and the theoretical concern that beta-blockers may potentiate cocaine toxicity by creating unopposed alpha-adrenergic stimulation. Clinical outcomes of beta-blocker use in patients with cocaine use and chest pain are unknown.

Study design: Retrospective cohort study.

Setting: San Francisco General Hospital, San Francisco.

Synopsis: Three hundred thirty-one patients with chest pain and positive urine toxicologic screening for cocaine were admitted during the study period. One hundred fifty-one (46%) received a beta-blocker in the ED, per the discretion of the treating physicians. There were no differences in ECG abnormalities, troponin levels, length of stay, intubation, ventricular arrhythmias, use of vasopressors, or death in those patients who did and who did not receive a beta-blocker. Over a median follow-up of 972 days, patients who had been discharged on a beta-blocker did have a significant reduction in cardiovascular death (hazard ratio 0.29, 95% CI, 0.09-0.98, P=0.047).

Because this was an observational study and post-discharge data were limited only to vital status, definitive conclusions regarding the safety of beta-blockers in cocaine-associated chest pain cannot be made. The authors acknowledge that more rigorous study is indicated given the potential benefit of beta-blockers in this population.

Bottom line: Use of beta-blockers in patients with chest pain and positive urine drug screen for cocaine is not associated with immediate adverse outcomes and might actually reduce cardiovascular mortality over time.

Citation: Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879.

Reviewed for TH eWire by Kelly Cunningham MD, Joshua LaBrin, MD, Amanda Salanitro, MD, MSPH, Kelly Sopko, MD, Shelley Ellis, MD, MPH, and Elizabeth Rice MD, Section of Hospital Medicine, Vanderbilt University.

For more physician reviews of literature, visit our website.

Clinical question: Are beta-blockers safe to use in patients with chest pain and recent cocaine use?

Background: Beta-blockers are known to improve outcomes after myocardial infarction, yet are contraindicated in chest pain associated with recent cocaine use. Recommendations against beta-blocker use in the setting of cocaine-induced chest pain are based on case reports, small human experiments, and the theoretical concern that beta-blockers may potentiate cocaine toxicity by creating unopposed alpha-adrenergic stimulation. Clinical outcomes of beta-blocker use in patients with cocaine use and chest pain are unknown.

Study design: Retrospective cohort study.

Setting: San Francisco General Hospital, San Francisco.

Synopsis: Three hundred thirty-one patients with chest pain and positive urine toxicologic screening for cocaine were admitted during the study period. One hundred fifty-one (46%) received a beta-blocker in the ED, per the discretion of the treating physicians. There were no differences in ECG abnormalities, troponin levels, length of stay, intubation, ventricular arrhythmias, use of vasopressors, or death in those patients who did and who did not receive a beta-blocker. Over a median follow-up of 972 days, patients who had been discharged on a beta-blocker did have a significant reduction in cardiovascular death (hazard ratio 0.29, 95% CI, 0.09-0.98, P=0.047).

Because this was an observational study and post-discharge data were limited only to vital status, definitive conclusions regarding the safety of beta-blockers in cocaine-associated chest pain cannot be made. The authors acknowledge that more rigorous study is indicated given the potential benefit of beta-blockers in this population.

Bottom line: Use of beta-blockers in patients with chest pain and positive urine drug screen for cocaine is not associated with immediate adverse outcomes and might actually reduce cardiovascular mortality over time.

Citation: Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879.

Reviewed for TH eWire by Kelly Cunningham MD, Joshua LaBrin, MD, Amanda Salanitro, MD, MSPH, Kelly Sopko, MD, Shelley Ellis, MD, MPH, and Elizabeth Rice MD, Section of Hospital Medicine, Vanderbilt University.

For more physician reviews of literature, visit our website.

By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.

But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.

Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.

Academia Fosters Cooperation—and Lack Thereof

An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.

“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.

It is the hospital that derives the most benefit from a [combined] hospitalist program. And as such, they were easy to convince of the benefits of a med-peds model and expansion into pediatrics.—Allen Liles, MD, director, hospital medicine program, UNC Hospitals, Chapel Hill, N.C.

“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”

Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.

“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”

For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:

• Typically more hospitalists in each department, leading to greater scheduling flexibility;
• Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
• The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.

Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.

As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.

Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.

“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”

“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”

The Community Setting: Challenges and Successes

Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.

“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”

In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.

click for large version

That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.

Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.

“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”

In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.

“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.

Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.

“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.

But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.

As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.

When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them.—Jacques-Bret Burgess, MD, MPH, FAAP, Hospitalists of Northern Michigan, Traverse City

Building the Perfect Beast

So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.

In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.

“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”

When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.

“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”

Call Protection

As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.

“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”

Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”

Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.

Back Where You Belong

Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.

If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.

Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.

Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.

It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.

“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”

As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.

Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.

“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”

The Future of Med-Ped Hospitalists

At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?

“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.

It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.

And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH

Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.

By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.

But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.

Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.

Academia Fosters Cooperation—and Lack Thereof

An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.

“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.

It is the hospital that derives the most benefit from a [combined] hospitalist program. And as such, they were easy to convince of the benefits of a med-peds model and expansion into pediatrics.—Allen Liles, MD, director, hospital medicine program, UNC Hospitals, Chapel Hill, N.C.

“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”

Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.

“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”

For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:

• Typically more hospitalists in each department, leading to greater scheduling flexibility;
• Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
• The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.

Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.

As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.

Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.

“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”

“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”

The Community Setting: Challenges and Successes

Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.

“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”

In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.

click for large version

That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.

Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.

“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”

In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.

“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.

Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.

“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.

But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.

As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.

When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them.—Jacques-Bret Burgess, MD, MPH, FAAP, Hospitalists of Northern Michigan, Traverse City

Building the Perfect Beast

So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.

In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.

“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”

When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.

“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”

Call Protection

As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.

“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”

Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”

Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.

Back Where You Belong

Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.

If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.

Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.

Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.

It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.

“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”

As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.

Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.

“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”

The Future of Med-Ped Hospitalists

At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?

“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.

It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.

And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH

Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.

By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.

But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.

Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.

Academia Fosters Cooperation—and Lack Thereof

An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.

“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.

It is the hospital that derives the most benefit from a [combined] hospitalist program. And as such, they were easy to convince of the benefits of a med-peds model and expansion into pediatrics.—Allen Liles, MD, director, hospital medicine program, UNC Hospitals, Chapel Hill, N.C.

“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”

Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.

“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”

For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:

• Typically more hospitalists in each department, leading to greater scheduling flexibility;
• Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
• The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.

Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.

As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.

Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.

“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”

“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”

The Community Setting: Challenges and Successes

Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.

“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”

In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.

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That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.

Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.

“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”

In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.

“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.

Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.

“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.

But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.

As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.

When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them.—Jacques-Bret Burgess, MD, MPH, FAAP, Hospitalists of Northern Michigan, Traverse City

Building the Perfect Beast

So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.

In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.

“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”

When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.

“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”

Call Protection

As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.

“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”

Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”

Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.

Back Where You Belong

Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.

If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.

Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.

Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.

It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.

“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”

As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.

Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.

“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”

The Future of Med-Ped Hospitalists

At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?

“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.

It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.

And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH

Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.

In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.

A runaway success? Not so fast.

Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.

The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.

Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.

“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”

Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.

After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.

SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.

With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.

CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”

Upfront Investment, Immediate Savings, Improved Quality

Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.

“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.

Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.

Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.

Dr. Aguirre

“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”

Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.

At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.

The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.

I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.—Lisa Kettering, MD, vice president of medical affairs, CMO, Exempla St. Joseph Hospital, Denver, former SHM board member

All Eggs in One Basket?

One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.

If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.

Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.

Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.

HM: Front and Center

Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.

In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”

Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?

If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”

As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”

Guterman

But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.

“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”

The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).

Dr. Berenson

“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”

L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.

Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.

To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.

But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.

Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.

A runaway success? Not so fast.

Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.

The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.

Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.

“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”

Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.

After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.

SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.

With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.

CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”

Upfront Investment, Immediate Savings, Improved Quality

Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.

“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.

Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.

Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.

Dr. Aguirre

“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”

Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.

At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.

The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.

I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.—Lisa Kettering, MD, vice president of medical affairs, CMO, Exempla St. Joseph Hospital, Denver, former SHM board member

All Eggs in One Basket?

One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.

If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.

Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.

Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.

HM: Front and Center

Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.

In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”

Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?

If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”

As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”

Guterman

But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.

“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”

The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).

Dr. Berenson

“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”

L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.

Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.

To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.

But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.

Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

In a single year, one health system saved itself more than $2 million on orthopedic, cardiology, and cardiovascular surgery procedures. Another hospital saved Medicare an estimated $750,000. Supply costs dropped, scores on quality metrics rose, and bonus payments were distributed to participating doctors.

A runaway success? Not so fast.

Encouraging, if early, results from Medicare’s Acute Care Episode (ACE) Demonstration might have strengthened the case for bundling payments around episodes of care as an effective way to rein in spiraling healthcare costs and transition from a volume-based to a value-based payment system. But broad skepticism persists over the wisdom of binding together the fates of hospitals and doctors, and critics are far from ready to drop their argument that bundling will be unworkable across wider, less-well-defined swaths of healthcare.

The current bundling and gain-sharing duo differs only superficially from the despised capitation model of the 1990s, argues Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company. “It’s capitation in a different dress, except that instead of over a patient population, it’s done over an individual patient’s case,” he says.

Not so, says Lisa Kettering, MD, SFHM, vice president of medical affairs and CMO at Exempla St. Joseph Hospital in Denver.

“I’ve been around in medicine long enough to have been around when there was capitation,” she says. “I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.”

Amid the swirling expectations and apprehensions, what has the ACE demo taught us so far about bundling, and what does it mean for the future of hospital medicine? In essence, bundling lumps Medicare Part A and Part B reimbursements into a single payment aimed at encouraging hospitals and doctors to work together to improve efficiency, maintain high-quality care, and reduce overall expenses. Hospitals participating in the ACE Demonstration provide a roughly 5% discount to Medicare for a specific list of diagnosis-related groups (DRGs), and the Centers for Medicare & Medicaid Services (CMS) passes on half of the savings to beneficiaries who use participating hospitals for the covered procedures.

After submitting their claims, the hospitals receive a bundled Medicare payment, from which they pay doctors 100% of their Part B fees. As an incentive, some providers are eligible for bonus payments in the form of gain-sharing. CMS rules preclude any payments for referrals, cap all payments at 25% of the physician fee schedule, and mandate that any payment be based on reductions in patient care costs due to ACE activities. But participating hospitals are otherwise free to devise their own formulas and specific quality metrics that doctors must meet to gain the bonus.

SHM repeatedly has signaled its support for exploring bundling as a way to better align financial incentives among providers and reward them for quality and efficiency instead of quantity. The 10,000-member society strongly supports further testing of payment bundling methodologies prior to a national rollout, however, and has called for the integral involvement of hospitalists in developing and implementing bundling projects.

With its main focus on cardiologists, orthopedic surgeons, and cardiovascular surgeons, the ACE Demonstration has had little direct impact on hospitalists’ jobs or bank accounts—so far. That could change with an expanded pilot mandated by healthcare reform legislation. Slated to begin by Jan. 1, 2013, the project will redefine covered episodes of care to include all medical services administered three days before a hospital admission through 30 days after discharge.

CMS hasn’t yet decided which procedures will be covered, but officials say they’ve learned from past experience to begin with well-defined episodes of care. “Back in the ’90s, we did a bundled demonstration for bypass procedures and also for cataract procedures,” says Cynthia Mason, project manager with the CMS Medicare Demonstrations Group. “What we learned from that is obviously it’s easier both for Medicare, as well as for the providers, to predict utilization when you have a more standardized package of services. You also need a variety and large number of services in order to give you opportunities for looking at efficiencies and improvements in the system.”

Upfront Investment, Immediate Savings, Improved Quality

Early opinions have been mostly positive among the ACE participants. Hillcrest Medical Center in Tulsa, Okla., was first out of the gate in May 2009. Over the project’s first year, Hillcrest CEO Steve Dobbs estimates that the 490-bed hospital has saved CMS about $750,000; half of that sum has been passed along to patients. The hospital itself has spent about $550,000 in marketing, start-up costs, corporate support, and paying third-party claims. But recent investments have led to double-digit gains in patient volume (24% in cardiology and cardiovascular surgery, and a whopping 37% in orthopedics), margins in orthopedics are up, and direct negotiations between participating doctors and national vendors have netted additional savings. As a reward for help with cost-cutting, Hillcrest recently passed along two gain-sharing checks totaling $130,000 to be split among six independent orthopedists.

“What’s actually driving this program is the supply cost savings from all of our national partners,” Dobbs says. A big question is whether the negotiated savings—and hence the gain-sharing—could be maintained over a greatly expanded pilot project. “If this goes nationwide and everybody’s in it, do you get the same benefit? I don’t know the answer to that right now,” he says.

Dobbs is careful to point out that success is not measured by patient volume and supply costs alone. Hillcrest’s gain-sharing plan stipulates that physicians must reach the 90% threshold for a range of quality metrics. For one previously problematic category—stopping antibiotics 24 hours post-surgery—Dobbs says both the orthopedics and cardiovascular surgery departments have dramatically increased their compliance rates.

Baptist Health System in San Antonio, which began its own demonstration in June 2009, has reported savings of $2.2 million for its 1,275-bed, four-campus health system. So far, the roughly 20 hospitalists employed by IPC: The Hospitalist Company who work within the Baptist Health System have not directly participated in the project. But Felix Aguirre, MD, FHM, IPC’s vice president of medical affairs in San Antonio, says the demonstration has had a definite impact on efficiency.

Dr. Aguirre

“Since the demonstration project has come up, it seems like everybody is obeying the evidence-based guidelines now,” says Dr. Aguirre, a member of SHM’s Public Policy Committee and Team Hospitalist. “So it’s not keeping the hip replacement patient in for five days, it’s what the guidelines say: three days.”

Some kinks still need to be worked out. Baptist has had trouble with double payments and other claims-related issues, Dr. Aguirre says. Hillcrest’s Dobbs complains that he has heard virtually no feedback from CMS. Medicare’s Mason says officials have been “very pleased” with the project’s progress so far, but concedes that a delay in updating a claims processing system has pushed back the launch at two other demonstration sites until Nov. 1.

At one of those sites, 361-bed Exempla St. Joseph Hospital, the three-year demonstration will encompass only cardiology and cardiovascular surgery. Dr. Kettering, a former SHM board member who serves as executive sponsor and director of St. Joseph Hospital’s ACE demo, says the shared-savings program will be limited to cardiovascular surgery for the first year to ensure the system is running smoothly. In the second or third year, however, hospitalists who care for eligible patients could theoretically benefit from a similar gain-sharing agreement, if they meet certain agreed-upon, evidence-based metrics. In that circumstance, she says, hospitalists would begin to learn the ropes and become directly involved in quality outcomes. Extending the model beyond ACE, their primary role could expand dramatically to that of learning how to operate bundling across the continuum of care.

The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.

I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.—Lisa Kettering, MD, vice president of medical affairs, CMO, Exempla St. Joseph Hospital, Denver, former SHM board member

All Eggs in One Basket?

One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.

If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.

Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.

Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.

HM: Front and Center

Hospitalists might be uniquely well positioned to bring more efficiency and value, as well as help hospitals manage that risk. With bundling, though, the big question is how they’ll be paid for their services amid the demands of multiple providers. “I’ve heard it described as a big potential food fight,” says Kirk Mathews, CEO of St. Louis-based Inpatient Management Inc. and a member of SHM’s Workforce Summit Committee.

In the scenario relayed to him by fearful hospitalists, a hospital administrator is seated at the table with pie in hand, with the various providers clamoring for a slice. “Everyone will be sitting there saying, ‘Here’s why we deserve this percent of the bundled payment,’” Mathews says. “Whether that’s an accurate portrayal or not, that’s the fear.”

Taken a step further, the scenario envisions hospitalists struggling to hold their own at the table against high-powered and higher-paid specialists. Some of the ACE Demonstration sites, however, have used physician-hospital organizations, or PHOs, to help decentralize the decision-making and ensure that stakeholders are represented. Similarly, if patient referrals to hospitalists from other providers drop—as they did for some of the ACE Demonstration bundles at Baptist and Hillcrest—could hospitalists lose their bargaining power through an erosion of recouped professional fees?

If bundling expands, Hillcrest’s CEO says hospitalists are instead likely to assume a more central role (see “Six Pieces of Bundling-Related Advice for Hospitalists,” right). “If we truly go to bundled payments on everything,” Dobbs says, “then I think everybody’s got to be at the table and contributing, and especially the hospitalist, because the medical DRGs, that’s going to be where the hospitalists drive the equation, and that’s going to be a huge part of this.”

As SHM’s CEO Larry Wellikson, MD, SFHM, wrote in The Hospitalist last year (see “Bundling Bedlam,” July 2009, p. 46), the bundling of Medicare Part A dollars that subsidize HM with Part B physicians’ payments might actually pave the way for a more professional discussion of the value that hospitalists deliver. With bundling, he wrote, “the need for subsidies or support could diminish or vanish.”

Guterman

But that doesn’t resolve the issue of how to fairly size each bundle. Stuart Guterman, vice president of the Washington, D.C.-based Common-wealth Fund’s Program on Payment and System Reform, says one lesson from the capitation scheme of the ’90s is that an overemphasis on cost savings can lead to payments that are frequently insufficient to cover the costs of appropriate care.

“So there’s got to be more collaboration on what an appropriate amount is, and that’s a very important feature,” Guterman says. “Clearly, if you don’t pay enough, it doesn’t bode well for the success of any kind of payment approach. If you pay too much, it means you’re wasting money.”

The size and complexity of healthcare networks will influence how those bundle-related payments are negotiated. And in this case, several analysts say bigger isn’t necessarily better. “My own view is that it’s easier for a handful of hospitalists and a few community doctors in the hospital to come to an agreement on how they’re going to work within a bundle,” says Robert Berenson, MD, a senior fellow in the Urban Institute’s Health Policy Center and vice chair of the Medicare Payment Advisory Commission (MedPAC).

Dr. Berenson

“My experience is that in rural communities, there’s a greater alliance of interests between the doctors and the hospitals, whereas in big urban areas they’re often competing with each other. So I don’t see that as the problem, frankly. I think this is probably better designed for smaller places where there’s already reasonably good relationships.”

L. Scott Sussman, MD, a hospitalist at Mt. Ascutney Hospital and Health Center in Windsor, Vt., agrees that bundling likely wouldn’t negatively affect the day-to-day operations of the 25-bed critical-access hospital. Almost all admitted patients have PCPs in the affiliated Mt. Ascutney Physicians Practice, aiding communication during hospitalizations and care transitions. Dr. Sussman thinks bundling fits well with the mission of hospitalists to provide quality care and help smooth their patients’ transition back to community providers. “From the reading that I’ve done on bundling, it does seem to me that if implemented properly, it really could achieve cost savings while maintaining quality care,” he says.

Nevertheless, he has plenty of questions and concerns. Bundling would be more complicated, he concedes, if most admissions were referred from private-practice physicians in the community. And because Mt. Ascutney is a critical-access hospital, patients who develop complications or require a higher level of care are transferred to a tertiary-care facility—in this case, a 22-mile drive over the state line to Dartmouth-Hitchcock Medical Center in Lebanon, N.H. “How would the payment be divided up at that point?” he asks.

To make bundling work, healthcare leaders will clearly need to blaze a trail through uncharted territory.

But if the goal is getting more from the trillions spent annually on healthcare, advocates like Guterman say it provides an important step toward a better-functioning system.

Among hospitalists, at least some observers are betting that bundling will ultimately find its way. “I think bundled payments are here to stay,” Dr. Aguirre says. “I think our goal now is to see how we can modify it or create it so it can have the best impact for us and we can have the best impact for it.” TH

Bryn Nelson is a freelance medical writer based in Seattle.

It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).

Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.

However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.¹ Corporate sponsorship via branded logos are prominent on our website.

Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.²

Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.³

Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”

I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.

The “others,” as you can guess, are not physicians.

Bradley Flansbaum, DO, MPH, SFHM,

director, hospitalist services,

Lenox Hill Hospital, New York

References

1. The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
2. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
3. Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.

It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).

Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.

However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.¹ Corporate sponsorship via branded logos are prominent on our website.

Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.²

Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.³

Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”

I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.

The “others,” as you can guess, are not physicians.

Bradley Flansbaum, DO, MPH, SFHM,

director, hospitalist services,

Lenox Hill Hospital, New York

References

1. The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
2. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
3. Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.

It was a propitious step to hear from Jeff Weise, MD, SFHM, current president of SHM, speaking in favor of increased transparency for our organization (see “To Err is Human,” October 2010, p. 42).

Encouragingly, when SHM has misstepped, we have corrected our transgressions. We have adopted rigorous conflict-of-interest policies, and we now disclose affiliations rapidly as a consequence—both for our board and for ranking members.

However, I do not believe, as Jeff states, we are the leaders in this domain. SHM still accepts large sums of money from industry, the exact amounts of which remain undisclosed on our website. Additionally, we underwrite our national meetings with corporate contributions, while other organizations have moved forward and shunned this process.¹ Corporate sponsorship via branded logos are prominent on our website.

Granted, we are far from alone in this endeavor. Nevertheless, even with full disclosure, the appearance of purity is far from assured, as an outstanding essay commenting on AAFP’s acceptance of monies from Coca-Cola conveys.²

Calls to reform professional medical society practices are increasing, and the new healthcare legislation will begin to mandate recording, and then reporting, of physician-industry affiliations.³

Whether our organization will continue to “lead” on this front is unknown, and a question we must ask is, “Are our members prepared to pay full freight and pony up the costs of running our society in lieu of outside dollars?” I hope at some point the answer is “Yes.”

I for one would welcome full SHM disclosure, front and center, at our next national meeting. Similar to consumer-directed healthcare plan (CDHP) uptake lagging in the presence of opaque transaction costs at hospitals, we cannot change unless as members we know exactly what percentage of our activity others remunerate.

The “others,” as you can guess, are not physicians.

Bradley Flansbaum, DO, MPH, SFHM,

director, hospitalist services,

Lenox Hill Hospital, New York

References

1. The American Psychiatric Association phases out industry-supported symposia. American Psychiatric Association website. Available at: http://psych.org/MainMenu/Newsroom/NewsReleases/2009NewsReleases/APAPhasesOutISS.aspx. Accessed Sept. 21, 2010.
2. Brody H. Professional medical organizations and commercial conflicts of interest: ethical issues. Ann Fam Med. 2010;8(4):354-358.
3. Rothman DJ, McDonald WJ, Berkowitz CD, et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA. 2009;301(13):1367-1372.

Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.

That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.

The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.

The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.

“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”

For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.

A Better Way to Communicate

The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.

“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”

One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.

Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.

A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.

The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.

The Originals

Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.

The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.

The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.

“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”

The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture.

Participants in the second SHM Leadership Academy course build on those skills and learn to:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive decision-making in clinical and operational practices;
• Recruit and retain the best physicians for their group;
• Build exceptional physician satisfaction; and
• Engage in effective, professional negotiation activities using proven techniques. TH

Brendon Shank is a freelance writer based in Philadelphia.

Fellow in Hospital Medicine Spotlight

Joseph Charles, MD, FACP, FHM

Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.

Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.

Medical school: Aberdeen University, Aberdeen, Scotland

Internship and residency: The Royal Infirmary in Aberdeen

Chief residency: Maricopa Medical Center in Phoenix

Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England

Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.

His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.

FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.

—Sarah Gelotte

HM11 Right Around the Corner

Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.

HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.

In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.

New pre-courses in 2011 include:

• Advanced Interactive Critical Care;
• Portable Ultrasound for the Hospitalist;
• Perioperative Medicine for the Hospitalist; and
• Succeeding in Challenging Times: Advances in Hospital Practice Management.

The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.

Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.

Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.

That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.

The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.

The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.

“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”

For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.

A Better Way to Communicate

The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.

“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”

One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.

Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.

A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.

The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.

The Originals

Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.

The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.

The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.

“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”

The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture.

Participants in the second SHM Leadership Academy course build on those skills and learn to:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive decision-making in clinical and operational practices;
• Recruit and retain the best physicians for their group;
• Build exceptional physician satisfaction; and
• Engage in effective, professional negotiation activities using proven techniques. TH

Brendon Shank is a freelance writer based in Philadelphia.

Fellow in Hospital Medicine Spotlight

Joseph Charles, MD, FACP, FHM

Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.

Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.

Medical school: Aberdeen University, Aberdeen, Scotland

Internship and residency: The Royal Infirmary in Aberdeen

Chief residency: Maricopa Medical Center in Phoenix

Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England

Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.

His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.

FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.

—Sarah Gelotte

HM11 Right Around the Corner

Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.

HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.

In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.

New pre-courses in 2011 include:

• Advanced Interactive Critical Care;
• Portable Ultrasound for the Hospitalist;
• Perioperative Medicine for the Hospitalist; and
• Succeeding in Challenging Times: Advances in Hospital Practice Management.

The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.

Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.

Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.

That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.

The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.

The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.

“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”

For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.

A Better Way to Communicate

The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.

“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”

One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.

Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.

A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.

The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.

The Originals

Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.

The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.

The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.

“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”

The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:

• Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
• Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
• Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
• Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
• Implement methods of effective change through leadership, shared vision, and managing the organizational culture.

Participants in the second SHM Leadership Academy course build on those skills and learn to:

• Drive culture change through specific leadership behaviors and actions;
• Use financial reports to drive decision-making in clinical and operational practices;
• Recruit and retain the best physicians for their group;
• Build exceptional physician satisfaction; and
• Engage in effective, professional negotiation activities using proven techniques. TH

Brendon Shank is a freelance writer based in Philadelphia.

Fellow in Hospital Medicine Spotlight

Joseph Charles, MD, FACP, FHM

Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.

Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.

Medical school: Aberdeen University, Aberdeen, Scotland

Internship and residency: The Royal Infirmary in Aberdeen

Chief residency: Maricopa Medical Center in Phoenix

Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England

Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.

His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.

FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.

—Sarah Gelotte

HM11 Right Around the Corner

Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.

HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.

In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.

New pre-courses in 2011 include:

• Advanced Interactive Critical Care;
• Portable Ultrasound for the Hospitalist;
• Perioperative Medicine for the Hospitalist; and
• Succeeding in Challenging Times: Advances in Hospital Practice Management.

The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.

Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.