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Hospitals and Recession
With the United States mired in its most severe recession in decades, stories of hospital struggles have emerged. Beaumont Hospital, located near the headquarters of major automakers and several assembly plants outside Detroit, recently cut hundreds of jobs and put major construction on indefinite hold.1 The CEO of Boston's Beth Israel Deaconess Medical Center made an agreement with employees to take large cuts in pay and vacation time to prevent laying off 10% of the staff.2 The University of Chicago Medical Center made plans to limit the number of emergency room beds, thereby decreasing low‐reimbursing emergency admissions while making beds available for higher‐paying elective hospitalizations.3
What is surprising about these stories is that hospitals have long been considered recession‐proof. Yet, with one‐half of US hospitals having reduced their staff to balance their budgets4 and with hospitals' financial margins falling dramatically,5 economic struggles are now a widespread problem.
Furthermore, it is difficult to determine if hospitals' clinical care has been damaged by the recession. The measurement of hospital quality is new and still under‐developed: there is virtually no reliable information on hospital quality from previous recessions, and even now it will be difficult to assess quality in real time.
Critics of waste and excess in the US health care system may see tough economic times as a Darwinian proving ground for hospitals, through which efficiency will improve and poor performers will close their doors. But more likely, hospital cutbacks will risk the quality and safety of health care delivery. For reasons of both public health and fiscal impact on communities, state and federal leaders may need to watch these trends closely to design and to be ready to implement potential government remedies for hospitals' fiscal woes.
In this commentary, we describe how hospitals have fared historically during recessions, how this recession could have different effectsfirst fiscally, then clinically, and we examine policy options to mitigate these untoward effects.
Decades of Recession‐Proof Hospitals
During the Great Depression, hospital insolvency was a national problem that prompted federal and state aid. Keeping hospitals alive was a critical policy goal and proved central to the early development of health insurance that focused on payment for hospital care.6
Since WWII, growth in America's hospitals has been only loosely related to national macroeconomic trends, with other changes like technological innovations and the advent of managed care far more influential to hospital finances. In fact, during recessions, hospital care spending growth often escalates in tandem with worsening unemployment (Figure 1). One explanation for this phenomenon is that economic pressures lead to declining primary care utilization, with adverse consequences for individuals' health.7
Hospitals' Current Fiscal Vulnerability
However, the current recession is the worst in 70 years. Every method of income generation available to hospitals appears at risk, including reimbursement per discharge (70% of hospitals report moderate or significant increases in uncompensated care), number of inpatient admissions (over one‐half report a moderate or significant decrease), difficulty obtaining bonds (60% report at least significant problems), and charitable donations.4 Over 50% of US hospitals had negative margins in the fourth quarter of 2008, though there has been some improvement since that time.8
Future hospital stability concerns remain. Growth in revenue per discharge is still below the norm.5 Because employment lags a recovering economy, further reimbursement decreases are possible from increasing proportions of patients with low‐reimbursing insurers or no coverage at all, decreasing payment rates from all payers, and decreasing elective care. The lower‐reimbursing payers, like state Medicaid programs, are experiencing increased enrollment as Americans lose their jobs and their better‐paying, employer‐sponsored private insurance.9 There's also evidence that reimbursement rates are declining from both Medicare and private insurers,10 which threatens the fragile cost‐shift through which hospitals have long used private insurance reimbursement to subsidize government reimbursements.11
Hospitals' specific financial challenges will likely vary across markets. The authors' state of Michigan has been hit particularly long and hard by the current recession. Unemployment rates exceeding 11% are expected to cause dramatic losses in private health insurance.9 Patients' increasing need with decreasing ability to pay will make markets in the deepest recession particularly vulnerable.
Hospital Quality and Safety at Risk?
The effect of the recession on the quality of hospital care is less clear. Until the 1990s, hospital quality was essentially assumed and virtually unmeasured. Even now, measuring hospital quality is difficult and rarely timely. Medicare data often take 1 to 2 years to become publicly available for analysis. Reports by trade organizations like the American Hospital Association are up‐to‐date but have conflicts of interest and are less rigorous. The most timely measures of hospitals' distressflawed as they may bewill come from the hospitals themselves, just like reports of economic woe from other businesses and government agencies during challenging economic times.
However, since the publication of the 1999 report To Err is Human,12 major improvements in hospital quality and safety have transformed the delivery of inpatient care. These improvements have taken the form of simple interventions like nationally consistent medical abbreviations, management initiatives like Six Sigma, and technological advances including computerized health records.
Nonetheless, during this recession and recovery, slashed hospital budgets may slow or even stop the momentum towards further improvements in quality and safety. Frontline care delivery could be at risk. Understaffed and under financed hospitals are rarely safe. Dissatisfaction and layoffs hurt the interactions between employees and patients. Robust nurse‐to‐patient ratios which have proven vital to patients' hospital outcomes could be at risk.13 Admittedly, recession‐induced threats to quality and safety are conjectures on our part: unfortunately, no recession measures of hospitals' specific spending on staffing, technology, or process improvements exist.
However, there are many small, evidence‐based changes that could improve hospital safety dramatically in the near future. Michigan's Keystone ICU Initiative showed that systematic interventions in routine care delivery could reduce the risk of catheter‐related bloodstream infections, which currently are implicated in the death of 28,000 Americans per year, to nearly zero.14 The Institute for Healthcare Improvement's 100,000 Lives Campaign also illustrated that dramatic improvements in hospital‐related mortality can occur with fairly focused interventions. In the month after discharge, more than one‐quarter of all hospitalized patients go to an emergency room or need to be rehospitalized. This rate can be cut by 30% by inserting a nurse discharge advocate into the discharge process.15 Instituting a simple safety checklist before surgery decreased surgery‐related mortality and complications by over one‐third.16
Such interventions are effective, reasonable, and widely accessible. Over the long‐term, many may even be cost‐saving. But, importantly, they all require an institutional investment in start‐up money and an organizational will to change how things have been done. In a period of recession with severe cost‐cutting, and a recovery period of cautious spending, this may not be possible.
A Possible Stimulus: Investing in Quality Initiatives at Fiscally Vulnerable Hospitals
It is not enough to keep hospitals' doors open in a recession. Hospitals must continue to improve the quality and safety of the care they delivervital for their future patients and also for their communities who depend on them as anchors of health systems. We believe there is a need for a new, federally supported alignment of hospital finance and hospital quality that can limit damage to hospitals, help community employment, and improve patient safety.
Timely, structural quality measures could speed the introduction of functional value‐based purchasing, promote hospital safety, and help local economies at the same time. There are many simple structural measures that could be examined, such as development of discharge coordinators, promoting effective nurse‐to‐patient ratios, and encouraging health information technology (IT). Importantly, this would not duplicate efforts already underway to promote quality with process measures. With effective financial monitoring in real time, these measures could focus on high‐risk, fiscally disadvantaged hospitals.
To its credit, the Obama administration has already reached out to support hospitals, although aid has not been targeted specifically to hospitals in the most dire financial circumstances. Along with support for Medicaid and community health centers to improve primary care during the recession, the administration has provided a $268 million increase in Disproportionate Share Hospital payments towards hospitals that care for vulnerable patients, an increase of about 3%.17 Concurrently, the Centers for Medicare and Medicaid Services are implementing a value‐based purchasing program that starts with a 5% withhold in reimbursement that institutions need to earn back through a combination of mortality, process, and patient satisfaction metrics.18 The administration also reserved $19 billion to promote improvement of health IT for American medicine.19
Using health IT investment to help hospitals is an appealing concept, but for many institutions the infrastructure required to make that transition directly competes with other patient needs, including bedside patient care. IT investments have large initial costs, at a time when bank loans are difficult to acquire and few organizations can make expensive capital improvements. In fact, one‐quarter of hospitals report scaling back health IT investments that they had already started, in spite of the stimulus funds available.4
Instead, the administration may have more influence on improving care delivery by focusing on connecting hospital safety with hospital financial stability, by appropriating stimulus funds to center on quality and safety programs like those described above. Here is how: a hospital that would receive stimulus money for employing nurse discharge advocates would preserve employment while advancing patient safety, as would a hospital that retains a nurse‐to‐patient ratio above a specified threshold. By focusing on measures of structural quality, the government could improve care in ways that are easy to measure and maximize local economic stimulus without difficult outcomes assessment, insurance reform, or duplicating process measure efforts. There could even be an innovation differential (ie, payment/reward) for hospitals that improve quality while holding flat or lowering overall costs.
Equally important is to use this national financial crisis as an opportunity to improve monitoring of hospital quality. While quality assessment of hospitals is difficult, increased federal awareness of local medical need, hospital financial stability, and government awareness of emergency services overcrowding, nurse‐to‐patient ratios, and IT utilization are all valuable and easy to measure.
None of these quality‐focused fiscal interventions would be guaranteed to prevent hospital closure. Especially in small population centers, hospital closures can affect an entire community's financial growth and clinical safety net,20 while leaving hundreds or even thousands unemployed. Hospital closure should be assessed by state and federal government officials in these larger terms, perhaps even encouraging closure when appropriate, and helping prevent it when necessary.
Conclusion
Hospitals, as complex pieces of America's health care system, are central to communities' safety and economic growth. While national health coverage reform, as currently being discussed in Washington, would make hospital infrastructure less sensitive to macroeconomic changes, major reform would not come fast enough if hospitals start closing. While the worst of the recession may be over, recovery and the continuing rise in unemployment is a tenuous lifeline for hospitals on the financial brink.
We are not arguing against all hospital layoffs, or even closures. Indeed, this recession is a lean time for most industries and is likely to lead to closures for hospitals that cannot compete on efficiency or quality. But a hospital closure is a major event for a community and should not be permitted to occur without thorough consideration of alternatives. Current data on hospitals' financial status and clinical safety are limited, potentially biased, and not timely enough for this rapidly changing economic crisis. Therefore, state and federal government officials should assess whether hospitals would be eligible not just for possible emergency loans, but for linking loans to quality of care and community need. In so doing, this difficult time could be an opportunity to help hospitals improve their care, rather than watching it diminish.
- Michigan's Health Care Safety Net: In Jeopardy.2009.
- .Final budget decisions.Running A Hospital. Vol 2009.Boston, MA;2009.
- .Doctors Plan to Limit Beds in ER.Wall Street Journal.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, DC2009.
- ,.Hospital Operational and Financial Performance Improving.Ann Arbor, MI:Thomson Reuters Center for Healthcare Improvement.2009.
- .The Social Transformation of American Medicine.New York, NY:Basic Books;1983.
- AAFP.Patient Care during the 2008‐2009 Recession – Online Survey.Leawood, KS:AAFP.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, D.C.:American Hospital Association.2009.
- The economic downturn and its impact on hospitals. American Hospital Association Trendwatch.2009.
- ,,.The Current Recession and U.S. Hospitals:Center for Healthcare Improvement.2009.
- ,,.The cost‐shift payment ‘hydraulic’: foundation, history, and implications.Health Aff (Millwood).2006;25(1):22–33.
- ,.To Err Is Human: Building a Safer Health System.Washington, DC:National Academy Press;1999.
- ,,,,.Nurse‐staffing levels and the quality of care in hospitals.N Engl J Med.2002;346(22):1715–1722.
- ,,, et al.An intervention to decrease catheter‐related bloodstream infections in the ICU.N Engl J Med.2006;355(26):2725–2732.
- ,,, et al.A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.Ann Intern Med.2009;150(3):178–187.
- ,,, et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med.2009;360(5):491–499.
- Disproportionate Share Hospital (DSH). Available at: http://www.hhs. gov/recovery/cms/dsh.html. Accessed December 2009.
- ,,.Measuring outcomes and efficiency in medicare value‐based purchasing.Health Aff (Millwood).2009;28(2):w251–w261.
- .Stimulating the adoption of health information technology.N Engl J Med.2009;360(15):1477–1479.
- ,,,.The effect of rural hospital closures on community economic health.Health Serv Res.2006;41(2):467–485.
With the United States mired in its most severe recession in decades, stories of hospital struggles have emerged. Beaumont Hospital, located near the headquarters of major automakers and several assembly plants outside Detroit, recently cut hundreds of jobs and put major construction on indefinite hold.1 The CEO of Boston's Beth Israel Deaconess Medical Center made an agreement with employees to take large cuts in pay and vacation time to prevent laying off 10% of the staff.2 The University of Chicago Medical Center made plans to limit the number of emergency room beds, thereby decreasing low‐reimbursing emergency admissions while making beds available for higher‐paying elective hospitalizations.3
What is surprising about these stories is that hospitals have long been considered recession‐proof. Yet, with one‐half of US hospitals having reduced their staff to balance their budgets4 and with hospitals' financial margins falling dramatically,5 economic struggles are now a widespread problem.
Furthermore, it is difficult to determine if hospitals' clinical care has been damaged by the recession. The measurement of hospital quality is new and still under‐developed: there is virtually no reliable information on hospital quality from previous recessions, and even now it will be difficult to assess quality in real time.
Critics of waste and excess in the US health care system may see tough economic times as a Darwinian proving ground for hospitals, through which efficiency will improve and poor performers will close their doors. But more likely, hospital cutbacks will risk the quality and safety of health care delivery. For reasons of both public health and fiscal impact on communities, state and federal leaders may need to watch these trends closely to design and to be ready to implement potential government remedies for hospitals' fiscal woes.
In this commentary, we describe how hospitals have fared historically during recessions, how this recession could have different effectsfirst fiscally, then clinically, and we examine policy options to mitigate these untoward effects.
Decades of Recession‐Proof Hospitals
During the Great Depression, hospital insolvency was a national problem that prompted federal and state aid. Keeping hospitals alive was a critical policy goal and proved central to the early development of health insurance that focused on payment for hospital care.6
Since WWII, growth in America's hospitals has been only loosely related to national macroeconomic trends, with other changes like technological innovations and the advent of managed care far more influential to hospital finances. In fact, during recessions, hospital care spending growth often escalates in tandem with worsening unemployment (Figure 1). One explanation for this phenomenon is that economic pressures lead to declining primary care utilization, with adverse consequences for individuals' health.7
Hospitals' Current Fiscal Vulnerability
However, the current recession is the worst in 70 years. Every method of income generation available to hospitals appears at risk, including reimbursement per discharge (70% of hospitals report moderate or significant increases in uncompensated care), number of inpatient admissions (over one‐half report a moderate or significant decrease), difficulty obtaining bonds (60% report at least significant problems), and charitable donations.4 Over 50% of US hospitals had negative margins in the fourth quarter of 2008, though there has been some improvement since that time.8
Future hospital stability concerns remain. Growth in revenue per discharge is still below the norm.5 Because employment lags a recovering economy, further reimbursement decreases are possible from increasing proportions of patients with low‐reimbursing insurers or no coverage at all, decreasing payment rates from all payers, and decreasing elective care. The lower‐reimbursing payers, like state Medicaid programs, are experiencing increased enrollment as Americans lose their jobs and their better‐paying, employer‐sponsored private insurance.9 There's also evidence that reimbursement rates are declining from both Medicare and private insurers,10 which threatens the fragile cost‐shift through which hospitals have long used private insurance reimbursement to subsidize government reimbursements.11
Hospitals' specific financial challenges will likely vary across markets. The authors' state of Michigan has been hit particularly long and hard by the current recession. Unemployment rates exceeding 11% are expected to cause dramatic losses in private health insurance.9 Patients' increasing need with decreasing ability to pay will make markets in the deepest recession particularly vulnerable.
Hospital Quality and Safety at Risk?
The effect of the recession on the quality of hospital care is less clear. Until the 1990s, hospital quality was essentially assumed and virtually unmeasured. Even now, measuring hospital quality is difficult and rarely timely. Medicare data often take 1 to 2 years to become publicly available for analysis. Reports by trade organizations like the American Hospital Association are up‐to‐date but have conflicts of interest and are less rigorous. The most timely measures of hospitals' distressflawed as they may bewill come from the hospitals themselves, just like reports of economic woe from other businesses and government agencies during challenging economic times.
However, since the publication of the 1999 report To Err is Human,12 major improvements in hospital quality and safety have transformed the delivery of inpatient care. These improvements have taken the form of simple interventions like nationally consistent medical abbreviations, management initiatives like Six Sigma, and technological advances including computerized health records.
Nonetheless, during this recession and recovery, slashed hospital budgets may slow or even stop the momentum towards further improvements in quality and safety. Frontline care delivery could be at risk. Understaffed and under financed hospitals are rarely safe. Dissatisfaction and layoffs hurt the interactions between employees and patients. Robust nurse‐to‐patient ratios which have proven vital to patients' hospital outcomes could be at risk.13 Admittedly, recession‐induced threats to quality and safety are conjectures on our part: unfortunately, no recession measures of hospitals' specific spending on staffing, technology, or process improvements exist.
However, there are many small, evidence‐based changes that could improve hospital safety dramatically in the near future. Michigan's Keystone ICU Initiative showed that systematic interventions in routine care delivery could reduce the risk of catheter‐related bloodstream infections, which currently are implicated in the death of 28,000 Americans per year, to nearly zero.14 The Institute for Healthcare Improvement's 100,000 Lives Campaign also illustrated that dramatic improvements in hospital‐related mortality can occur with fairly focused interventions. In the month after discharge, more than one‐quarter of all hospitalized patients go to an emergency room or need to be rehospitalized. This rate can be cut by 30% by inserting a nurse discharge advocate into the discharge process.15 Instituting a simple safety checklist before surgery decreased surgery‐related mortality and complications by over one‐third.16
Such interventions are effective, reasonable, and widely accessible. Over the long‐term, many may even be cost‐saving. But, importantly, they all require an institutional investment in start‐up money and an organizational will to change how things have been done. In a period of recession with severe cost‐cutting, and a recovery period of cautious spending, this may not be possible.
A Possible Stimulus: Investing in Quality Initiatives at Fiscally Vulnerable Hospitals
It is not enough to keep hospitals' doors open in a recession. Hospitals must continue to improve the quality and safety of the care they delivervital for their future patients and also for their communities who depend on them as anchors of health systems. We believe there is a need for a new, federally supported alignment of hospital finance and hospital quality that can limit damage to hospitals, help community employment, and improve patient safety.
Timely, structural quality measures could speed the introduction of functional value‐based purchasing, promote hospital safety, and help local economies at the same time. There are many simple structural measures that could be examined, such as development of discharge coordinators, promoting effective nurse‐to‐patient ratios, and encouraging health information technology (IT). Importantly, this would not duplicate efforts already underway to promote quality with process measures. With effective financial monitoring in real time, these measures could focus on high‐risk, fiscally disadvantaged hospitals.
To its credit, the Obama administration has already reached out to support hospitals, although aid has not been targeted specifically to hospitals in the most dire financial circumstances. Along with support for Medicaid and community health centers to improve primary care during the recession, the administration has provided a $268 million increase in Disproportionate Share Hospital payments towards hospitals that care for vulnerable patients, an increase of about 3%.17 Concurrently, the Centers for Medicare and Medicaid Services are implementing a value‐based purchasing program that starts with a 5% withhold in reimbursement that institutions need to earn back through a combination of mortality, process, and patient satisfaction metrics.18 The administration also reserved $19 billion to promote improvement of health IT for American medicine.19
Using health IT investment to help hospitals is an appealing concept, but for many institutions the infrastructure required to make that transition directly competes with other patient needs, including bedside patient care. IT investments have large initial costs, at a time when bank loans are difficult to acquire and few organizations can make expensive capital improvements. In fact, one‐quarter of hospitals report scaling back health IT investments that they had already started, in spite of the stimulus funds available.4
Instead, the administration may have more influence on improving care delivery by focusing on connecting hospital safety with hospital financial stability, by appropriating stimulus funds to center on quality and safety programs like those described above. Here is how: a hospital that would receive stimulus money for employing nurse discharge advocates would preserve employment while advancing patient safety, as would a hospital that retains a nurse‐to‐patient ratio above a specified threshold. By focusing on measures of structural quality, the government could improve care in ways that are easy to measure and maximize local economic stimulus without difficult outcomes assessment, insurance reform, or duplicating process measure efforts. There could even be an innovation differential (ie, payment/reward) for hospitals that improve quality while holding flat or lowering overall costs.
Equally important is to use this national financial crisis as an opportunity to improve monitoring of hospital quality. While quality assessment of hospitals is difficult, increased federal awareness of local medical need, hospital financial stability, and government awareness of emergency services overcrowding, nurse‐to‐patient ratios, and IT utilization are all valuable and easy to measure.
None of these quality‐focused fiscal interventions would be guaranteed to prevent hospital closure. Especially in small population centers, hospital closures can affect an entire community's financial growth and clinical safety net,20 while leaving hundreds or even thousands unemployed. Hospital closure should be assessed by state and federal government officials in these larger terms, perhaps even encouraging closure when appropriate, and helping prevent it when necessary.
Conclusion
Hospitals, as complex pieces of America's health care system, are central to communities' safety and economic growth. While national health coverage reform, as currently being discussed in Washington, would make hospital infrastructure less sensitive to macroeconomic changes, major reform would not come fast enough if hospitals start closing. While the worst of the recession may be over, recovery and the continuing rise in unemployment is a tenuous lifeline for hospitals on the financial brink.
We are not arguing against all hospital layoffs, or even closures. Indeed, this recession is a lean time for most industries and is likely to lead to closures for hospitals that cannot compete on efficiency or quality. But a hospital closure is a major event for a community and should not be permitted to occur without thorough consideration of alternatives. Current data on hospitals' financial status and clinical safety are limited, potentially biased, and not timely enough for this rapidly changing economic crisis. Therefore, state and federal government officials should assess whether hospitals would be eligible not just for possible emergency loans, but for linking loans to quality of care and community need. In so doing, this difficult time could be an opportunity to help hospitals improve their care, rather than watching it diminish.
With the United States mired in its most severe recession in decades, stories of hospital struggles have emerged. Beaumont Hospital, located near the headquarters of major automakers and several assembly plants outside Detroit, recently cut hundreds of jobs and put major construction on indefinite hold.1 The CEO of Boston's Beth Israel Deaconess Medical Center made an agreement with employees to take large cuts in pay and vacation time to prevent laying off 10% of the staff.2 The University of Chicago Medical Center made plans to limit the number of emergency room beds, thereby decreasing low‐reimbursing emergency admissions while making beds available for higher‐paying elective hospitalizations.3
What is surprising about these stories is that hospitals have long been considered recession‐proof. Yet, with one‐half of US hospitals having reduced their staff to balance their budgets4 and with hospitals' financial margins falling dramatically,5 economic struggles are now a widespread problem.
Furthermore, it is difficult to determine if hospitals' clinical care has been damaged by the recession. The measurement of hospital quality is new and still under‐developed: there is virtually no reliable information on hospital quality from previous recessions, and even now it will be difficult to assess quality in real time.
Critics of waste and excess in the US health care system may see tough economic times as a Darwinian proving ground for hospitals, through which efficiency will improve and poor performers will close their doors. But more likely, hospital cutbacks will risk the quality and safety of health care delivery. For reasons of both public health and fiscal impact on communities, state and federal leaders may need to watch these trends closely to design and to be ready to implement potential government remedies for hospitals' fiscal woes.
In this commentary, we describe how hospitals have fared historically during recessions, how this recession could have different effectsfirst fiscally, then clinically, and we examine policy options to mitigate these untoward effects.
Decades of Recession‐Proof Hospitals
During the Great Depression, hospital insolvency was a national problem that prompted federal and state aid. Keeping hospitals alive was a critical policy goal and proved central to the early development of health insurance that focused on payment for hospital care.6
Since WWII, growth in America's hospitals has been only loosely related to national macroeconomic trends, with other changes like technological innovations and the advent of managed care far more influential to hospital finances. In fact, during recessions, hospital care spending growth often escalates in tandem with worsening unemployment (Figure 1). One explanation for this phenomenon is that economic pressures lead to declining primary care utilization, with adverse consequences for individuals' health.7
Hospitals' Current Fiscal Vulnerability
However, the current recession is the worst in 70 years. Every method of income generation available to hospitals appears at risk, including reimbursement per discharge (70% of hospitals report moderate or significant increases in uncompensated care), number of inpatient admissions (over one‐half report a moderate or significant decrease), difficulty obtaining bonds (60% report at least significant problems), and charitable donations.4 Over 50% of US hospitals had negative margins in the fourth quarter of 2008, though there has been some improvement since that time.8
Future hospital stability concerns remain. Growth in revenue per discharge is still below the norm.5 Because employment lags a recovering economy, further reimbursement decreases are possible from increasing proportions of patients with low‐reimbursing insurers or no coverage at all, decreasing payment rates from all payers, and decreasing elective care. The lower‐reimbursing payers, like state Medicaid programs, are experiencing increased enrollment as Americans lose their jobs and their better‐paying, employer‐sponsored private insurance.9 There's also evidence that reimbursement rates are declining from both Medicare and private insurers,10 which threatens the fragile cost‐shift through which hospitals have long used private insurance reimbursement to subsidize government reimbursements.11
Hospitals' specific financial challenges will likely vary across markets. The authors' state of Michigan has been hit particularly long and hard by the current recession. Unemployment rates exceeding 11% are expected to cause dramatic losses in private health insurance.9 Patients' increasing need with decreasing ability to pay will make markets in the deepest recession particularly vulnerable.
Hospital Quality and Safety at Risk?
The effect of the recession on the quality of hospital care is less clear. Until the 1990s, hospital quality was essentially assumed and virtually unmeasured. Even now, measuring hospital quality is difficult and rarely timely. Medicare data often take 1 to 2 years to become publicly available for analysis. Reports by trade organizations like the American Hospital Association are up‐to‐date but have conflicts of interest and are less rigorous. The most timely measures of hospitals' distressflawed as they may bewill come from the hospitals themselves, just like reports of economic woe from other businesses and government agencies during challenging economic times.
However, since the publication of the 1999 report To Err is Human,12 major improvements in hospital quality and safety have transformed the delivery of inpatient care. These improvements have taken the form of simple interventions like nationally consistent medical abbreviations, management initiatives like Six Sigma, and technological advances including computerized health records.
Nonetheless, during this recession and recovery, slashed hospital budgets may slow or even stop the momentum towards further improvements in quality and safety. Frontline care delivery could be at risk. Understaffed and under financed hospitals are rarely safe. Dissatisfaction and layoffs hurt the interactions between employees and patients. Robust nurse‐to‐patient ratios which have proven vital to patients' hospital outcomes could be at risk.13 Admittedly, recession‐induced threats to quality and safety are conjectures on our part: unfortunately, no recession measures of hospitals' specific spending on staffing, technology, or process improvements exist.
However, there are many small, evidence‐based changes that could improve hospital safety dramatically in the near future. Michigan's Keystone ICU Initiative showed that systematic interventions in routine care delivery could reduce the risk of catheter‐related bloodstream infections, which currently are implicated in the death of 28,000 Americans per year, to nearly zero.14 The Institute for Healthcare Improvement's 100,000 Lives Campaign also illustrated that dramatic improvements in hospital‐related mortality can occur with fairly focused interventions. In the month after discharge, more than one‐quarter of all hospitalized patients go to an emergency room or need to be rehospitalized. This rate can be cut by 30% by inserting a nurse discharge advocate into the discharge process.15 Instituting a simple safety checklist before surgery decreased surgery‐related mortality and complications by over one‐third.16
Such interventions are effective, reasonable, and widely accessible. Over the long‐term, many may even be cost‐saving. But, importantly, they all require an institutional investment in start‐up money and an organizational will to change how things have been done. In a period of recession with severe cost‐cutting, and a recovery period of cautious spending, this may not be possible.
A Possible Stimulus: Investing in Quality Initiatives at Fiscally Vulnerable Hospitals
It is not enough to keep hospitals' doors open in a recession. Hospitals must continue to improve the quality and safety of the care they delivervital for their future patients and also for their communities who depend on them as anchors of health systems. We believe there is a need for a new, federally supported alignment of hospital finance and hospital quality that can limit damage to hospitals, help community employment, and improve patient safety.
Timely, structural quality measures could speed the introduction of functional value‐based purchasing, promote hospital safety, and help local economies at the same time. There are many simple structural measures that could be examined, such as development of discharge coordinators, promoting effective nurse‐to‐patient ratios, and encouraging health information technology (IT). Importantly, this would not duplicate efforts already underway to promote quality with process measures. With effective financial monitoring in real time, these measures could focus on high‐risk, fiscally disadvantaged hospitals.
To its credit, the Obama administration has already reached out to support hospitals, although aid has not been targeted specifically to hospitals in the most dire financial circumstances. Along with support for Medicaid and community health centers to improve primary care during the recession, the administration has provided a $268 million increase in Disproportionate Share Hospital payments towards hospitals that care for vulnerable patients, an increase of about 3%.17 Concurrently, the Centers for Medicare and Medicaid Services are implementing a value‐based purchasing program that starts with a 5% withhold in reimbursement that institutions need to earn back through a combination of mortality, process, and patient satisfaction metrics.18 The administration also reserved $19 billion to promote improvement of health IT for American medicine.19
Using health IT investment to help hospitals is an appealing concept, but for many institutions the infrastructure required to make that transition directly competes with other patient needs, including bedside patient care. IT investments have large initial costs, at a time when bank loans are difficult to acquire and few organizations can make expensive capital improvements. In fact, one‐quarter of hospitals report scaling back health IT investments that they had already started, in spite of the stimulus funds available.4
Instead, the administration may have more influence on improving care delivery by focusing on connecting hospital safety with hospital financial stability, by appropriating stimulus funds to center on quality and safety programs like those described above. Here is how: a hospital that would receive stimulus money for employing nurse discharge advocates would preserve employment while advancing patient safety, as would a hospital that retains a nurse‐to‐patient ratio above a specified threshold. By focusing on measures of structural quality, the government could improve care in ways that are easy to measure and maximize local economic stimulus without difficult outcomes assessment, insurance reform, or duplicating process measure efforts. There could even be an innovation differential (ie, payment/reward) for hospitals that improve quality while holding flat or lowering overall costs.
Equally important is to use this national financial crisis as an opportunity to improve monitoring of hospital quality. While quality assessment of hospitals is difficult, increased federal awareness of local medical need, hospital financial stability, and government awareness of emergency services overcrowding, nurse‐to‐patient ratios, and IT utilization are all valuable and easy to measure.
None of these quality‐focused fiscal interventions would be guaranteed to prevent hospital closure. Especially in small population centers, hospital closures can affect an entire community's financial growth and clinical safety net,20 while leaving hundreds or even thousands unemployed. Hospital closure should be assessed by state and federal government officials in these larger terms, perhaps even encouraging closure when appropriate, and helping prevent it when necessary.
Conclusion
Hospitals, as complex pieces of America's health care system, are central to communities' safety and economic growth. While national health coverage reform, as currently being discussed in Washington, would make hospital infrastructure less sensitive to macroeconomic changes, major reform would not come fast enough if hospitals start closing. While the worst of the recession may be over, recovery and the continuing rise in unemployment is a tenuous lifeline for hospitals on the financial brink.
We are not arguing against all hospital layoffs, or even closures. Indeed, this recession is a lean time for most industries and is likely to lead to closures for hospitals that cannot compete on efficiency or quality. But a hospital closure is a major event for a community and should not be permitted to occur without thorough consideration of alternatives. Current data on hospitals' financial status and clinical safety are limited, potentially biased, and not timely enough for this rapidly changing economic crisis. Therefore, state and federal government officials should assess whether hospitals would be eligible not just for possible emergency loans, but for linking loans to quality of care and community need. In so doing, this difficult time could be an opportunity to help hospitals improve their care, rather than watching it diminish.
- Michigan's Health Care Safety Net: In Jeopardy.2009.
- .Final budget decisions.Running A Hospital. Vol 2009.Boston, MA;2009.
- .Doctors Plan to Limit Beds in ER.Wall Street Journal.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, DC2009.
- ,.Hospital Operational and Financial Performance Improving.Ann Arbor, MI:Thomson Reuters Center for Healthcare Improvement.2009.
- .The Social Transformation of American Medicine.New York, NY:Basic Books;1983.
- AAFP.Patient Care during the 2008‐2009 Recession – Online Survey.Leawood, KS:AAFP.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, D.C.:American Hospital Association.2009.
- The economic downturn and its impact on hospitals. American Hospital Association Trendwatch.2009.
- ,,.The Current Recession and U.S. Hospitals:Center for Healthcare Improvement.2009.
- ,,.The cost‐shift payment ‘hydraulic’: foundation, history, and implications.Health Aff (Millwood).2006;25(1):22–33.
- ,.To Err Is Human: Building a Safer Health System.Washington, DC:National Academy Press;1999.
- ,,,,.Nurse‐staffing levels and the quality of care in hospitals.N Engl J Med.2002;346(22):1715–1722.
- ,,, et al.An intervention to decrease catheter‐related bloodstream infections in the ICU.N Engl J Med.2006;355(26):2725–2732.
- ,,, et al.A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.Ann Intern Med.2009;150(3):178–187.
- ,,, et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med.2009;360(5):491–499.
- Disproportionate Share Hospital (DSH). Available at: http://www.hhs. gov/recovery/cms/dsh.html. Accessed December 2009.
- ,,.Measuring outcomes and efficiency in medicare value‐based purchasing.Health Aff (Millwood).2009;28(2):w251–w261.
- .Stimulating the adoption of health information technology.N Engl J Med.2009;360(15):1477–1479.
- ,,,.The effect of rural hospital closures on community economic health.Health Serv Res.2006;41(2):467–485.
- Michigan's Health Care Safety Net: In Jeopardy.2009.
- .Final budget decisions.Running A Hospital. Vol 2009.Boston, MA;2009.
- .Doctors Plan to Limit Beds in ER.Wall Street Journal.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, DC2009.
- ,.Hospital Operational and Financial Performance Improving.Ann Arbor, MI:Thomson Reuters Center for Healthcare Improvement.2009.
- .The Social Transformation of American Medicine.New York, NY:Basic Books;1983.
- AAFP.Patient Care during the 2008‐2009 Recession – Online Survey.Leawood, KS:AAFP.2009.
- The Impact of the Economic Crisis on Health Services for Patients and Communities.Washington, D.C.:American Hospital Association.2009.
- The economic downturn and its impact on hospitals. American Hospital Association Trendwatch.2009.
- ,,.The Current Recession and U.S. Hospitals:Center for Healthcare Improvement.2009.
- ,,.The cost‐shift payment ‘hydraulic’: foundation, history, and implications.Health Aff (Millwood).2006;25(1):22–33.
- ,.To Err Is Human: Building a Safer Health System.Washington, DC:National Academy Press;1999.
- ,,,,.Nurse‐staffing levels and the quality of care in hospitals.N Engl J Med.2002;346(22):1715–1722.
- ,,, et al.An intervention to decrease catheter‐related bloodstream infections in the ICU.N Engl J Med.2006;355(26):2725–2732.
- ,,, et al.A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.Ann Intern Med.2009;150(3):178–187.
- ,,, et al.A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med.2009;360(5):491–499.
- Disproportionate Share Hospital (DSH). Available at: http://www.hhs. gov/recovery/cms/dsh.html. Accessed December 2009.
- ,,.Measuring outcomes and efficiency in medicare value‐based purchasing.Health Aff (Millwood).2009;28(2):w251–w261.
- .Stimulating the adoption of health information technology.N Engl J Med.2009;360(15):1477–1479.
- ,,,.The effect of rural hospital closures on community economic health.Health Serv Res.2006;41(2):467–485.
New Resident Regulations on the Horizon
The Accreditation Council for Graduate Medical Education (ACGME) task force is close to offering revised standards for medical resident work hours—a decision that could significantly change the landscape for academic hospitalist programs.
While no date has been set for the unveiling, a May 4 letter written by ACGME CEO Thomas Nasca, MD, MACP, says “the work of the task force is nearly complete.” Many expect the rules will be offered as a draft for public comment in the coming weeks. If approved, the new regulations would probably take effect in July 2011. ACGME formed the task force more than a year ago as the prescribed five-year update to the landmark 2003 duty-hour standards.
Medical experts say the new rules will in many ways mirror the recommendations of the Institute of Medicine’s 2008 report “Resident Duty Hours: Enhancing Sleep, Supervision and Safety.” The oft-quoted report recommended residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.
Many HM physicians expect the new ACGME rules will include a 60-hour workweek cap, part of a growing trend to try to balance the educational requirements of medical school with the need to expose residents to practical experience. Dr. Nasca gave no hint as to what ACGME’s recommendations will be.
In an article in this month’s The Hospitalist, academic and community hospitalists say they have been keeping on eye on how the newest rules will change their playing fields: Will a wave of academics flee teaching hospitals, as additional clinical duties become an intrusion? Will teaching hospitals face financial pressure as they struggle to replace the lower-cost labor force that residents represent? And—perhaps most importantly from a medical perspective—will graduate trainees be as prepared as their predecessors when they enter practice?
“Hospitalists will always be involved in teaching—it will never go away,” says Julia Wright, MD, FHM, a member of Team Hospitalist and clinical associate professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison. “But it will be a very different balance, a different kind of feel.”
The Accreditation Council for Graduate Medical Education (ACGME) task force is close to offering revised standards for medical resident work hours—a decision that could significantly change the landscape for academic hospitalist programs.
While no date has been set for the unveiling, a May 4 letter written by ACGME CEO Thomas Nasca, MD, MACP, says “the work of the task force is nearly complete.” Many expect the rules will be offered as a draft for public comment in the coming weeks. If approved, the new regulations would probably take effect in July 2011. ACGME formed the task force more than a year ago as the prescribed five-year update to the landmark 2003 duty-hour standards.
Medical experts say the new rules will in many ways mirror the recommendations of the Institute of Medicine’s 2008 report “Resident Duty Hours: Enhancing Sleep, Supervision and Safety.” The oft-quoted report recommended residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.
Many HM physicians expect the new ACGME rules will include a 60-hour workweek cap, part of a growing trend to try to balance the educational requirements of medical school with the need to expose residents to practical experience. Dr. Nasca gave no hint as to what ACGME’s recommendations will be.
In an article in this month’s The Hospitalist, academic and community hospitalists say they have been keeping on eye on how the newest rules will change their playing fields: Will a wave of academics flee teaching hospitals, as additional clinical duties become an intrusion? Will teaching hospitals face financial pressure as they struggle to replace the lower-cost labor force that residents represent? And—perhaps most importantly from a medical perspective—will graduate trainees be as prepared as their predecessors when they enter practice?
“Hospitalists will always be involved in teaching—it will never go away,” says Julia Wright, MD, FHM, a member of Team Hospitalist and clinical associate professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison. “But it will be a very different balance, a different kind of feel.”
The Accreditation Council for Graduate Medical Education (ACGME) task force is close to offering revised standards for medical resident work hours—a decision that could significantly change the landscape for academic hospitalist programs.
While no date has been set for the unveiling, a May 4 letter written by ACGME CEO Thomas Nasca, MD, MACP, says “the work of the task force is nearly complete.” Many expect the rules will be offered as a draft for public comment in the coming weeks. If approved, the new regulations would probably take effect in July 2011. ACGME formed the task force more than a year ago as the prescribed five-year update to the landmark 2003 duty-hour standards.
Medical experts say the new rules will in many ways mirror the recommendations of the Institute of Medicine’s 2008 report “Resident Duty Hours: Enhancing Sleep, Supervision and Safety.” The oft-quoted report recommended residents only treat patients for up to 16 hours during their shift, down from the current recommendation of 24 hours. It also suggests residents take an uninterrupted five hours for a continuous sleep period between 10 p.m. and 8 a.m.
Many HM physicians expect the new ACGME rules will include a 60-hour workweek cap, part of a growing trend to try to balance the educational requirements of medical school with the need to expose residents to practical experience. Dr. Nasca gave no hint as to what ACGME’s recommendations will be.
In an article in this month’s The Hospitalist, academic and community hospitalists say they have been keeping on eye on how the newest rules will change their playing fields: Will a wave of academics flee teaching hospitals, as additional clinical duties become an intrusion? Will teaching hospitals face financial pressure as they struggle to replace the lower-cost labor force that residents represent? And—perhaps most importantly from a medical perspective—will graduate trainees be as prepared as their predecessors when they enter practice?
“Hospitalists will always be involved in teaching—it will never go away,” says Julia Wright, MD, FHM, a member of Team Hospitalist and clinical associate professor of medicine and director of hospital medicine at the University of Wisconsin School of Medicine and Public Health in Madison. “But it will be a very different balance, a different kind of feel.”
In the Literature: Research You Need to Know
Clinical question: Is recombinant tissue-type plasminogen activator (rt-PA) at 50 mg/2 hr as effective and safe as 100 mg/2 hr for acute pulmonary thromboembolism (PTE)?
Background: The U.S. Food and Drug Administration approved a 100 mg/2 hr dose of rt-PA, which has been recommended as the standard regimen for PTE. Lower doses potentially have less bleeding but their clinical efficacy in PTE has not yet been evaluated. If efficacious, rt-PA at 50 mg/2 hr used for treating acute MI might prove to be a better regimen for acute PTE.
Study design: Prospective, randomized, open-label, multicenter trial.
Setting: Multiple centers in China.
Synopsis: 118 patients with PTE, with either hemodynamic instability or anatomically massive obstruction, were assigned to receive rt-PA at 50 mg/2 hr (n=65) or 100 mg/2 hr (n=53) and followed for 14 days. Clinical efficacy as serially measured by improvement in pulmonary artery pressure and right ventricular function on echocardiogram, lung perfusion on V/Q scan, and pulmonary artery obstruction by CTPA was not significantly different between the two groups.
Though mortality was not significantly different between both groups (three in the high-dose group and one in the low-dose group), there was one fatal ICH in the high-dose group. As can be expected, total bleeding prevalence (major and minor) was lower in the 50-mg group (17% vs. 32%, p=0.084), especially in patients with body weight <65 kgs or BMI <24 kg/m2.
The fact that two-thirds of the patients had only anatomically massive PTE without any hemodynamic instability limits the extrapolation of the efficacy of low-dose rt-PA because heparin alone is generally used in these cases. Also, patients with body weight >100 kg may need the higher dose but were not evaluated adequately in this study.
Bottom line: A lower-dose regimen of 50 mg/2 hr of rt-PA is as efficacious as 100 mg/2 hr in treatment of PTE but offers a better safety profile in patients with weight <65kg.
Citation: Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010;137(2):254-262.
Clinical question: Is recombinant tissue-type plasminogen activator (rt-PA) at 50 mg/2 hr as effective and safe as 100 mg/2 hr for acute pulmonary thromboembolism (PTE)?
Background: The U.S. Food and Drug Administration approved a 100 mg/2 hr dose of rt-PA, which has been recommended as the standard regimen for PTE. Lower doses potentially have less bleeding but their clinical efficacy in PTE has not yet been evaluated. If efficacious, rt-PA at 50 mg/2 hr used for treating acute MI might prove to be a better regimen for acute PTE.
Study design: Prospective, randomized, open-label, multicenter trial.
Setting: Multiple centers in China.
Synopsis: 118 patients with PTE, with either hemodynamic instability or anatomically massive obstruction, were assigned to receive rt-PA at 50 mg/2 hr (n=65) or 100 mg/2 hr (n=53) and followed for 14 days. Clinical efficacy as serially measured by improvement in pulmonary artery pressure and right ventricular function on echocardiogram, lung perfusion on V/Q scan, and pulmonary artery obstruction by CTPA was not significantly different between the two groups.
Though mortality was not significantly different between both groups (three in the high-dose group and one in the low-dose group), there was one fatal ICH in the high-dose group. As can be expected, total bleeding prevalence (major and minor) was lower in the 50-mg group (17% vs. 32%, p=0.084), especially in patients with body weight <65 kgs or BMI <24 kg/m2.
The fact that two-thirds of the patients had only anatomically massive PTE without any hemodynamic instability limits the extrapolation of the efficacy of low-dose rt-PA because heparin alone is generally used in these cases. Also, patients with body weight >100 kg may need the higher dose but were not evaluated adequately in this study.
Bottom line: A lower-dose regimen of 50 mg/2 hr of rt-PA is as efficacious as 100 mg/2 hr in treatment of PTE but offers a better safety profile in patients with weight <65kg.
Citation: Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010;137(2):254-262.
Clinical question: Is recombinant tissue-type plasminogen activator (rt-PA) at 50 mg/2 hr as effective and safe as 100 mg/2 hr for acute pulmonary thromboembolism (PTE)?
Background: The U.S. Food and Drug Administration approved a 100 mg/2 hr dose of rt-PA, which has been recommended as the standard regimen for PTE. Lower doses potentially have less bleeding but their clinical efficacy in PTE has not yet been evaluated. If efficacious, rt-PA at 50 mg/2 hr used for treating acute MI might prove to be a better regimen for acute PTE.
Study design: Prospective, randomized, open-label, multicenter trial.
Setting: Multiple centers in China.
Synopsis: 118 patients with PTE, with either hemodynamic instability or anatomically massive obstruction, were assigned to receive rt-PA at 50 mg/2 hr (n=65) or 100 mg/2 hr (n=53) and followed for 14 days. Clinical efficacy as serially measured by improvement in pulmonary artery pressure and right ventricular function on echocardiogram, lung perfusion on V/Q scan, and pulmonary artery obstruction by CTPA was not significantly different between the two groups.
Though mortality was not significantly different between both groups (three in the high-dose group and one in the low-dose group), there was one fatal ICH in the high-dose group. As can be expected, total bleeding prevalence (major and minor) was lower in the 50-mg group (17% vs. 32%, p=0.084), especially in patients with body weight <65 kgs or BMI <24 kg/m2.
The fact that two-thirds of the patients had only anatomically massive PTE without any hemodynamic instability limits the extrapolation of the efficacy of low-dose rt-PA because heparin alone is generally used in these cases. Also, patients with body weight >100 kg may need the higher dose but were not evaluated adequately in this study.
Bottom line: A lower-dose regimen of 50 mg/2 hr of rt-PA is as efficacious as 100 mg/2 hr in treatment of PTE but offers a better safety profile in patients with weight <65kg.
Citation: Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010;137(2):254-262.
ONLINE EXCLUSIVE: Workforce Readiness
In the battle over how to best cope with the changing landscape of medical training, a key front could be job descriptions. That’s right: job descriptions.
“It behooves a program to define what and who they are, and follow it through in the hiring process,” says Ken Simone, DO, FHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and author of the recently published Hospitalist Recruitment and Retention: Building a Hospital Medicine Program (Hoboken, N.J.: Wiley-Blackwell, 2010).
Dr. Simone, a member of Team Hospitalist, notes that the way any successful program—private, academic, or community—hires and keeps quality staff is to attract like-minded physicians.
For younger physicians, he says a major factor in job selection is the role of mentoring. And in the wake of new and potentially continuing changes to the training that residents are allowed to experience, that training role becomes even more important. “The good news is we can basically mold this person and we can support this person, so they become the provider we want them to be, as opposed to an experienced doctor who has habits they won’t change,” Dr. Simone says.
—Ken Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine
And while much of the discussion about residency regulations focuses on potential downsides, Dr. Simone quickly points out that post-graduate physicians often are well versed in technology, evidence-based protocols, and other modern techniques that older physicians are reticent to adopt.
“Although we recognize that recruiting is challenging, that’s not been something that has prohibited [HM] from agreeing to be the solution here,” says Shaun Frost, MD, FACP, FHM, regional director for Cogent Healthcare in St. Paul, Minn., and an SHM board member. “With education, training, and mentoring, young hospitalists fresh out of their residencies can learn to practice as efficiently as so-called 20th-century residents.”
Richard Quinn is a freelance writer based in New Jersey.
In the battle over how to best cope with the changing landscape of medical training, a key front could be job descriptions. That’s right: job descriptions.
“It behooves a program to define what and who they are, and follow it through in the hiring process,” says Ken Simone, DO, FHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and author of the recently published Hospitalist Recruitment and Retention: Building a Hospital Medicine Program (Hoboken, N.J.: Wiley-Blackwell, 2010).
Dr. Simone, a member of Team Hospitalist, notes that the way any successful program—private, academic, or community—hires and keeps quality staff is to attract like-minded physicians.
For younger physicians, he says a major factor in job selection is the role of mentoring. And in the wake of new and potentially continuing changes to the training that residents are allowed to experience, that training role becomes even more important. “The good news is we can basically mold this person and we can support this person, so they become the provider we want them to be, as opposed to an experienced doctor who has habits they won’t change,” Dr. Simone says.
—Ken Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine
And while much of the discussion about residency regulations focuses on potential downsides, Dr. Simone quickly points out that post-graduate physicians often are well versed in technology, evidence-based protocols, and other modern techniques that older physicians are reticent to adopt.
“Although we recognize that recruiting is challenging, that’s not been something that has prohibited [HM] from agreeing to be the solution here,” says Shaun Frost, MD, FACP, FHM, regional director for Cogent Healthcare in St. Paul, Minn., and an SHM board member. “With education, training, and mentoring, young hospitalists fresh out of their residencies can learn to practice as efficiently as so-called 20th-century residents.”
Richard Quinn is a freelance writer based in New Jersey.
In the battle over how to best cope with the changing landscape of medical training, a key front could be job descriptions. That’s right: job descriptions.
“It behooves a program to define what and who they are, and follow it through in the hiring process,” says Ken Simone, DO, FHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and author of the recently published Hospitalist Recruitment and Retention: Building a Hospital Medicine Program (Hoboken, N.J.: Wiley-Blackwell, 2010).
Dr. Simone, a member of Team Hospitalist, notes that the way any successful program—private, academic, or community—hires and keeps quality staff is to attract like-minded physicians.
For younger physicians, he says a major factor in job selection is the role of mentoring. And in the wake of new and potentially continuing changes to the training that residents are allowed to experience, that training role becomes even more important. “The good news is we can basically mold this person and we can support this person, so they become the provider we want them to be, as opposed to an experienced doctor who has habits they won’t change,” Dr. Simone says.
—Ken Simone, DO, FHM, president, Hospitalist and Practice Solutions, Veazie, Maine
And while much of the discussion about residency regulations focuses on potential downsides, Dr. Simone quickly points out that post-graduate physicians often are well versed in technology, evidence-based protocols, and other modern techniques that older physicians are reticent to adopt.
“Although we recognize that recruiting is challenging, that’s not been something that has prohibited [HM] from agreeing to be the solution here,” says Shaun Frost, MD, FACP, FHM, regional director for Cogent Healthcare in St. Paul, Minn., and an SHM board member. “With education, training, and mentoring, young hospitalists fresh out of their residencies can learn to practice as efficiently as so-called 20th-century residents.”
Richard Quinn is a freelance writer based in New Jersey.
ONLINE EXCLUSIVE: Audio interview with ABIM Learning Session Director Julius Yang, MD
Focused Practice in Hospital Medicine Worth the Additional Cost
Focused Practice in Hospital Medicine Worth the Additional Cost
Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.
Dr. Ragan
Grass Valley, Calif.
Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.
To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.
Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.
It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.
What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.
I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.
So how about it, Dr. Ragan? Will you join me?
What Certification Requirements Should a Hospitalist Program Have for Its Physicians?
I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.
Marisa Sellers,
Medical Staff Coordinator,
Hartselle Medical Center,
Hartselle, Ala.
Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.
Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.
Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-
practice-hospital-medicine-qa.aspx.
I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.
Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?
Focused Practice in Hospital Medicine Worth the Additional Cost
Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.
Dr. Ragan
Grass Valley, Calif.
Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.
To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.
Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.
It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.
What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.
I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.
So how about it, Dr. Ragan? Will you join me?
What Certification Requirements Should a Hospitalist Program Have for Its Physicians?
I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.
Marisa Sellers,
Medical Staff Coordinator,
Hartselle Medical Center,
Hartselle, Ala.
Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.
Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.
Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-
practice-hospital-medicine-qa.aspx.
I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.
Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?
Focused Practice in Hospital Medicine Worth the Additional Cost
Why are we being required to fork over an extra $380 for the Focused Practice in Hospital Medicine MOC? This feels like the icing on the cake of already a major ripoff.
Dr. Ragan
Grass Valley, Calif.
Dr. Hospitalist responds: Thank you for your frank reaction to the much-anticipated American Board of Internal Medicine (ABIM) Focused Practice in Hospital Medicine (FPHM) Maintenance of Certification (MOC) program. As you noted, an additional fee is required to participate in this recertification program.
To my knowledge, any and all fees associated with recertification are paid to ABIM. No other organization benefits from the added cost, so your question might be more appropriately addressed to ABIM (see “Focused Practice in Hospital Medicine,” May 2010, p. 1). But because you asked the question, I am happy to respond with my thoughts.
Participation in the FPHM MOC program is not mandatory. I am not aware of any organization that is requiring hospitalists to participate. I don’t expect that your lack of participation will affect your ability to obtain hospital privileges. Like any new MOC program, I would expect some up-front administrative costs associated with developing and administering the practice-improvement modules and the secure examination.
It’s up to you and others to decide whether this added recognition is worth the cost. I can tell you that I have made the decision to participate. I fully expect to be part of the inaugural class of ABIM diplomates with this added recognition by the end of the year.
What went into my own decision to participate? I can tell you that I am a practicing hospitalist who makes a salary typical of most hospitalists. I am frugal with my money and certainly do not view the added cost as an insignificant amount of money. Like most hospitalists, I am not only busy with my professional life, but I have plenty of family commitments as well.
I expect the exam will be rigorous, and the requirements of the practice-improvement modules will be demanding. I would not want it any other way. In the fast-changing healthcare environment, I believe that hospitalists will be challenged to think about what it means to care for a hospitalized patient. To succeed in the future, hospitalists will be expected to not only participate, but also lead QI efforts at their institutions. The FPHM MOC will distinguish me as a hospitalist with added qualifications in the field of QI.
So how about it, Dr. Ragan? Will you join me?
What Certification Requirements Should a Hospitalist Program Have for Its Physicians?
I hope you can help me with some questions I have concerning starting a hospitalist program at my medical center. Are there certain requirements (e.g., board certification in internal medicine, ACLS, etc.) that need to be met, or is that up to the facility? The physician interested in the position is board-certified in infectious disease. Any direction you can give me on this would be greatly appreciated.
Marisa Sellers,
Medical Staff Coordinator,
Hartselle Medical Center,
Hartselle, Ala.
Dr. Hospitalist responds: Congratulations on your medical center’s decision to establish a hospitalist program. Over the past decade, HM has been the fastest-growing field in all of American medicine. The majority of the country’s acute-care hospitals have hospitalists on staff.
Approximately 85% of the country’s hospitalists received training in internal medicine. Most of the other hospitalists received training in pediatrics or family medicine. While most hospitalists are general internists, some also have additional subspecialty training, which seems to be the case of the physician at your medical center. As you know, different medical facilities have different requirements of their medical staff. At the acute-care hospital where I work clinically, maintenance of board certification is required of all medical staff. I know that is not the case for all hospitals, yet I’m not aware of any hospitals with hospitalist-specific medical staff requirements.
Most of the hospitalists who are internists will be either board-eligible or board-certified with the American Board of Internal Medicine (ABIM). You should be aware that ABIM has developed a new program, the Recognition of Focused Practice (RFP) in Hospital Medicine. As part of this maintenance of certification (MOC) program, ABIM diplomates will have the opportunity to take the first ABIM Hospital Medicine examination in October. For more information about this exam, ABIM’s rationale for recognizing a focused practice in HM, and any other questions about this program, please visit the ABIM Web site at www.abim.org/news/news/focused-
practice-hospital-medicine-qa.aspx.
I have heard from hospitalists trained as family physicians who are interested in RFP as hospitalists. It is my understanding that the American Board of Family Medicine is studying the ABIM program and working to develop a similar program for hospitalists with family medicine board certifications.
Regarding your question about hospitalists and the American Heart Association’s advanced cardiac life support (ACLS) training and certification: While I think it is a great idea for hospitalists to receive this training and maintain this certification, I am not aware of any mandate for hospitalists to be uniformly ACLS-certified. I think this is an issue the medical staff at your medical center will have to decide; basically, what is in the best interests of your patients?
To Vary Is Human …
Just a few years ago, if I had been asked to comment on variation in healthcare, I would have said it needed a fundraising event for awareness, or even a respected celebrity patron—maybe Sandra Bullock decrying unnecessary variation on Oprah. Fortunately, more socially influential forces evolved. In a relatively short (from a cultural perspective) span of time, variation has emerged to become standard water-cooler talk amongst physicians and politicians alike.
Although the first analysis of medical variation surfaced in 1938, it wasn’t until Wennberg and Gittelsohn’s seminal paper that our collective medical consciousness emerged.1 Wennberg noted that if his children had simply gone to school in the neighboring district of Stowe, Vt., they would have had a 70% chance of having a tonsillectomy, as opposed to a 20% chance in their chosen district of Waterbury. Decades later, that work is the foundation of the Dartmouth Atlas project, which has turned its lenses toward unexplained variation in the costs of healthcare.
Meanwhile, in a parallel—nonmedical—universe, two engineer-statisticians were busy refining quality-control theory in the late 1930s. Shewhart developed the PDCA (plan-do-check-act) cycle, and Deming took it to Japan, revolutionizing that country’s manufacturing industry. They recognized that unwarranted variations were key quality constraints in any process, and that sustained improvements in outcomes could be attained only through careful analysis and control of this variation.
Hospital Variation and Application
Following the Institute of Medicine’s landmark report a decade ago, these fields of study explicitly converged, and variation began to emerge as a key player in healthcare quality discussions. Sprinkle in a few more ingredients—such as the looming cliff that is Medicare insolvency, a failing economy, and Atul Gawande’s uncloaking of McAllen, Texas—and the transformation of the Kool-Aid is now complete.
A fortunate (or unfortunate, depending on your perspective) byproduct of these analyses has been that physicians are at the sharp end of the most important yet variable decisions in medicine. Why are doctors so different in their practices? The short answer is that we’re human; the long answer is that, well, we’re human.
In complex settings, the literature on medical decision-making tells us that we humans simply are not wired to process more than three to five different options at any one time. Even rocket scientists might disagree if they regularly encountered large boluses of clinical data in the face of an ever-exploding body of knowledge. When we dissect the more straightforward daily decisions, the complexity of the human persona then becomes an overlay with as much variability and heterogeneity as our own genetic makeup.
The Simple Life
The late John Eisenberg, in a book titled Doctors’ Decisions and the Cost of Medical Care, lists a dizzying array of reasons behind physician decision-making: experience, risk tolerance, practice style, incentives, and concept of social good, to name a few.2 Each of these domains could be a unique area of study—just for each individual human practitioner. In an era of genomic medicine, the strongest predictor of the phenotypic quality of care might simply be the genotype of the physician.
This is not a revelation for anyone who has ever questioned another physician’s care. My guess is that it’s been less than a week for most of us. After all, we’re hospitalists, perfectly perched as second-tier providers to judge other physicians’ care. We are air-traffic control for doctors’ decisions, and it’s quite a scene: thousands of independent physicians practicing on isolated islands. Like “outside EDs,” some of these habitats appear quite a bit more aboriginal and remote than others. Now, I will admit that I’ve often dreamed of practicing on an isolated, single-palm-tree island. Armed with only a coconut (my patient) and evidence-based medicine, this would be an overdue retreat from the chaotic morass of illogical (i.e., different from my own) medical decisions.
But it is exactly this reaction that provides clues to our current state. No one prepared us for the fact that healthcare delivery is a social science, so frustration and avoidance are merely natural reflections of our immaturity. If we did receive any coaching, it tended to be of the Monday-morning-quarterback school, autocratic and self-serving in nature. We were trained to critique only the finer details of scientific “fact,” not humans in context. How, then, are we to improve our care when we can barely handle the variation?
Advanced Concepts
Adapting a Darwinian perspective, we might hunt out the highly developed and advanced tribes in our midst. One such tribe is pediatric oncology. For decades, almost all variation in pediatric oncology has been controlled through treatment protocols tailored to the particular risk factors of the patient, not the physician. Although this ostensibly improves quality of care, it has had an even greater impact on learning and eventual outcomes.
For this reason and this reason alone, if your 18-year-old child develops leukemia, you probably want to send them to a pediatric oncologist rather than an adult oncologist.7 Survival rates are better because pediatric oncologists have been able to rapidly learn from the enrollment of almost all patients into trials with standardized treatment protocols. By collecting data on a limited number of options and sharing information across practices, true rapid-cycle improvement has materialized.
The key here is not the degree of standardization or the creation of large-scale research networks. It is the extent to which independent practitioners are able to sacrifice their individual beliefs in order to partner for the greater good. Growth and learning do not occur in isolation. A team-based approach, in the setting of standardization and measurement, will accelerate the pace of our evolution. Think about this the next time you feel like throwing a coconut at the infectious-disease consultant who dares cross your island of practice. For if it is human to vary, then only through collaboration may we truly divine. TH
Dr. Shen is The Hospitalist’s pediatric editor. Read his monthly review of pediatric research in our “In the Literature” section (see p. 16).
References
- Wennberg J, Gittelsohn. Small area variations in health care delivery. Science. 1973:182(117):1102-1108.
- Eisenberg JM. Doctors’ Decisions and the Cost of Medical Care: The Reasons for Doctor’s Practice Patterns and Ways to Change Them. Chicago: Health Administration Press; 1986.
Just a few years ago, if I had been asked to comment on variation in healthcare, I would have said it needed a fundraising event for awareness, or even a respected celebrity patron—maybe Sandra Bullock decrying unnecessary variation on Oprah. Fortunately, more socially influential forces evolved. In a relatively short (from a cultural perspective) span of time, variation has emerged to become standard water-cooler talk amongst physicians and politicians alike.
Although the first analysis of medical variation surfaced in 1938, it wasn’t until Wennberg and Gittelsohn’s seminal paper that our collective medical consciousness emerged.1 Wennberg noted that if his children had simply gone to school in the neighboring district of Stowe, Vt., they would have had a 70% chance of having a tonsillectomy, as opposed to a 20% chance in their chosen district of Waterbury. Decades later, that work is the foundation of the Dartmouth Atlas project, which has turned its lenses toward unexplained variation in the costs of healthcare.
Meanwhile, in a parallel—nonmedical—universe, two engineer-statisticians were busy refining quality-control theory in the late 1930s. Shewhart developed the PDCA (plan-do-check-act) cycle, and Deming took it to Japan, revolutionizing that country’s manufacturing industry. They recognized that unwarranted variations were key quality constraints in any process, and that sustained improvements in outcomes could be attained only through careful analysis and control of this variation.
Hospital Variation and Application
Following the Institute of Medicine’s landmark report a decade ago, these fields of study explicitly converged, and variation began to emerge as a key player in healthcare quality discussions. Sprinkle in a few more ingredients—such as the looming cliff that is Medicare insolvency, a failing economy, and Atul Gawande’s uncloaking of McAllen, Texas—and the transformation of the Kool-Aid is now complete.
A fortunate (or unfortunate, depending on your perspective) byproduct of these analyses has been that physicians are at the sharp end of the most important yet variable decisions in medicine. Why are doctors so different in their practices? The short answer is that we’re human; the long answer is that, well, we’re human.
In complex settings, the literature on medical decision-making tells us that we humans simply are not wired to process more than three to five different options at any one time. Even rocket scientists might disagree if they regularly encountered large boluses of clinical data in the face of an ever-exploding body of knowledge. When we dissect the more straightforward daily decisions, the complexity of the human persona then becomes an overlay with as much variability and heterogeneity as our own genetic makeup.
The Simple Life
The late John Eisenberg, in a book titled Doctors’ Decisions and the Cost of Medical Care, lists a dizzying array of reasons behind physician decision-making: experience, risk tolerance, practice style, incentives, and concept of social good, to name a few.2 Each of these domains could be a unique area of study—just for each individual human practitioner. In an era of genomic medicine, the strongest predictor of the phenotypic quality of care might simply be the genotype of the physician.
This is not a revelation for anyone who has ever questioned another physician’s care. My guess is that it’s been less than a week for most of us. After all, we’re hospitalists, perfectly perched as second-tier providers to judge other physicians’ care. We are air-traffic control for doctors’ decisions, and it’s quite a scene: thousands of independent physicians practicing on isolated islands. Like “outside EDs,” some of these habitats appear quite a bit more aboriginal and remote than others. Now, I will admit that I’ve often dreamed of practicing on an isolated, single-palm-tree island. Armed with only a coconut (my patient) and evidence-based medicine, this would be an overdue retreat from the chaotic morass of illogical (i.e., different from my own) medical decisions.
But it is exactly this reaction that provides clues to our current state. No one prepared us for the fact that healthcare delivery is a social science, so frustration and avoidance are merely natural reflections of our immaturity. If we did receive any coaching, it tended to be of the Monday-morning-quarterback school, autocratic and self-serving in nature. We were trained to critique only the finer details of scientific “fact,” not humans in context. How, then, are we to improve our care when we can barely handle the variation?
Advanced Concepts
Adapting a Darwinian perspective, we might hunt out the highly developed and advanced tribes in our midst. One such tribe is pediatric oncology. For decades, almost all variation in pediatric oncology has been controlled through treatment protocols tailored to the particular risk factors of the patient, not the physician. Although this ostensibly improves quality of care, it has had an even greater impact on learning and eventual outcomes.
For this reason and this reason alone, if your 18-year-old child develops leukemia, you probably want to send them to a pediatric oncologist rather than an adult oncologist.7 Survival rates are better because pediatric oncologists have been able to rapidly learn from the enrollment of almost all patients into trials with standardized treatment protocols. By collecting data on a limited number of options and sharing information across practices, true rapid-cycle improvement has materialized.
The key here is not the degree of standardization or the creation of large-scale research networks. It is the extent to which independent practitioners are able to sacrifice their individual beliefs in order to partner for the greater good. Growth and learning do not occur in isolation. A team-based approach, in the setting of standardization and measurement, will accelerate the pace of our evolution. Think about this the next time you feel like throwing a coconut at the infectious-disease consultant who dares cross your island of practice. For if it is human to vary, then only through collaboration may we truly divine. TH
Dr. Shen is The Hospitalist’s pediatric editor. Read his monthly review of pediatric research in our “In the Literature” section (see p. 16).
References
- Wennberg J, Gittelsohn. Small area variations in health care delivery. Science. 1973:182(117):1102-1108.
- Eisenberg JM. Doctors’ Decisions and the Cost of Medical Care: The Reasons for Doctor’s Practice Patterns and Ways to Change Them. Chicago: Health Administration Press; 1986.
Just a few years ago, if I had been asked to comment on variation in healthcare, I would have said it needed a fundraising event for awareness, or even a respected celebrity patron—maybe Sandra Bullock decrying unnecessary variation on Oprah. Fortunately, more socially influential forces evolved. In a relatively short (from a cultural perspective) span of time, variation has emerged to become standard water-cooler talk amongst physicians and politicians alike.
Although the first analysis of medical variation surfaced in 1938, it wasn’t until Wennberg and Gittelsohn’s seminal paper that our collective medical consciousness emerged.1 Wennberg noted that if his children had simply gone to school in the neighboring district of Stowe, Vt., they would have had a 70% chance of having a tonsillectomy, as opposed to a 20% chance in their chosen district of Waterbury. Decades later, that work is the foundation of the Dartmouth Atlas project, which has turned its lenses toward unexplained variation in the costs of healthcare.
Meanwhile, in a parallel—nonmedical—universe, two engineer-statisticians were busy refining quality-control theory in the late 1930s. Shewhart developed the PDCA (plan-do-check-act) cycle, and Deming took it to Japan, revolutionizing that country’s manufacturing industry. They recognized that unwarranted variations were key quality constraints in any process, and that sustained improvements in outcomes could be attained only through careful analysis and control of this variation.
Hospital Variation and Application
Following the Institute of Medicine’s landmark report a decade ago, these fields of study explicitly converged, and variation began to emerge as a key player in healthcare quality discussions. Sprinkle in a few more ingredients—such as the looming cliff that is Medicare insolvency, a failing economy, and Atul Gawande’s uncloaking of McAllen, Texas—and the transformation of the Kool-Aid is now complete.
A fortunate (or unfortunate, depending on your perspective) byproduct of these analyses has been that physicians are at the sharp end of the most important yet variable decisions in medicine. Why are doctors so different in their practices? The short answer is that we’re human; the long answer is that, well, we’re human.
In complex settings, the literature on medical decision-making tells us that we humans simply are not wired to process more than three to five different options at any one time. Even rocket scientists might disagree if they regularly encountered large boluses of clinical data in the face of an ever-exploding body of knowledge. When we dissect the more straightforward daily decisions, the complexity of the human persona then becomes an overlay with as much variability and heterogeneity as our own genetic makeup.
The Simple Life
The late John Eisenberg, in a book titled Doctors’ Decisions and the Cost of Medical Care, lists a dizzying array of reasons behind physician decision-making: experience, risk tolerance, practice style, incentives, and concept of social good, to name a few.2 Each of these domains could be a unique area of study—just for each individual human practitioner. In an era of genomic medicine, the strongest predictor of the phenotypic quality of care might simply be the genotype of the physician.
This is not a revelation for anyone who has ever questioned another physician’s care. My guess is that it’s been less than a week for most of us. After all, we’re hospitalists, perfectly perched as second-tier providers to judge other physicians’ care. We are air-traffic control for doctors’ decisions, and it’s quite a scene: thousands of independent physicians practicing on isolated islands. Like “outside EDs,” some of these habitats appear quite a bit more aboriginal and remote than others. Now, I will admit that I’ve often dreamed of practicing on an isolated, single-palm-tree island. Armed with only a coconut (my patient) and evidence-based medicine, this would be an overdue retreat from the chaotic morass of illogical (i.e., different from my own) medical decisions.
But it is exactly this reaction that provides clues to our current state. No one prepared us for the fact that healthcare delivery is a social science, so frustration and avoidance are merely natural reflections of our immaturity. If we did receive any coaching, it tended to be of the Monday-morning-quarterback school, autocratic and self-serving in nature. We were trained to critique only the finer details of scientific “fact,” not humans in context. How, then, are we to improve our care when we can barely handle the variation?
Advanced Concepts
Adapting a Darwinian perspective, we might hunt out the highly developed and advanced tribes in our midst. One such tribe is pediatric oncology. For decades, almost all variation in pediatric oncology has been controlled through treatment protocols tailored to the particular risk factors of the patient, not the physician. Although this ostensibly improves quality of care, it has had an even greater impact on learning and eventual outcomes.
For this reason and this reason alone, if your 18-year-old child develops leukemia, you probably want to send them to a pediatric oncologist rather than an adult oncologist.7 Survival rates are better because pediatric oncologists have been able to rapidly learn from the enrollment of almost all patients into trials with standardized treatment protocols. By collecting data on a limited number of options and sharing information across practices, true rapid-cycle improvement has materialized.
The key here is not the degree of standardization or the creation of large-scale research networks. It is the extent to which independent practitioners are able to sacrifice their individual beliefs in order to partner for the greater good. Growth and learning do not occur in isolation. A team-based approach, in the setting of standardization and measurement, will accelerate the pace of our evolution. Think about this the next time you feel like throwing a coconut at the infectious-disease consultant who dares cross your island of practice. For if it is human to vary, then only through collaboration may we truly divine. TH
Dr. Shen is The Hospitalist’s pediatric editor. Read his monthly review of pediatric research in our “In the Literature” section (see p. 16).
References
- Wennberg J, Gittelsohn. Small area variations in health care delivery. Science. 1973:182(117):1102-1108.
- Eisenberg JM. Doctors’ Decisions and the Cost of Medical Care: The Reasons for Doctor’s Practice Patterns and Ways to Change Them. Chicago: Health Administration Press; 1986.
Square Peg, Square Hole
I encounter a lot of hospitalists who complain that the other doctors at their hospital think of hospitalists as second-class citizens, as sort of like career residents. HM program directors need to make sure that is not the case for the hospitalists in their practice.
SHM has worked with the AMA’s Organized Medical Staff Section to assess the perception of hospitalists by primary-care physicians (PCPs) and hospitalists themselves. When asked in a 2009 survey, “Do you agree or disagree that hospitalists are respected members of the medical staff at a hospital?” only 3 out of 4 respondents agreed or highly agreed. That percentage is up slightly from the same survey conducted in 2007, and we don’t have data regarding how the responses would have been different if the question had been asked about other specialties. But I still find it concerning that about 25% of PCPs and hospitalists don’t see hospitalists as respected members of a medical staff. (If you are wondering, there wasn’t much of a difference between how hospitalists and PCPs answered the question.)
Use First Names
In the 1980s, I left residency and entered private practice as a hospitalist in a nonteaching, suburban hospital. I had a really hard time calling other doctors by their first names, especially the highly regarded senior internist who was my former roommate’s dad. He had always been Dr. McCollough to me, and I insisted calling him “Doctor” until we had been peers on the same medical staff for about a year.
Finally, in a somewhat annoyed voice, he told me I had to start calling him “Bob,” and that I should call all the doctors by their first names. It took a while, but using first names began to feel normal. Looking back on it, I think Dr. McCollough Bob taught me an important lesson about fitting in.
So make sure the hospitalists in your group call other doctors by their first names, too.
Dress the Part
I’ve come to believe that there are a number of things some hospitalists do to sabotage their own interest in being respected by the medical staff at their hospital. To my surprise, I’ve worked with a number of hospitalist groups in which most dress and act like residents, then complain that other doctors at their hospital treat them like residents. I think the way we dress, especially early in our careers, is a pretty big deal. If you’re similar in age to residents, then you’ll sure look like a resident if you dress like them. So don’t wear scrubs and Skechers unless all of the doctors in your hospital wear scrubs and Skechers.
The best advice is to dress the way the respected doctors dress. Follow the lead on things like neckties, dresses, and the white coat (the latter is almost unheard of at my hospital unless it is used to cover up scrubs). Fortunately, few doctors dress formally anymore (e.g., suit, and tie or sport coat for men). Emerging research might push all of us toward shedding ties, long sleeves, and the white coat before long.
Of course, you should keep in mind the way patients would like to see you dress. You can find information about patient expectations through a simple Internet search or by asking the person in charge of patient satisfaction at your hospital.
Seek Social Connections
Just like the issue of dress, I’ve encountered a number of hospitalist groups that have a habit of sneaking into the physician lunchroom, grabbing food in a “to go” container, and heading back to their office to eat together. These hospitalists are missing a valuable opportunity to enjoy social conversation with physicians of all specialties. If your hospital has a physician lunch room that is crowded with doctors, take advantage of the opportunity to build social networks.
You don’t need to eat there every day. (For a number of years, I enjoyed having lunch with the social workers in our main cafeteria.) But you should eat there more frequently than sneaking back to your office to eat only with other hospitalists. (If you don’t have time for lunch, then we need to talk about workload and efficiency issues.)
Look for other opportunities to make connections with other doctors through service on hospital committees, participation in social events at the hospital, or speaking at grand rounds. Although any single activity might not have significant impact, if you do these things regularly, you will form better relationships and be less likely to be or feel “dumped on,” and if it does happen, you’re in a much better position to address it if the dumping doctor is a friend.
Leadership Positions
Work to ensure a member of your group always sits on the medical staff executive committee, and seek out leadership positions like chief of medicine or chief of staff. Don’t simply assume you are too young or too inexperienced. Your hospital really needs the leadership of doctors who have a broad view of hospital operations and medical staff affairs. Few doctors have a broader view than hospitalists.
And if you have an interest in medical staff leadership, think about whether you’d like to serve as your hospital’s chief medical officer (aka vice president of medical affairs). All of these activities are important ways to influence what happens at your hospital, but aside from that, they are an excellent way to build relationships and gain respect from throughout the medical staff.
Worthwhile Effort
Ensuring that the hospitalists in your group feel respected and valued by other doctors and everyone they work with is important. Don’t make the mistake of thinking that working on this is just about stroking hospitalists’ egos.
I coauthored a 2001 research study on hospitalist burnout that failed to show a correlation between workload and burnout, but the study found that things like poor occupational solidarity are associated with burnout.1
Feeling like you fit in and are a respected member of your peer group (medical staff) is important and worth working on diligently. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Reference
- Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. Jrl Health Social Behavior. 2001;43:72-91.
I encounter a lot of hospitalists who complain that the other doctors at their hospital think of hospitalists as second-class citizens, as sort of like career residents. HM program directors need to make sure that is not the case for the hospitalists in their practice.
SHM has worked with the AMA’s Organized Medical Staff Section to assess the perception of hospitalists by primary-care physicians (PCPs) and hospitalists themselves. When asked in a 2009 survey, “Do you agree or disagree that hospitalists are respected members of the medical staff at a hospital?” only 3 out of 4 respondents agreed or highly agreed. That percentage is up slightly from the same survey conducted in 2007, and we don’t have data regarding how the responses would have been different if the question had been asked about other specialties. But I still find it concerning that about 25% of PCPs and hospitalists don’t see hospitalists as respected members of a medical staff. (If you are wondering, there wasn’t much of a difference between how hospitalists and PCPs answered the question.)
Use First Names
In the 1980s, I left residency and entered private practice as a hospitalist in a nonteaching, suburban hospital. I had a really hard time calling other doctors by their first names, especially the highly regarded senior internist who was my former roommate’s dad. He had always been Dr. McCollough to me, and I insisted calling him “Doctor” until we had been peers on the same medical staff for about a year.
Finally, in a somewhat annoyed voice, he told me I had to start calling him “Bob,” and that I should call all the doctors by their first names. It took a while, but using first names began to feel normal. Looking back on it, I think Dr. McCollough Bob taught me an important lesson about fitting in.
So make sure the hospitalists in your group call other doctors by their first names, too.
Dress the Part
I’ve come to believe that there are a number of things some hospitalists do to sabotage their own interest in being respected by the medical staff at their hospital. To my surprise, I’ve worked with a number of hospitalist groups in which most dress and act like residents, then complain that other doctors at their hospital treat them like residents. I think the way we dress, especially early in our careers, is a pretty big deal. If you’re similar in age to residents, then you’ll sure look like a resident if you dress like them. So don’t wear scrubs and Skechers unless all of the doctors in your hospital wear scrubs and Skechers.
The best advice is to dress the way the respected doctors dress. Follow the lead on things like neckties, dresses, and the white coat (the latter is almost unheard of at my hospital unless it is used to cover up scrubs). Fortunately, few doctors dress formally anymore (e.g., suit, and tie or sport coat for men). Emerging research might push all of us toward shedding ties, long sleeves, and the white coat before long.
Of course, you should keep in mind the way patients would like to see you dress. You can find information about patient expectations through a simple Internet search or by asking the person in charge of patient satisfaction at your hospital.
Seek Social Connections
Just like the issue of dress, I’ve encountered a number of hospitalist groups that have a habit of sneaking into the physician lunchroom, grabbing food in a “to go” container, and heading back to their office to eat together. These hospitalists are missing a valuable opportunity to enjoy social conversation with physicians of all specialties. If your hospital has a physician lunch room that is crowded with doctors, take advantage of the opportunity to build social networks.
You don’t need to eat there every day. (For a number of years, I enjoyed having lunch with the social workers in our main cafeteria.) But you should eat there more frequently than sneaking back to your office to eat only with other hospitalists. (If you don’t have time for lunch, then we need to talk about workload and efficiency issues.)
Look for other opportunities to make connections with other doctors through service on hospital committees, participation in social events at the hospital, or speaking at grand rounds. Although any single activity might not have significant impact, if you do these things regularly, you will form better relationships and be less likely to be or feel “dumped on,” and if it does happen, you’re in a much better position to address it if the dumping doctor is a friend.
Leadership Positions
Work to ensure a member of your group always sits on the medical staff executive committee, and seek out leadership positions like chief of medicine or chief of staff. Don’t simply assume you are too young or too inexperienced. Your hospital really needs the leadership of doctors who have a broad view of hospital operations and medical staff affairs. Few doctors have a broader view than hospitalists.
And if you have an interest in medical staff leadership, think about whether you’d like to serve as your hospital’s chief medical officer (aka vice president of medical affairs). All of these activities are important ways to influence what happens at your hospital, but aside from that, they are an excellent way to build relationships and gain respect from throughout the medical staff.
Worthwhile Effort
Ensuring that the hospitalists in your group feel respected and valued by other doctors and everyone they work with is important. Don’t make the mistake of thinking that working on this is just about stroking hospitalists’ egos.
I coauthored a 2001 research study on hospitalist burnout that failed to show a correlation between workload and burnout, but the study found that things like poor occupational solidarity are associated with burnout.1
Feeling like you fit in and are a respected member of your peer group (medical staff) is important and worth working on diligently. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Reference
- Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. Jrl Health Social Behavior. 2001;43:72-91.
I encounter a lot of hospitalists who complain that the other doctors at their hospital think of hospitalists as second-class citizens, as sort of like career residents. HM program directors need to make sure that is not the case for the hospitalists in their practice.
SHM has worked with the AMA’s Organized Medical Staff Section to assess the perception of hospitalists by primary-care physicians (PCPs) and hospitalists themselves. When asked in a 2009 survey, “Do you agree or disagree that hospitalists are respected members of the medical staff at a hospital?” only 3 out of 4 respondents agreed or highly agreed. That percentage is up slightly from the same survey conducted in 2007, and we don’t have data regarding how the responses would have been different if the question had been asked about other specialties. But I still find it concerning that about 25% of PCPs and hospitalists don’t see hospitalists as respected members of a medical staff. (If you are wondering, there wasn’t much of a difference between how hospitalists and PCPs answered the question.)
Use First Names
In the 1980s, I left residency and entered private practice as a hospitalist in a nonteaching, suburban hospital. I had a really hard time calling other doctors by their first names, especially the highly regarded senior internist who was my former roommate’s dad. He had always been Dr. McCollough to me, and I insisted calling him “Doctor” until we had been peers on the same medical staff for about a year.
Finally, in a somewhat annoyed voice, he told me I had to start calling him “Bob,” and that I should call all the doctors by their first names. It took a while, but using first names began to feel normal. Looking back on it, I think Dr. McCollough Bob taught me an important lesson about fitting in.
So make sure the hospitalists in your group call other doctors by their first names, too.
Dress the Part
I’ve come to believe that there are a number of things some hospitalists do to sabotage their own interest in being respected by the medical staff at their hospital. To my surprise, I’ve worked with a number of hospitalist groups in which most dress and act like residents, then complain that other doctors at their hospital treat them like residents. I think the way we dress, especially early in our careers, is a pretty big deal. If you’re similar in age to residents, then you’ll sure look like a resident if you dress like them. So don’t wear scrubs and Skechers unless all of the doctors in your hospital wear scrubs and Skechers.
The best advice is to dress the way the respected doctors dress. Follow the lead on things like neckties, dresses, and the white coat (the latter is almost unheard of at my hospital unless it is used to cover up scrubs). Fortunately, few doctors dress formally anymore (e.g., suit, and tie or sport coat for men). Emerging research might push all of us toward shedding ties, long sleeves, and the white coat before long.
Of course, you should keep in mind the way patients would like to see you dress. You can find information about patient expectations through a simple Internet search or by asking the person in charge of patient satisfaction at your hospital.
Seek Social Connections
Just like the issue of dress, I’ve encountered a number of hospitalist groups that have a habit of sneaking into the physician lunchroom, grabbing food in a “to go” container, and heading back to their office to eat together. These hospitalists are missing a valuable opportunity to enjoy social conversation with physicians of all specialties. If your hospital has a physician lunch room that is crowded with doctors, take advantage of the opportunity to build social networks.
You don’t need to eat there every day. (For a number of years, I enjoyed having lunch with the social workers in our main cafeteria.) But you should eat there more frequently than sneaking back to your office to eat only with other hospitalists. (If you don’t have time for lunch, then we need to talk about workload and efficiency issues.)
Look for other opportunities to make connections with other doctors through service on hospital committees, participation in social events at the hospital, or speaking at grand rounds. Although any single activity might not have significant impact, if you do these things regularly, you will form better relationships and be less likely to be or feel “dumped on,” and if it does happen, you’re in a much better position to address it if the dumping doctor is a friend.
Leadership Positions
Work to ensure a member of your group always sits on the medical staff executive committee, and seek out leadership positions like chief of medicine or chief of staff. Don’t simply assume you are too young or too inexperienced. Your hospital really needs the leadership of doctors who have a broad view of hospital operations and medical staff affairs. Few doctors have a broader view than hospitalists.
And if you have an interest in medical staff leadership, think about whether you’d like to serve as your hospital’s chief medical officer (aka vice president of medical affairs). All of these activities are important ways to influence what happens at your hospital, but aside from that, they are an excellent way to build relationships and gain respect from throughout the medical staff.
Worthwhile Effort
Ensuring that the hospitalists in your group feel respected and valued by other doctors and everyone they work with is important. Don’t make the mistake of thinking that working on this is just about stroking hospitalists’ egos.
I coauthored a 2001 research study on hospitalist burnout that failed to show a correlation between workload and burnout, but the study found that things like poor occupational solidarity are associated with burnout.1
Feeling like you fit in and are a respected member of your peer group (medical staff) is important and worth working on diligently. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.
Reference
- Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new medical career: the case of hospitalist physicians. Jrl Health Social Behavior. 2001;43:72-91.
Transitions Telethon
The headline was as biting as it was inciting. “Frustrations with hospitalist care: Need to improve transitions and communication,” it screamed from the cover of a recent issue of the Annals of Internal Medicine.1 Reading on the run, I thumbed to page 469 and glanced at the first few paragraphs, my mind spinning with the implications.
The article was an editorial following a recent thought piece by a primary-care physician (PCP) frustrated with his interactions with the HM model—mainly around the lack of communication from hospitalists about his patients, his marginalized role with his patients’ hospital care, and the lack of information transfer around transitions.2
Frustrations and Slapstick Comedy
Frustration with hospitalist care? Is this how PCPs see us? Are we really “frustrating” our outpatient colleagues? To an outsider, this presented a one-sided view of the issue—the side that sounds simplistically negative. What if someone important to our group should read this article, someone like my hospital CEO? I didn’t have to wonder for long as I looked up from my elevator reading to note my hospital CEO entering.
What followed eerily resembled one of those scenes from a slapstick comedy, as the boob, played perfectly by me, obviously fumbles something he intends to hide from his boss behind his back to escape the knowing eye of said boss. And, like a pornographic-magazine-sniffing parent, my CEO knowingly diagnosed the situation.
“Whatcha reading?” he sagely queried.
“Nothing,” I replied unconvincingly.
“Nothing? It sure looks like you hastily stuffed a magazine or something down the back of your pants as I walked in.”
“Oh, this?” I responded, unearthing a large medical journal from my pants, leaving an untucked shirt in its wake. “This is just a medical journal. You know, lots of medical stuff. It’s pretty complex. Probably hard for nonmedical types to understand,” I replied, employing a bit of professorial condescension to throw him off track.
“Annals of Internal Medicine,” he replied. “What a coincidence. I just received an e-mail from a friend with an Annals article about the issues of transitions of care with the hospitalist model. Sounds like a real problem. Maybe our new electronic health records will fix that. If not, you should fix it. Let’s chat about it soon.”
“Right,” I said as the elevator doors swished behind him, leaving me disheveled in both appearance and thoughts.
Testimonials?
The more recent Annals editorial summarized—and then printed—a few of the many online responses to the original thought piece.3 The responses ranged from outrage with the HM model of care to more measured discussions of the limitations of the “old” model it replaced. However, the tone and implications were clear: At least some, if not many, PCPs are displeased with the HM model.
One writer related a recent example in which his elderly patient was admitted unbeknownst to him. After receiving a query from a family member, he called the hospitalist on duty, who was uninformed about the patient details, had made questionable therapeutic changes, and was “unapologetic” about her team’s lack of communication, arguing that the ED physician “should have called.” That led this PCP to conclude that the system is “disjointed and isolating,” leaving “patients feeling abandoned.” Another writer commented that the current system of communication results in “potentially detrimental and demoralizing degrees of separation.” A response by a hospitalist detailed how they were able to put a system in place to contact PCPs with whom they are contracted 80% of the time.
The Annals editors concluded that the letters they received in response to the first article “reflect a schism that exists in internal medicine about the positive and negative effects of hospitalist care,” noting that “the evidence is still deficient about how to deliver care optimally when complex, seriously-ill patients must transition between multiple providers in diverse health care settings.” The authors go on to call for “intensive research and productive debates” about the HM model of care.
A Challenge to You
“Disjointed and isolating”? … “Detrimental and demoralizing”? … Lauding 80% PCP contact rates? … “Intensive research and debate”?
I get that this is a complex issue and that healthcare in the U.S. is fragmented to the point of fracture. To wit, it can be agonizingly time-consuming to track down PCPs and wade through their automated phone systems. And this assumes that your patient has a PCP, can identify that PCP, and has their phone number. If they don’t, you’re left to sift through online phone books, clinic websites, or Google searches with the hopes that you can summon the right Dr. Davis, Davies, or Daves—the patient’s not quite sure of the spelling but knows “she’s a nice lady doctor.” I know firsthand the tension between taking the time to make that PCP call and getting home in time for dinner with my family—I’m often guilty of choosing dinner.
However, I’m not sure “intensive research” is the answer. Nor is this a problem that can wait for technological solutions. I don’t want to diminish the great strides that have been made or understate the need to continue to innovate around transitions—this needs to be an area of ongoing study. But this is a problem that has at least one relatively simple, short-term solution: Just pick up the phone. As one Annals writer rightly questions: “How has inter-physician communication come to be regarded as an unexpected courtesy rather than an obligation?”
Good question.
So, I have a simple challenge for you: For one week, join me in committing to calling 100% of the available PCPs on patient discharge. I can guarantee you this will prove to be a hard, time-consuming, and, at times, migraine-inducing process. But it is an intervention that will make a difference, can be launched tomorrow, and does not require “intensive research and debate.”
We’ll no doubt gain some insight into our patients’ current therapeutic regimens, enlist PCPs’ help with the treatment decisions, and ensure that our patients’ transitions are as safe as possible. My guess is that we’ll also find it valuable to the point it becomes habit.
Start by committing with me to just one week.
Then go home and have dinner. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Frustrations with hospitalist care: need to improve transitions and communication. Ann Intern Med. 2010;152(7):469.
- Beckman H. Three degrees of separation. Ann Intern Med. 2009;151(12):890-891.
- The relationship between hospitalists and primary care physicians. Ann Intern Med. 2010;152(7):474-6.
The headline was as biting as it was inciting. “Frustrations with hospitalist care: Need to improve transitions and communication,” it screamed from the cover of a recent issue of the Annals of Internal Medicine.1 Reading on the run, I thumbed to page 469 and glanced at the first few paragraphs, my mind spinning with the implications.
The article was an editorial following a recent thought piece by a primary-care physician (PCP) frustrated with his interactions with the HM model—mainly around the lack of communication from hospitalists about his patients, his marginalized role with his patients’ hospital care, and the lack of information transfer around transitions.2
Frustrations and Slapstick Comedy
Frustration with hospitalist care? Is this how PCPs see us? Are we really “frustrating” our outpatient colleagues? To an outsider, this presented a one-sided view of the issue—the side that sounds simplistically negative. What if someone important to our group should read this article, someone like my hospital CEO? I didn’t have to wonder for long as I looked up from my elevator reading to note my hospital CEO entering.
What followed eerily resembled one of those scenes from a slapstick comedy, as the boob, played perfectly by me, obviously fumbles something he intends to hide from his boss behind his back to escape the knowing eye of said boss. And, like a pornographic-magazine-sniffing parent, my CEO knowingly diagnosed the situation.
“Whatcha reading?” he sagely queried.
“Nothing,” I replied unconvincingly.
“Nothing? It sure looks like you hastily stuffed a magazine or something down the back of your pants as I walked in.”
“Oh, this?” I responded, unearthing a large medical journal from my pants, leaving an untucked shirt in its wake. “This is just a medical journal. You know, lots of medical stuff. It’s pretty complex. Probably hard for nonmedical types to understand,” I replied, employing a bit of professorial condescension to throw him off track.
“Annals of Internal Medicine,” he replied. “What a coincidence. I just received an e-mail from a friend with an Annals article about the issues of transitions of care with the hospitalist model. Sounds like a real problem. Maybe our new electronic health records will fix that. If not, you should fix it. Let’s chat about it soon.”
“Right,” I said as the elevator doors swished behind him, leaving me disheveled in both appearance and thoughts.
Testimonials?
The more recent Annals editorial summarized—and then printed—a few of the many online responses to the original thought piece.3 The responses ranged from outrage with the HM model of care to more measured discussions of the limitations of the “old” model it replaced. However, the tone and implications were clear: At least some, if not many, PCPs are displeased with the HM model.
One writer related a recent example in which his elderly patient was admitted unbeknownst to him. After receiving a query from a family member, he called the hospitalist on duty, who was uninformed about the patient details, had made questionable therapeutic changes, and was “unapologetic” about her team’s lack of communication, arguing that the ED physician “should have called.” That led this PCP to conclude that the system is “disjointed and isolating,” leaving “patients feeling abandoned.” Another writer commented that the current system of communication results in “potentially detrimental and demoralizing degrees of separation.” A response by a hospitalist detailed how they were able to put a system in place to contact PCPs with whom they are contracted 80% of the time.
The Annals editors concluded that the letters they received in response to the first article “reflect a schism that exists in internal medicine about the positive and negative effects of hospitalist care,” noting that “the evidence is still deficient about how to deliver care optimally when complex, seriously-ill patients must transition between multiple providers in diverse health care settings.” The authors go on to call for “intensive research and productive debates” about the HM model of care.
A Challenge to You
“Disjointed and isolating”? … “Detrimental and demoralizing”? … Lauding 80% PCP contact rates? … “Intensive research and debate”?
I get that this is a complex issue and that healthcare in the U.S. is fragmented to the point of fracture. To wit, it can be agonizingly time-consuming to track down PCPs and wade through their automated phone systems. And this assumes that your patient has a PCP, can identify that PCP, and has their phone number. If they don’t, you’re left to sift through online phone books, clinic websites, or Google searches with the hopes that you can summon the right Dr. Davis, Davies, or Daves—the patient’s not quite sure of the spelling but knows “she’s a nice lady doctor.” I know firsthand the tension between taking the time to make that PCP call and getting home in time for dinner with my family—I’m often guilty of choosing dinner.
However, I’m not sure “intensive research” is the answer. Nor is this a problem that can wait for technological solutions. I don’t want to diminish the great strides that have been made or understate the need to continue to innovate around transitions—this needs to be an area of ongoing study. But this is a problem that has at least one relatively simple, short-term solution: Just pick up the phone. As one Annals writer rightly questions: “How has inter-physician communication come to be regarded as an unexpected courtesy rather than an obligation?”
Good question.
So, I have a simple challenge for you: For one week, join me in committing to calling 100% of the available PCPs on patient discharge. I can guarantee you this will prove to be a hard, time-consuming, and, at times, migraine-inducing process. But it is an intervention that will make a difference, can be launched tomorrow, and does not require “intensive research and debate.”
We’ll no doubt gain some insight into our patients’ current therapeutic regimens, enlist PCPs’ help with the treatment decisions, and ensure that our patients’ transitions are as safe as possible. My guess is that we’ll also find it valuable to the point it becomes habit.
Start by committing with me to just one week.
Then go home and have dinner. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Frustrations with hospitalist care: need to improve transitions and communication. Ann Intern Med. 2010;152(7):469.
- Beckman H. Three degrees of separation. Ann Intern Med. 2009;151(12):890-891.
- The relationship between hospitalists and primary care physicians. Ann Intern Med. 2010;152(7):474-6.
The headline was as biting as it was inciting. “Frustrations with hospitalist care: Need to improve transitions and communication,” it screamed from the cover of a recent issue of the Annals of Internal Medicine.1 Reading on the run, I thumbed to page 469 and glanced at the first few paragraphs, my mind spinning with the implications.
The article was an editorial following a recent thought piece by a primary-care physician (PCP) frustrated with his interactions with the HM model—mainly around the lack of communication from hospitalists about his patients, his marginalized role with his patients’ hospital care, and the lack of information transfer around transitions.2
Frustrations and Slapstick Comedy
Frustration with hospitalist care? Is this how PCPs see us? Are we really “frustrating” our outpatient colleagues? To an outsider, this presented a one-sided view of the issue—the side that sounds simplistically negative. What if someone important to our group should read this article, someone like my hospital CEO? I didn’t have to wonder for long as I looked up from my elevator reading to note my hospital CEO entering.
What followed eerily resembled one of those scenes from a slapstick comedy, as the boob, played perfectly by me, obviously fumbles something he intends to hide from his boss behind his back to escape the knowing eye of said boss. And, like a pornographic-magazine-sniffing parent, my CEO knowingly diagnosed the situation.
“Whatcha reading?” he sagely queried.
“Nothing,” I replied unconvincingly.
“Nothing? It sure looks like you hastily stuffed a magazine or something down the back of your pants as I walked in.”
“Oh, this?” I responded, unearthing a large medical journal from my pants, leaving an untucked shirt in its wake. “This is just a medical journal. You know, lots of medical stuff. It’s pretty complex. Probably hard for nonmedical types to understand,” I replied, employing a bit of professorial condescension to throw him off track.
“Annals of Internal Medicine,” he replied. “What a coincidence. I just received an e-mail from a friend with an Annals article about the issues of transitions of care with the hospitalist model. Sounds like a real problem. Maybe our new electronic health records will fix that. If not, you should fix it. Let’s chat about it soon.”
“Right,” I said as the elevator doors swished behind him, leaving me disheveled in both appearance and thoughts.
Testimonials?
The more recent Annals editorial summarized—and then printed—a few of the many online responses to the original thought piece.3 The responses ranged from outrage with the HM model of care to more measured discussions of the limitations of the “old” model it replaced. However, the tone and implications were clear: At least some, if not many, PCPs are displeased with the HM model.
One writer related a recent example in which his elderly patient was admitted unbeknownst to him. After receiving a query from a family member, he called the hospitalist on duty, who was uninformed about the patient details, had made questionable therapeutic changes, and was “unapologetic” about her team’s lack of communication, arguing that the ED physician “should have called.” That led this PCP to conclude that the system is “disjointed and isolating,” leaving “patients feeling abandoned.” Another writer commented that the current system of communication results in “potentially detrimental and demoralizing degrees of separation.” A response by a hospitalist detailed how they were able to put a system in place to contact PCPs with whom they are contracted 80% of the time.
The Annals editors concluded that the letters they received in response to the first article “reflect a schism that exists in internal medicine about the positive and negative effects of hospitalist care,” noting that “the evidence is still deficient about how to deliver care optimally when complex, seriously-ill patients must transition between multiple providers in diverse health care settings.” The authors go on to call for “intensive research and productive debates” about the HM model of care.
A Challenge to You
“Disjointed and isolating”? … “Detrimental and demoralizing”? … Lauding 80% PCP contact rates? … “Intensive research and debate”?
I get that this is a complex issue and that healthcare in the U.S. is fragmented to the point of fracture. To wit, it can be agonizingly time-consuming to track down PCPs and wade through their automated phone systems. And this assumes that your patient has a PCP, can identify that PCP, and has their phone number. If they don’t, you’re left to sift through online phone books, clinic websites, or Google searches with the hopes that you can summon the right Dr. Davis, Davies, or Daves—the patient’s not quite sure of the spelling but knows “she’s a nice lady doctor.” I know firsthand the tension between taking the time to make that PCP call and getting home in time for dinner with my family—I’m often guilty of choosing dinner.
However, I’m not sure “intensive research” is the answer. Nor is this a problem that can wait for technological solutions. I don’t want to diminish the great strides that have been made or understate the need to continue to innovate around transitions—this needs to be an area of ongoing study. But this is a problem that has at least one relatively simple, short-term solution: Just pick up the phone. As one Annals writer rightly questions: “How has inter-physician communication come to be regarded as an unexpected courtesy rather than an obligation?”
Good question.
So, I have a simple challenge for you: For one week, join me in committing to calling 100% of the available PCPs on patient discharge. I can guarantee you this will prove to be a hard, time-consuming, and, at times, migraine-inducing process. But it is an intervention that will make a difference, can be launched tomorrow, and does not require “intensive research and debate.”
We’ll no doubt gain some insight into our patients’ current therapeutic regimens, enlist PCPs’ help with the treatment decisions, and ensure that our patients’ transitions are as safe as possible. My guess is that we’ll also find it valuable to the point it becomes habit.
Start by committing with me to just one week.
Then go home and have dinner. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.
References
- Frustrations with hospitalist care: need to improve transitions and communication. Ann Intern Med. 2010;152(7):469.
- Beckman H. Three degrees of separation. Ann Intern Med. 2009;151(12):890-891.
- The relationship between hospitalists and primary care physicians. Ann Intern Med. 2010;152(7):474-6.
Care Critical
There is a brewing crisis in critical-care medicine, a crisis that already is impacting HM. It would be easier for hospitalists to look the other way and say, “This is not our problem.” Make no mistake: It is our problem. There are not enough intensive-care physicians to go around.
In my generation, most physicians who trained in pulmonary and critical-care medicine thought they would do some office care, some bronchoscopies, and some critical care for the first several years of their professional lives. Few imagined that, in their 60s, their practice would still include rescuing patients from death at 2 a.m. Couple the intensity of care with such a demanding lifestyle, and it is hardly surprising that many critical-care doctors seek less-stressful practices (e.g., sleep medicine) or retirement.
New physicians who see the work-life imbalance are shying away from critical care in significant enough numbers, yet the demand for these doctors is growing. Whether that shift is due to the attraction of careers in HM, emergency medicine, or other IM specialties, or the perceived negatives to being a full-time intensivist, is beside the point. The medical workforce needs more critical-care physicians. And we are not going to be able to meet this need by assuming we will be able to recruit and train more surgeons, anesthesiologists, or pulmonary physicians in traditional critical-care pathways.
The situation is further complicated by workforce shortages on the rest of the ICU healthcare team. Many senior ICU nurses are reaching the end of their careers, and the pipeline to replace them is anything but robust. And all this comes at a time when the acuity of hospitalized patients is increasing and the demands for ICU expertise is at its height.
It is no surprise that hospitalists are called upon to fill the critical-care gap. SHM surveys show that 92% of hospitalists include ICU care in their practice. While hospitalists clearly do not have the training or skills to replace the intensivist, we clearly are witnessing a “scope creep.” Hospitalists are being asked to stretch their skills to fill the void in critical care.
Competence Question
The response to this is manifest in many ways. For example, steadily increasing numbers of hospitalists attend SHM’s annual critical-care precourses, and our procedures courses invariably sell out. These brief courses are important to hospitalists and their patients. Yet a day (or even two) of focused training for hospitalists will not raise their skill set to replace or even augment critical-care-trained physicians at their hospitals. The patients will keep coming and continue to need the expertise for their most-acute-care needs. Something must be done.
There are pockets of experiments on filling the increasing critical-care gap. Emory University’s Center for Critical Care in Atlanta will soon launch an experimental, HM-critical-care training program that will attempt to develop and verify critical-care competencies in just one postgraduate year after IM residency. A complementary approach could include a hospitalist-focused track within the three years of IM residency to include less outpatient medicine and more intensive-care training. This could be part of a broader restructuring of internal and family medicine residencies, which recognize the career paths (and needs) of their residents as some enter hospital-focused practice (e.g., as hospitalists, cardiologists, intensivists) and some concentrate more on the patient outside the hospital (e.g., primary care, endocrinology, rheumatology).
As training evolves, there will be practical issues of credentialing. Currently, a general-IM-trained hospitalist is required to complete a two-year fellowship in critical care to be a specialist. Interestingly, if one’s residency training is in surgery, anesthesia, or rheumatology, that physician requires only one additional year in critical care to become eligible for added/special qualifications in critical-care medicine. What, precisely, is the carryover of the longer residency experience that makes it possible to attain competency in critical care in half the training time?
There also is the risk that we will create a workforce that includes the intensivist-lite—someone who does not have complete, recognized training in critical care but has more than the typical hospitalist, and is perceived as “better than having no intensivist.” Is this in the best interest of our patients or our discipline?
Supply Solutions
There are other approaches to the workforce challenge beyond asking hospitalists to step away from practice for an additional year or two of training. As in other aspects of the hospital workforce, it is time to examine alternative deployment of the entire healthcare team. If intensivists and hospitalists are in limited supply, we need to revisit their roles and further look for opportunities to engage acute-care nurse practitioners, physician assistants, RNs, and others on the healthcare team to meet the expanding needs of our patients and our hospitals.
Another strategy would include regionalization of healthcare in population centers with multiple hospitals. In Orange County, Calif., where I live, there are 33 hospitals for 3 million people, each with some form of an ICU. Is it time to set standards of coverage and expertise so that 10 to 15 hospitals can provide a fully staffed ICU, and the other hospitals refer their most-acute patients rather than be stretched to staff their ICUs at a time of workforce shortages? Is it time to do what we did with trauma centers and set various levels of care so that not every hospital can or should be doing the most intense and costly level of care?
SHM, HM, and, most importantly, hospitalists find themselves in the midst of this growing problem. We must be part of the solution.
It is important to recognize the significant variability in the intensivist skill sets that individual hospitalists and HM groups currently possess; the variance creates hurdles in being able to step up and fill the critical-care gap. I’ve heard about hospitalists pausing their practices to obtain additional training in critical care. Hospitals across America are (or soon will be) scrambling to integrate their hospitalists and intensivists to maximize coverage and expertise. SHM has noticed an increased demand on hospitalists to increase knowledge and skills so they can extend the local coverage of critically ill patients.
It is time for SHM to clearly understand how this sea change is affecting you professionally and personally, because you practice on the frontlines of our nation’s hospitals.
It is time for SHM to engage our colleagues in the ICU—critical-care physicians and their professional societies—to understand their perspective and initiatives on this growing crisis.
It is time for SHM to engage medical educators in residency and fellowship training to explore potential changes in the curriculum—changes aimed at young physicians proceeding through their training that yield hospital-based physicians better prepared to enter the hospital environment of the 21st century.
And SHM may need to engage the boards and other credentialing bodies to look for flexibility that will reflect today’s realities, attract the best-trained physicians to care for the most-acutely-ill patients, and protect our patients by demanding expertise and training at the most appropriate levels. TH
Dr. Wellikson is CEO of SHM.
There is a brewing crisis in critical-care medicine, a crisis that already is impacting HM. It would be easier for hospitalists to look the other way and say, “This is not our problem.” Make no mistake: It is our problem. There are not enough intensive-care physicians to go around.
In my generation, most physicians who trained in pulmonary and critical-care medicine thought they would do some office care, some bronchoscopies, and some critical care for the first several years of their professional lives. Few imagined that, in their 60s, their practice would still include rescuing patients from death at 2 a.m. Couple the intensity of care with such a demanding lifestyle, and it is hardly surprising that many critical-care doctors seek less-stressful practices (e.g., sleep medicine) or retirement.
New physicians who see the work-life imbalance are shying away from critical care in significant enough numbers, yet the demand for these doctors is growing. Whether that shift is due to the attraction of careers in HM, emergency medicine, or other IM specialties, or the perceived negatives to being a full-time intensivist, is beside the point. The medical workforce needs more critical-care physicians. And we are not going to be able to meet this need by assuming we will be able to recruit and train more surgeons, anesthesiologists, or pulmonary physicians in traditional critical-care pathways.
The situation is further complicated by workforce shortages on the rest of the ICU healthcare team. Many senior ICU nurses are reaching the end of their careers, and the pipeline to replace them is anything but robust. And all this comes at a time when the acuity of hospitalized patients is increasing and the demands for ICU expertise is at its height.
It is no surprise that hospitalists are called upon to fill the critical-care gap. SHM surveys show that 92% of hospitalists include ICU care in their practice. While hospitalists clearly do not have the training or skills to replace the intensivist, we clearly are witnessing a “scope creep.” Hospitalists are being asked to stretch their skills to fill the void in critical care.
Competence Question
The response to this is manifest in many ways. For example, steadily increasing numbers of hospitalists attend SHM’s annual critical-care precourses, and our procedures courses invariably sell out. These brief courses are important to hospitalists and their patients. Yet a day (or even two) of focused training for hospitalists will not raise their skill set to replace or even augment critical-care-trained physicians at their hospitals. The patients will keep coming and continue to need the expertise for their most-acute-care needs. Something must be done.
There are pockets of experiments on filling the increasing critical-care gap. Emory University’s Center for Critical Care in Atlanta will soon launch an experimental, HM-critical-care training program that will attempt to develop and verify critical-care competencies in just one postgraduate year after IM residency. A complementary approach could include a hospitalist-focused track within the three years of IM residency to include less outpatient medicine and more intensive-care training. This could be part of a broader restructuring of internal and family medicine residencies, which recognize the career paths (and needs) of their residents as some enter hospital-focused practice (e.g., as hospitalists, cardiologists, intensivists) and some concentrate more on the patient outside the hospital (e.g., primary care, endocrinology, rheumatology).
As training evolves, there will be practical issues of credentialing. Currently, a general-IM-trained hospitalist is required to complete a two-year fellowship in critical care to be a specialist. Interestingly, if one’s residency training is in surgery, anesthesia, or rheumatology, that physician requires only one additional year in critical care to become eligible for added/special qualifications in critical-care medicine. What, precisely, is the carryover of the longer residency experience that makes it possible to attain competency in critical care in half the training time?
There also is the risk that we will create a workforce that includes the intensivist-lite—someone who does not have complete, recognized training in critical care but has more than the typical hospitalist, and is perceived as “better than having no intensivist.” Is this in the best interest of our patients or our discipline?
Supply Solutions
There are other approaches to the workforce challenge beyond asking hospitalists to step away from practice for an additional year or two of training. As in other aspects of the hospital workforce, it is time to examine alternative deployment of the entire healthcare team. If intensivists and hospitalists are in limited supply, we need to revisit their roles and further look for opportunities to engage acute-care nurse practitioners, physician assistants, RNs, and others on the healthcare team to meet the expanding needs of our patients and our hospitals.
Another strategy would include regionalization of healthcare in population centers with multiple hospitals. In Orange County, Calif., where I live, there are 33 hospitals for 3 million people, each with some form of an ICU. Is it time to set standards of coverage and expertise so that 10 to 15 hospitals can provide a fully staffed ICU, and the other hospitals refer their most-acute patients rather than be stretched to staff their ICUs at a time of workforce shortages? Is it time to do what we did with trauma centers and set various levels of care so that not every hospital can or should be doing the most intense and costly level of care?
SHM, HM, and, most importantly, hospitalists find themselves in the midst of this growing problem. We must be part of the solution.
It is important to recognize the significant variability in the intensivist skill sets that individual hospitalists and HM groups currently possess; the variance creates hurdles in being able to step up and fill the critical-care gap. I’ve heard about hospitalists pausing their practices to obtain additional training in critical care. Hospitals across America are (or soon will be) scrambling to integrate their hospitalists and intensivists to maximize coverage and expertise. SHM has noticed an increased demand on hospitalists to increase knowledge and skills so they can extend the local coverage of critically ill patients.
It is time for SHM to clearly understand how this sea change is affecting you professionally and personally, because you practice on the frontlines of our nation’s hospitals.
It is time for SHM to engage our colleagues in the ICU—critical-care physicians and their professional societies—to understand their perspective and initiatives on this growing crisis.
It is time for SHM to engage medical educators in residency and fellowship training to explore potential changes in the curriculum—changes aimed at young physicians proceeding through their training that yield hospital-based physicians better prepared to enter the hospital environment of the 21st century.
And SHM may need to engage the boards and other credentialing bodies to look for flexibility that will reflect today’s realities, attract the best-trained physicians to care for the most-acutely-ill patients, and protect our patients by demanding expertise and training at the most appropriate levels. TH
Dr. Wellikson is CEO of SHM.
There is a brewing crisis in critical-care medicine, a crisis that already is impacting HM. It would be easier for hospitalists to look the other way and say, “This is not our problem.” Make no mistake: It is our problem. There are not enough intensive-care physicians to go around.
In my generation, most physicians who trained in pulmonary and critical-care medicine thought they would do some office care, some bronchoscopies, and some critical care for the first several years of their professional lives. Few imagined that, in their 60s, their practice would still include rescuing patients from death at 2 a.m. Couple the intensity of care with such a demanding lifestyle, and it is hardly surprising that many critical-care doctors seek less-stressful practices (e.g., sleep medicine) or retirement.
New physicians who see the work-life imbalance are shying away from critical care in significant enough numbers, yet the demand for these doctors is growing. Whether that shift is due to the attraction of careers in HM, emergency medicine, or other IM specialties, or the perceived negatives to being a full-time intensivist, is beside the point. The medical workforce needs more critical-care physicians. And we are not going to be able to meet this need by assuming we will be able to recruit and train more surgeons, anesthesiologists, or pulmonary physicians in traditional critical-care pathways.
The situation is further complicated by workforce shortages on the rest of the ICU healthcare team. Many senior ICU nurses are reaching the end of their careers, and the pipeline to replace them is anything but robust. And all this comes at a time when the acuity of hospitalized patients is increasing and the demands for ICU expertise is at its height.
It is no surprise that hospitalists are called upon to fill the critical-care gap. SHM surveys show that 92% of hospitalists include ICU care in their practice. While hospitalists clearly do not have the training or skills to replace the intensivist, we clearly are witnessing a “scope creep.” Hospitalists are being asked to stretch their skills to fill the void in critical care.
Competence Question
The response to this is manifest in many ways. For example, steadily increasing numbers of hospitalists attend SHM’s annual critical-care precourses, and our procedures courses invariably sell out. These brief courses are important to hospitalists and their patients. Yet a day (or even two) of focused training for hospitalists will not raise their skill set to replace or even augment critical-care-trained physicians at their hospitals. The patients will keep coming and continue to need the expertise for their most-acute-care needs. Something must be done.
There are pockets of experiments on filling the increasing critical-care gap. Emory University’s Center for Critical Care in Atlanta will soon launch an experimental, HM-critical-care training program that will attempt to develop and verify critical-care competencies in just one postgraduate year after IM residency. A complementary approach could include a hospitalist-focused track within the three years of IM residency to include less outpatient medicine and more intensive-care training. This could be part of a broader restructuring of internal and family medicine residencies, which recognize the career paths (and needs) of their residents as some enter hospital-focused practice (e.g., as hospitalists, cardiologists, intensivists) and some concentrate more on the patient outside the hospital (e.g., primary care, endocrinology, rheumatology).
As training evolves, there will be practical issues of credentialing. Currently, a general-IM-trained hospitalist is required to complete a two-year fellowship in critical care to be a specialist. Interestingly, if one’s residency training is in surgery, anesthesia, or rheumatology, that physician requires only one additional year in critical care to become eligible for added/special qualifications in critical-care medicine. What, precisely, is the carryover of the longer residency experience that makes it possible to attain competency in critical care in half the training time?
There also is the risk that we will create a workforce that includes the intensivist-lite—someone who does not have complete, recognized training in critical care but has more than the typical hospitalist, and is perceived as “better than having no intensivist.” Is this in the best interest of our patients or our discipline?
Supply Solutions
There are other approaches to the workforce challenge beyond asking hospitalists to step away from practice for an additional year or two of training. As in other aspects of the hospital workforce, it is time to examine alternative deployment of the entire healthcare team. If intensivists and hospitalists are in limited supply, we need to revisit their roles and further look for opportunities to engage acute-care nurse practitioners, physician assistants, RNs, and others on the healthcare team to meet the expanding needs of our patients and our hospitals.
Another strategy would include regionalization of healthcare in population centers with multiple hospitals. In Orange County, Calif., where I live, there are 33 hospitals for 3 million people, each with some form of an ICU. Is it time to set standards of coverage and expertise so that 10 to 15 hospitals can provide a fully staffed ICU, and the other hospitals refer their most-acute patients rather than be stretched to staff their ICUs at a time of workforce shortages? Is it time to do what we did with trauma centers and set various levels of care so that not every hospital can or should be doing the most intense and costly level of care?
SHM, HM, and, most importantly, hospitalists find themselves in the midst of this growing problem. We must be part of the solution.
It is important to recognize the significant variability in the intensivist skill sets that individual hospitalists and HM groups currently possess; the variance creates hurdles in being able to step up and fill the critical-care gap. I’ve heard about hospitalists pausing their practices to obtain additional training in critical care. Hospitals across America are (or soon will be) scrambling to integrate their hospitalists and intensivists to maximize coverage and expertise. SHM has noticed an increased demand on hospitalists to increase knowledge and skills so they can extend the local coverage of critically ill patients.
It is time for SHM to clearly understand how this sea change is affecting you professionally and personally, because you practice on the frontlines of our nation’s hospitals.
It is time for SHM to engage our colleagues in the ICU—critical-care physicians and their professional societies—to understand their perspective and initiatives on this growing crisis.
It is time for SHM to engage medical educators in residency and fellowship training to explore potential changes in the curriculum—changes aimed at young physicians proceeding through their training that yield hospital-based physicians better prepared to enter the hospital environment of the 21st century.
And SHM may need to engage the boards and other credentialing bodies to look for flexibility that will reflect today’s realities, attract the best-trained physicians to care for the most-acutely-ill patients, and protect our patients by demanding expertise and training at the most appropriate levels. TH
Dr. Wellikson is CEO of SHM.