When recruiting a hospitalist for his company, Jason Stuckey makes it a point to call the candidate’s home. His goal isn’t to speak with the hospitalist the company is interested in hiring—it’s to talk with the candidate’s spouse.

“One of the top five mistakes recruiters make is to not involve the spouse in the [recruitment] process,” says Stuckey, who directs HM recruiting for TeamHealth, a Knoxville, Tenn.-based company that provides healthcare staffing and administrative services to hospitals in 14 states.

Hospitalists are generally so busy with work that the spouse is often the person in the family who takes the lead in the job search, says Tim Lary, vice president of profession staffing for IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif.

The spouse often gives final approval on a decision to accept a job offer, adds Peggy Fricke, director of physician staffing for Eagle Hospital Physicians, an Atlanta-based company that manages hospitalist practices for hospitals in the Southeast and Mid-Atlantic regions.

“The physician could be making the most money, but if their spouse and family are not happy, then they won’t stay in the position long,” Stuckey explains. “I’ve also found that if the spouse is not on board with moving and uprooting the family to a new location, then it’s not going to happen.”

As a result, recruiters and prospective employers often spend just as much time engaging the spouse as they do the actual job candidate, the recruiters say. For this reason, hospitalists who are searching for a new job would be wise to include their husband or wife as early as possible in the job hunt in order to get the most out of the recruiting process.

For example, while the hospitalist focuses on determining if the work is the right fit professionally and financially, the spouse can appraise the community to see if it meets the family’s needs in such areas as schools, neighborhoods, religious services, community groups, and entertainment/cultural outlets. If the hospitalist is invited for an on-site interview, it’s important that their spouse makes the trip as well.

“We always do a community tour, and we will do school tours when asked,” Fricke says of Eagle’s recruiting efforts. “We can introduce the families of the other hospitalists in the practice so a spouse can meet and get to know them.”

Upfront Inclusion

When the spouse is involved in the process, they usually are more receptive to receiving information about what opportunities exist in other communities and more open to the idea of moving to a new place, Stuckey says.

For instances in which children are involved, the spouse is most often interested in learning about the location’s school districts and private schools, and determining if the community has a good quality of life for families, Fricke says. For situations in which there are no children or the children are grown, the spouse often focuses on job prospects in their own profession.

Hospitalists with a husband or wife who works and whose career is important to them should see if the HM recruiter can help put their spouse in touch with potential employers in the community, because many times they will, says Fricke, who has connected spouses in IT and engineering fields with people who could assist them in their job search.

“It goes back to making sure everyone is happy. If the spouse can’t find work, that is going to affect their happiness,” says Darren Swenson, MD, medical affairs director for IPC of Nevada and regional chair of IPC’s national advisory board.

Aside from schools, quality of life, and their own job opportunities, spouses also ask about what their hospitalist husband or wife’s work schedule would be and how much vacation and holiday time they would have in the prospective job, Dr. Swenson says.

“It’s extremely important that we look at our hospitalists and their spouses being happy in their home life, because if they’re not, that is going to spill over into in their work life,” IPC’s Lary says.

Good Partnership, Bad Partnership

Times arise when the spouse takes a proactive role in evaluating the actual HM job offer, the recruiters say. “In all couples, there is someone who is dominant and someone who is not,” says Fricke, who has seen spouses participate in job interviews with hospital administrators. “If the spouse is dominant, we try to understand them and listen to what is important to them.”

Sometimes the spouse is an attorney or other type of professional who wants to review the hospitalist contract and has the most questions about it, Dr. Swenson says. When that happens, recruiters will often have group members sit in to answer their questions, he says.

“Absolutely, without question, the spouse has to be involved. But if the spouse is too demanding and everything has to be run through them, to an employer, that can be a big turnoff,” Stuckey says.

When it comes to business matters, the physician—not the spouse—has to take the lead, he says. If the physician doesn’t, it could make the prospective employer wonder what challenges could be ahead should the candidate be hired, Stuckey says.

Two-Physician Families

One time when it is acceptable for a spouse to get intimately involved in the contract and negotiations is when he or she is a hospitalist who also is being recruited by the same prospective employer.

“It’s a unique situation. It’s great to have two for the price of one, so to speak,” Stuckey says. “But there are challenges from the employer’s perspective—for example, scheduling—that have to be resolved on the front end rather than when they get there.”

While still relatively rare, husband-wife hospitalist couples are becoming more prevalent because there are more hospitalists, Fricke says. They tend to meet each other in medical school or residency, she says.

“Even though they are a couple, we treat them as individuals during the recruiting process,” Fricke says. “I think the most important thing is we try to do anything we can—within reason, of course—to help the hospitalist and their spouse make the best decision for themselves and their family.” TH

Lisa Ryan is a freelance writer based in New Jersey.

When recruiting a hospitalist for his company, Jason Stuckey makes it a point to call the candidate’s home. His goal isn’t to speak with the hospitalist the company is interested in hiring—it’s to talk with the candidate’s spouse.

“One of the top five mistakes recruiters make is to not involve the spouse in the [recruitment] process,” says Stuckey, who directs HM recruiting for TeamHealth, a Knoxville, Tenn.-based company that provides healthcare staffing and administrative services to hospitals in 14 states.

Hospitalists are generally so busy with work that the spouse is often the person in the family who takes the lead in the job search, says Tim Lary, vice president of profession staffing for IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif.

The spouse often gives final approval on a decision to accept a job offer, adds Peggy Fricke, director of physician staffing for Eagle Hospital Physicians, an Atlanta-based company that manages hospitalist practices for hospitals in the Southeast and Mid-Atlantic regions.

“The physician could be making the most money, but if their spouse and family are not happy, then they won’t stay in the position long,” Stuckey explains. “I’ve also found that if the spouse is not on board with moving and uprooting the family to a new location, then it’s not going to happen.”

As a result, recruiters and prospective employers often spend just as much time engaging the spouse as they do the actual job candidate, the recruiters say. For this reason, hospitalists who are searching for a new job would be wise to include their husband or wife as early as possible in the job hunt in order to get the most out of the recruiting process.

For example, while the hospitalist focuses on determining if the work is the right fit professionally and financially, the spouse can appraise the community to see if it meets the family’s needs in such areas as schools, neighborhoods, religious services, community groups, and entertainment/cultural outlets. If the hospitalist is invited for an on-site interview, it’s important that their spouse makes the trip as well.

“We always do a community tour, and we will do school tours when asked,” Fricke says of Eagle’s recruiting efforts. “We can introduce the families of the other hospitalists in the practice so a spouse can meet and get to know them.”

Upfront Inclusion

When the spouse is involved in the process, they usually are more receptive to receiving information about what opportunities exist in other communities and more open to the idea of moving to a new place, Stuckey says.

For instances in which children are involved, the spouse is most often interested in learning about the location’s school districts and private schools, and determining if the community has a good quality of life for families, Fricke says. For situations in which there are no children or the children are grown, the spouse often focuses on job prospects in their own profession.

Hospitalists with a husband or wife who works and whose career is important to them should see if the HM recruiter can help put their spouse in touch with potential employers in the community, because many times they will, says Fricke, who has connected spouses in IT and engineering fields with people who could assist them in their job search.

“It goes back to making sure everyone is happy. If the spouse can’t find work, that is going to affect their happiness,” says Darren Swenson, MD, medical affairs director for IPC of Nevada and regional chair of IPC’s national advisory board.

Aside from schools, quality of life, and their own job opportunities, spouses also ask about what their hospitalist husband or wife’s work schedule would be and how much vacation and holiday time they would have in the prospective job, Dr. Swenson says.

“It’s extremely important that we look at our hospitalists and their spouses being happy in their home life, because if they’re not, that is going to spill over into in their work life,” IPC’s Lary says.

Good Partnership, Bad Partnership

Times arise when the spouse takes a proactive role in evaluating the actual HM job offer, the recruiters say. “In all couples, there is someone who is dominant and someone who is not,” says Fricke, who has seen spouses participate in job interviews with hospital administrators. “If the spouse is dominant, we try to understand them and listen to what is important to them.”

Sometimes the spouse is an attorney or other type of professional who wants to review the hospitalist contract and has the most questions about it, Dr. Swenson says. When that happens, recruiters will often have group members sit in to answer their questions, he says.

“Absolutely, without question, the spouse has to be involved. But if the spouse is too demanding and everything has to be run through them, to an employer, that can be a big turnoff,” Stuckey says.

When it comes to business matters, the physician—not the spouse—has to take the lead, he says. If the physician doesn’t, it could make the prospective employer wonder what challenges could be ahead should the candidate be hired, Stuckey says.

Two-Physician Families

One time when it is acceptable for a spouse to get intimately involved in the contract and negotiations is when he or she is a hospitalist who also is being recruited by the same prospective employer.

“It’s a unique situation. It’s great to have two for the price of one, so to speak,” Stuckey says. “But there are challenges from the employer’s perspective—for example, scheduling—that have to be resolved on the front end rather than when they get there.”

While still relatively rare, husband-wife hospitalist couples are becoming more prevalent because there are more hospitalists, Fricke says. They tend to meet each other in medical school or residency, she says.

“Even though they are a couple, we treat them as individuals during the recruiting process,” Fricke says. “I think the most important thing is we try to do anything we can—within reason, of course—to help the hospitalist and their spouse make the best decision for themselves and their family.” TH

Lisa Ryan is a freelance writer based in New Jersey.

When recruiting a hospitalist for his company, Jason Stuckey makes it a point to call the candidate’s home. His goal isn’t to speak with the hospitalist the company is interested in hiring—it’s to talk with the candidate’s spouse.

“One of the top five mistakes recruiters make is to not involve the spouse in the [recruitment] process,” says Stuckey, who directs HM recruiting for TeamHealth, a Knoxville, Tenn.-based company that provides healthcare staffing and administrative services to hospitals in 14 states.

Hospitalists are generally so busy with work that the spouse is often the person in the family who takes the lead in the job search, says Tim Lary, vice president of profession staffing for IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif.

The spouse often gives final approval on a decision to accept a job offer, adds Peggy Fricke, director of physician staffing for Eagle Hospital Physicians, an Atlanta-based company that manages hospitalist practices for hospitals in the Southeast and Mid-Atlantic regions.

“The physician could be making the most money, but if their spouse and family are not happy, then they won’t stay in the position long,” Stuckey explains. “I’ve also found that if the spouse is not on board with moving and uprooting the family to a new location, then it’s not going to happen.”

As a result, recruiters and prospective employers often spend just as much time engaging the spouse as they do the actual job candidate, the recruiters say. For this reason, hospitalists who are searching for a new job would be wise to include their husband or wife as early as possible in the job hunt in order to get the most out of the recruiting process.

For example, while the hospitalist focuses on determining if the work is the right fit professionally and financially, the spouse can appraise the community to see if it meets the family’s needs in such areas as schools, neighborhoods, religious services, community groups, and entertainment/cultural outlets. If the hospitalist is invited for an on-site interview, it’s important that their spouse makes the trip as well.

“We always do a community tour, and we will do school tours when asked,” Fricke says of Eagle’s recruiting efforts. “We can introduce the families of the other hospitalists in the practice so a spouse can meet and get to know them.”

Upfront Inclusion

When the spouse is involved in the process, they usually are more receptive to receiving information about what opportunities exist in other communities and more open to the idea of moving to a new place, Stuckey says.

For instances in which children are involved, the spouse is most often interested in learning about the location’s school districts and private schools, and determining if the community has a good quality of life for families, Fricke says. For situations in which there are no children or the children are grown, the spouse often focuses on job prospects in their own profession.

Hospitalists with a husband or wife who works and whose career is important to them should see if the HM recruiter can help put their spouse in touch with potential employers in the community, because many times they will, says Fricke, who has connected spouses in IT and engineering fields with people who could assist them in their job search.

“It goes back to making sure everyone is happy. If the spouse can’t find work, that is going to affect their happiness,” says Darren Swenson, MD, medical affairs director for IPC of Nevada and regional chair of IPC’s national advisory board.

Aside from schools, quality of life, and their own job opportunities, spouses also ask about what their hospitalist husband or wife’s work schedule would be and how much vacation and holiday time they would have in the prospective job, Dr. Swenson says.

“It’s extremely important that we look at our hospitalists and their spouses being happy in their home life, because if they’re not, that is going to spill over into in their work life,” IPC’s Lary says.

Good Partnership, Bad Partnership

Times arise when the spouse takes a proactive role in evaluating the actual HM job offer, the recruiters say. “In all couples, there is someone who is dominant and someone who is not,” says Fricke, who has seen spouses participate in job interviews with hospital administrators. “If the spouse is dominant, we try to understand them and listen to what is important to them.”

Sometimes the spouse is an attorney or other type of professional who wants to review the hospitalist contract and has the most questions about it, Dr. Swenson says. When that happens, recruiters will often have group members sit in to answer their questions, he says.

“Absolutely, without question, the spouse has to be involved. But if the spouse is too demanding and everything has to be run through them, to an employer, that can be a big turnoff,” Stuckey says.

When it comes to business matters, the physician—not the spouse—has to take the lead, he says. If the physician doesn’t, it could make the prospective employer wonder what challenges could be ahead should the candidate be hired, Stuckey says.

Two-Physician Families

One time when it is acceptable for a spouse to get intimately involved in the contract and negotiations is when he or she is a hospitalist who also is being recruited by the same prospective employer.

“It’s a unique situation. It’s great to have two for the price of one, so to speak,” Stuckey says. “But there are challenges from the employer’s perspective—for example, scheduling—that have to be resolved on the front end rather than when they get there.”

While still relatively rare, husband-wife hospitalist couples are becoming more prevalent because there are more hospitalists, Fricke says. They tend to meet each other in medical school or residency, she says.

“Even though they are a couple, we treat them as individuals during the recruiting process,” Fricke says. “I think the most important thing is we try to do anything we can—within reason, of course—to help the hospitalist and their spouse make the best decision for themselves and their family.” TH

Lisa Ryan is a freelance writer based in New Jersey.

Discharge day management services (99238-99239) seem unlikely to cause confusion in the physician community; however, continued requests for documentation involving these CPT codes prove the opposite.

Here’s an example of how a billing error might be made for discharge day management services. A patient with diabetes mellitus, hypertension, and chronic kidney disease is stable for discharge. The patient is being transferred to a skilled nursing facility (SNF). Dr. Aardsma prepares the patient for hospital discharge, and Dr. Broxton admits the patient to the SNF later that day. Dr. Aardsma and Dr. Broxton are members of the same group practice, with the same specialty designation. Can both physicians report their services?

Key Elements

Consider the basic billing principles of discharge services: what, who, and when.

Hospital discharge day management codes are used to report the physician’s total duration of time spent preparing the patient for discharge. These codes include, as appropriate:

• Final examination of the patient;
• Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;
• Instructions for continuing care to all relevant caregivers; and
• Preparation of discharge records, prescriptions, and referral forms.¹

Hospitalists should report one discharge code per hospitalization, but only when the service occurs after the initial date of admission: 99238, hospital discharge day management, 30 minutes or less; or 99239, hospital discharge day management, more than 30 minutes.^1,2 Select one of the two codes, depending upon the cumulative discharge service time provided on the patient’s hospital unit/floor during a single calendar day. Do not count time for services performed outside of the patient’s unit or floor (i.e., calls to the receiving physician/facility made from the physician’s private office) or services performed after the patient physically leaves the hospital.

Physician documentation must refer to the discharge status, as well as other clinically relevant information. Don’t be misled into believing that the presence of a discharge summary alone satisfies documentation requirements. In addition to the discharge groundwork, hospitalists must physically see the patient on the day he or she reports discharge management. Discharge summaries are not always useful in noting the physician’s required face-to-face encounter with the patient. Simply state, “Patient seen and examined by me on discharge day.”

Alternatively, hospitalists can elect to include details of a discharge day exam. Although a final exam isn’t mandatory for billing 99238-99239, it is the best justification of a face-to-face encounter on discharge day. Documentation of the time is required when reporting 99239 (e.g., discharge time >30 minutes). Time isn’t typically included in a discharge summary, and upon post-payment payor review, a claim involving 99239 without documented time in the patient’s medical record might result in either a service reduction to the lower level of care (99238) or a request for payment refund.³ Physicians can document all necessary details in the formal summary or a progress note.

Transfers of Care

The admitting physician or group is responsible for performing discharge services unless a formal transfer of care occurs, such as the patient’s transfer from the ICU to the standard medical floor as the patient’s condition improves. Without this transfer of care, comanaging physicians should merely report subsequent hospital-care codes (99231-99233) for the final patient encounter. An example of this is surgical comanagement: If a surgeon is identified as the attending of record, they are responsible for postoperative management of the patient, including discharge services.^4,5 Providers in a different group or specialty report 99231-99233 for their medically necessary care.

As with all other time-based services, only the billing provider’s time counts. Discharge-related services performed by residents, students, or ancillary staff (i.e., RNs) do not count toward the physician’s discharge service time. Report the date of the physician’s actual discharge visit even if the patient leaves the facility on a different calendar date—for example, if a patient leaves the next day due to availability of the receiving facility.

Pronouncement of Death

Physicians might not realize that they can report discharge day management codes for pronouncement of death.⁷ Only the hospitalist who performs the pronouncement is allowed to report this service on the date pronouncement occurred, even if the paperwork is delayed to a subsequent date. Completion of the death certificate alone is not sufficient for billing. Hospitalists must “examine” the patient, thus satisfying the “face to face” visit requirement.

Additional services (e.g., speaking with family members, speaking with healthcare providers, filling out the necessary documentation) count toward the cumulative discharge service time, if performed on the patient’s unit or floor. Document the cumulative time when reporting 99239.

Back to the Case

Typical billing and payment rules mandate the reporting of only one E/M service per specialty, per patient, per day. One of the few exceptions involves reporting a hospital discharge code (99238-99239) with initial nursing facility care (99304-99306). Either the same physician or different physicians from the same group and specialty can report the hospital discharge and the nursing facility admission on the same day. When the same physician or group discharges the patient from any other location (e.g., observation unit) on the same day, report only one service: either the observation discharge (99217) or the initial nursing facility care (99304-99306).

When the same physician or group discharges a patient from the hospital and admits the patient to a facility other than a nursing facility on the same day, report only one service: either the hospital discharge (99228-99239) or the admission care (e.g., long-term acute-care hospital: 99221-99223). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1C. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 3, 2010.
3. Highmark Medicare Services Provider Bulletins: Hospital Discharge Day Management Codes 99238 and 99239. Highmark Medicare Services Web site. Available at: www.highmarkmedicareservices.com/bulletins/partb/news02212008a.html. Accessed March 4, 2010.
4. Medicare Claims Processing Manual: Chapter 12, Section 40.1A. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
5. Medicare Claims Processing Manual: Chapter 12, Section 40.3B. Centers for Medicare & Medicaid Services Web site, Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
6. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2E. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1d. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
8. Reporting inpatient hospital evaluation and management (E/M) services that could be described by current procedural terminology (CPT) consultation codes. Cigna Government Services Web site. Available at: www.cignagovernmentservices.com/partb/pubs/news/2010/0210/cope11694.html. Accessed March 5, 2010.

Discharge day management services (99238-99239) seem unlikely to cause confusion in the physician community; however, continued requests for documentation involving these CPT codes prove the opposite.

Here’s an example of how a billing error might be made for discharge day management services. A patient with diabetes mellitus, hypertension, and chronic kidney disease is stable for discharge. The patient is being transferred to a skilled nursing facility (SNF). Dr. Aardsma prepares the patient for hospital discharge, and Dr. Broxton admits the patient to the SNF later that day. Dr. Aardsma and Dr. Broxton are members of the same group practice, with the same specialty designation. Can both physicians report their services?

Key Elements

Consider the basic billing principles of discharge services: what, who, and when.

Hospital discharge day management codes are used to report the physician’s total duration of time spent preparing the patient for discharge. These codes include, as appropriate:

• Final examination of the patient;
• Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;
• Instructions for continuing care to all relevant caregivers; and
• Preparation of discharge records, prescriptions, and referral forms.¹

Hospitalists should report one discharge code per hospitalization, but only when the service occurs after the initial date of admission: 99238, hospital discharge day management, 30 minutes or less; or 99239, hospital discharge day management, more than 30 minutes.^1,2 Select one of the two codes, depending upon the cumulative discharge service time provided on the patient’s hospital unit/floor during a single calendar day. Do not count time for services performed outside of the patient’s unit or floor (i.e., calls to the receiving physician/facility made from the physician’s private office) or services performed after the patient physically leaves the hospital.

Physician documentation must refer to the discharge status, as well as other clinically relevant information. Don’t be misled into believing that the presence of a discharge summary alone satisfies documentation requirements. In addition to the discharge groundwork, hospitalists must physically see the patient on the day he or she reports discharge management. Discharge summaries are not always useful in noting the physician’s required face-to-face encounter with the patient. Simply state, “Patient seen and examined by me on discharge day.”

Alternatively, hospitalists can elect to include details of a discharge day exam. Although a final exam isn’t mandatory for billing 99238-99239, it is the best justification of a face-to-face encounter on discharge day. Documentation of the time is required when reporting 99239 (e.g., discharge time >30 minutes). Time isn’t typically included in a discharge summary, and upon post-payment payor review, a claim involving 99239 without documented time in the patient’s medical record might result in either a service reduction to the lower level of care (99238) or a request for payment refund.³ Physicians can document all necessary details in the formal summary or a progress note.

Transfers of Care

The admitting physician or group is responsible for performing discharge services unless a formal transfer of care occurs, such as the patient’s transfer from the ICU to the standard medical floor as the patient’s condition improves. Without this transfer of care, comanaging physicians should merely report subsequent hospital-care codes (99231-99233) for the final patient encounter. An example of this is surgical comanagement: If a surgeon is identified as the attending of record, they are responsible for postoperative management of the patient, including discharge services.^4,5 Providers in a different group or specialty report 99231-99233 for their medically necessary care.

As with all other time-based services, only the billing provider’s time counts. Discharge-related services performed by residents, students, or ancillary staff (i.e., RNs) do not count toward the physician’s discharge service time. Report the date of the physician’s actual discharge visit even if the patient leaves the facility on a different calendar date—for example, if a patient leaves the next day due to availability of the receiving facility.

Pronouncement of Death

Physicians might not realize that they can report discharge day management codes for pronouncement of death.⁷ Only the hospitalist who performs the pronouncement is allowed to report this service on the date pronouncement occurred, even if the paperwork is delayed to a subsequent date. Completion of the death certificate alone is not sufficient for billing. Hospitalists must “examine” the patient, thus satisfying the “face to face” visit requirement.

Additional services (e.g., speaking with family members, speaking with healthcare providers, filling out the necessary documentation) count toward the cumulative discharge service time, if performed on the patient’s unit or floor. Document the cumulative time when reporting 99239.

Back to the Case

Typical billing and payment rules mandate the reporting of only one E/M service per specialty, per patient, per day. One of the few exceptions involves reporting a hospital discharge code (99238-99239) with initial nursing facility care (99304-99306). Either the same physician or different physicians from the same group and specialty can report the hospital discharge and the nursing facility admission on the same day. When the same physician or group discharges the patient from any other location (e.g., observation unit) on the same day, report only one service: either the observation discharge (99217) or the initial nursing facility care (99304-99306).

When the same physician or group discharges a patient from the hospital and admits the patient to a facility other than a nursing facility on the same day, report only one service: either the hospital discharge (99228-99239) or the admission care (e.g., long-term acute-care hospital: 99221-99223). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1C. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 3, 2010.
3. Highmark Medicare Services Provider Bulletins: Hospital Discharge Day Management Codes 99238 and 99239. Highmark Medicare Services Web site. Available at: www.highmarkmedicareservices.com/bulletins/partb/news02212008a.html. Accessed March 4, 2010.
4. Medicare Claims Processing Manual: Chapter 12, Section 40.1A. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
5. Medicare Claims Processing Manual: Chapter 12, Section 40.3B. Centers for Medicare & Medicaid Services Web site, Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
6. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2E. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1d. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
8. Reporting inpatient hospital evaluation and management (E/M) services that could be described by current procedural terminology (CPT) consultation codes. Cigna Government Services Web site. Available at: www.cignagovernmentservices.com/partb/pubs/news/2010/0210/cope11694.html. Accessed March 5, 2010.

Discharge day management services (99238-99239) seem unlikely to cause confusion in the physician community; however, continued requests for documentation involving these CPT codes prove the opposite.

Here’s an example of how a billing error might be made for discharge day management services. A patient with diabetes mellitus, hypertension, and chronic kidney disease is stable for discharge. The patient is being transferred to a skilled nursing facility (SNF). Dr. Aardsma prepares the patient for hospital discharge, and Dr. Broxton admits the patient to the SNF later that day. Dr. Aardsma and Dr. Broxton are members of the same group practice, with the same specialty designation. Can both physicians report their services?

Key Elements

Consider the basic billing principles of discharge services: what, who, and when.

Hospital discharge day management codes are used to report the physician’s total duration of time spent preparing the patient for discharge. These codes include, as appropriate:

• Final examination of the patient;
• Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;
• Instructions for continuing care to all relevant caregivers; and
• Preparation of discharge records, prescriptions, and referral forms.¹

Hospitalists should report one discharge code per hospitalization, but only when the service occurs after the initial date of admission: 99238, hospital discharge day management, 30 minutes or less; or 99239, hospital discharge day management, more than 30 minutes.^1,2 Select one of the two codes, depending upon the cumulative discharge service time provided on the patient’s hospital unit/floor during a single calendar day. Do not count time for services performed outside of the patient’s unit or floor (i.e., calls to the receiving physician/facility made from the physician’s private office) or services performed after the patient physically leaves the hospital.

Physician documentation must refer to the discharge status, as well as other clinically relevant information. Don’t be misled into believing that the presence of a discharge summary alone satisfies documentation requirements. In addition to the discharge groundwork, hospitalists must physically see the patient on the day he or she reports discharge management. Discharge summaries are not always useful in noting the physician’s required face-to-face encounter with the patient. Simply state, “Patient seen and examined by me on discharge day.”

Alternatively, hospitalists can elect to include details of a discharge day exam. Although a final exam isn’t mandatory for billing 99238-99239, it is the best justification of a face-to-face encounter on discharge day. Documentation of the time is required when reporting 99239 (e.g., discharge time >30 minutes). Time isn’t typically included in a discharge summary, and upon post-payment payor review, a claim involving 99239 without documented time in the patient’s medical record might result in either a service reduction to the lower level of care (99238) or a request for payment refund.³ Physicians can document all necessary details in the formal summary or a progress note.

Transfers of Care

The admitting physician or group is responsible for performing discharge services unless a formal transfer of care occurs, such as the patient’s transfer from the ICU to the standard medical floor as the patient’s condition improves. Without this transfer of care, comanaging physicians should merely report subsequent hospital-care codes (99231-99233) for the final patient encounter. An example of this is surgical comanagement: If a surgeon is identified as the attending of record, they are responsible for postoperative management of the patient, including discharge services.^4,5 Providers in a different group or specialty report 99231-99233 for their medically necessary care.

As with all other time-based services, only the billing provider’s time counts. Discharge-related services performed by residents, students, or ancillary staff (i.e., RNs) do not count toward the physician’s discharge service time. Report the date of the physician’s actual discharge visit even if the patient leaves the facility on a different calendar date—for example, if a patient leaves the next day due to availability of the receiving facility.

Pronouncement of Death

Physicians might not realize that they can report discharge day management codes for pronouncement of death.⁷ Only the hospitalist who performs the pronouncement is allowed to report this service on the date pronouncement occurred, even if the paperwork is delayed to a subsequent date. Completion of the death certificate alone is not sufficient for billing. Hospitalists must “examine” the patient, thus satisfying the “face to face” visit requirement.

Additional services (e.g., speaking with family members, speaking with healthcare providers, filling out the necessary documentation) count toward the cumulative discharge service time, if performed on the patient’s unit or floor. Document the cumulative time when reporting 99239.

Back to the Case

Typical billing and payment rules mandate the reporting of only one E/M service per specialty, per patient, per day. One of the few exceptions involves reporting a hospital discharge code (99238-99239) with initial nursing facility care (99304-99306). Either the same physician or different physicians from the same group and specialty can report the hospital discharge and the nursing facility admission on the same day. When the same physician or group discharges the patient from any other location (e.g., observation unit) on the same day, report only one service: either the observation discharge (99217) or the initial nursing facility care (99304-99306).

When the same physician or group discharges a patient from the hospital and admits the patient to a facility other than a nursing facility on the same day, report only one service: either the hospital discharge (99228-99239) or the admission care (e.g., long-term acute-care hospital: 99221-99223). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1C. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 3, 2010.
3. Highmark Medicare Services Provider Bulletins: Hospital Discharge Day Management Codes 99238 and 99239. Highmark Medicare Services Web site. Available at: www.highmarkmedicareservices.com/bulletins/partb/news02212008a.html. Accessed March 4, 2010.
4. Medicare Claims Processing Manual: Chapter 12, Section 40.1A. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
5. Medicare Claims Processing Manual: Chapter 12, Section 40.3B. Centers for Medicare & Medicaid Services Web site, Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
6. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2E. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1d. Centers for Medicare & Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2010.
8. Reporting inpatient hospital evaluation and management (E/M) services that could be described by current procedural terminology (CPT) consultation codes. Cigna Government Services Web site. Available at: www.cignagovernmentservices.com/partb/pubs/news/2010/0210/cope11694.html. Accessed March 5, 2010.

In 1973, a survey was conducted to evaluate physician satisfaction. Less than 15% of physicians reported any doubt that they had made the right career choice, with 3.7% stating that they were “not happy.”¹ Twenty years later, surveys revealed a different story: Forty percent of physicians stated that they would not choose the medical profession if they had to choose a career again.²

Dissatisfaction in medicine has been reported in diverse age groups, different areas of the country, and various medical specialties.³ When dissatisfied, physicians often leave their jobs and, consequently, the patient-physician relationship is disrupted. This turnover is quite costly to the healthcare system. In primary care, the cost of replacing a physician is estimated at $250,000.⁴

Here are some of the factors that contribute to burnout, as well as solutions for ensuring job satisfaction.

Challenges Ahead

Burnout is an interesting phenomenon in the medical profession. Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at an early stage in their careers—during medical school and residency. By midcareer, the momentum is maintained as colleagues recognize their hard work, and they continue to place service to others before themselves. Physicians who encounter burnout often experience emotional exhaustion, impaired job performance, relationship difficulties, and poor health, including irritability, sleep disturbances, headaches, depression, and drug addictions.

Increased rates of burnout have been linked to several internal and external factors. Internal factors—management style in a workplace, multiple demands at work, social support from colleagues, lack of control over the work environment—have been illustrated to correlate with higher rates of burnout. The ever-increasing demand on physicians’ time leads to higher rates of dissatisfaction. There are an exponentially increasing number of medications, tests, and procedures to discuss with patients and families. This is complicated by the rise of e-mail and the Internet, as some patients expect immediate responses to their concerns.

Some studies have shown that personality factors can lead to burnout. Compulsiveness, a trait often seen in physicians, is an adaptive behavior for the demands of medical education and practice. However, it can lead to chronic feelings of inadequacy, an exaggerated sense of responsibility, and difficulty setting limits. Furthermore, physicians often are conditioned in the psychology of postponement. It takes root in the early years of medical education and leads to habitually delaying various sources of renewal, such as vacations and relationships.

External factors include payment reductions, managing various insurers, and increasing malpractice cases.^1,2,5 Evaluating the changing landscape of managed-care organizations reveals that while a small fraction of physicians are employed by them, more than 90% contract with them. Commonly cited reasons for dissatisfaction with managed care include “trafficking” of patients in and out of care, administrative paperwork, limitations on referring patients to specialists, financial incentives to curb medical workups, and pressure to evaluate increasing numbers of patients.⁶

Malpractice cases have increased in the past 30 years. The American Medical Association (AMA) has identified 18 states where providers are finding it challenging to purchase affordable insurance.⁷ An additional 26 states have been placed on “orange alert,” indicating a worsening situation in availability and affordability of insurance. Physicians who are not personally burdened by malpractice suits feel its repercussions. They practice “defensive medicine” by ordering increasing numbers of tests and procedures to avoid potential litigation. Physicians involved in lawsuits, regardless of the outcome, describe feeling shame, self-doubt, and disillusionment with medical practice.

What Makes You Happy?

In the December 2006 issue of The Hospitalist (see “Are You Satisfied?” p. 4), Mary Jo Gorman, MD, MBA, FHM, then president of SHM, pointed out five factors that contribute to physician satisfaction:

1. Stimulation and challenge at work. It’s critical to have a job that requires technically difficult tasks, procedures, or intellectual challenges. The ability to interact and collaborate with other physicians further adds depth and richness to hospitalists’ clinical practice. However, it’s important to realize that overstimulation can lead to discomfort and unhappiness.
2. Feeling appreciated. Recog-nition for your performance leads to feeling valued at work and has a strong correlation with overall job satisfaction. It keeps hospitalists interested and motivated. However, recognition should be personalized; otherwise, it can have a detrimental effect.
3. Control over work. Auto-nomy and control over work is important to ensuring job satisfaction. This includes actively participating in the design of your work schedule and other work-related matters. When decisions are imposed on physicians, it creates tension and stress.
4. Work environment. This includes the type of work, support, and opportunities for growth and development, as well as interactions with colleagues and staff.
5. Income. Compensation is often fourth or fifth on the list of priorities for physicians. While all of us seek fair compensation for our work, it often is not the main reason we choose an employment.

Solutions

Burnout prevention is the responsibility of all healthcare professionals. It’s critical to promote well-being on all levels: physical, emotional, psychological, and spiritual. The following recommendations are based on various interventions established nationally to address physician burnout:

Establish realistic goals. Identify realistic goals for your professional and personal life, and actively work on balancing the two. Emphasize these goals throughout your professional career, avoiding the natural tendency for postponement.

Improve your work environment. Involve physicians in the design and management of the practice; build flexible schedules that allow coverage during important life events (i.e., graduations, births, weddings); minimize paperwork and improve efficiency; and establish a committee for open discussion of physician wellness issues.

Take care of yourself. Mentorship programs support junior members in their career development and help them balance the challenges of their personal and professional lives. Mentors can detect dissatisfaction and help physicians re-evaluate their interests and career paths. Require physicians to have their own primary-care physician (PCP) to ensure their physical and mental well-being. Offer memberships to fitness centers.

Provide opportunities to grow. Seek opportunities for medical education; address personal goals and aspirations, such as hobbies and interests; and establish sabbatical programs to gain perspective and broaden your horizons.

Fortunately, medicine has an enthusiastic applicant pool. There is hope that highly motivated and qualified students will continue to apply and enter the medical profession. However, there is concern that the dissatisfaction in medicine might influence the caliber of applicants who apply.

Medical education and training needs to address the challenges of practicing medicine. Students should be taught about the challenges of delivering high-quality care, risk management, cost containment, and utilization review. During the clinical years in medical school and residency, trainees need to experience the fast pace of medicine, the realities of payment dilemmas, and increased paperwork. It ultimately is the responsibility of educators in the medical profession to encourage students and residents to establish more accurate expectations of the practice of medicine. TH

Dr. Afsarmanesh is director of hospital medicine quality initiatives at Ronald Reagan UCLA Medical Center in Los Angeles.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348(23):2281-2284.
2. Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB. Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med. 1992;67:180-190.
3. Harvey LK, Shubat SC. AMA Public Opinion on Healthcare Issues. Chicago: American Medical Association Press; 1988.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
5. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431-1438.
6. Reams HR, Dunstone DC. Professional satisfaction of physicians. Arch Intern Med. 1989;149:1951-1956.
7. McMurray JE, Williams E, Schwartz MD, et al. Developing a model using qualitative data. J Gen Intern Med. 1997;12(11):711–714.

In 1973, a survey was conducted to evaluate physician satisfaction. Less than 15% of physicians reported any doubt that they had made the right career choice, with 3.7% stating that they were “not happy.”¹ Twenty years later, surveys revealed a different story: Forty percent of physicians stated that they would not choose the medical profession if they had to choose a career again.²

Dissatisfaction in medicine has been reported in diverse age groups, different areas of the country, and various medical specialties.³ When dissatisfied, physicians often leave their jobs and, consequently, the patient-physician relationship is disrupted. This turnover is quite costly to the healthcare system. In primary care, the cost of replacing a physician is estimated at $250,000.⁴

Here are some of the factors that contribute to burnout, as well as solutions for ensuring job satisfaction.

Challenges Ahead

Burnout is an interesting phenomenon in the medical profession. Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at an early stage in their careers—during medical school and residency. By midcareer, the momentum is maintained as colleagues recognize their hard work, and they continue to place service to others before themselves. Physicians who encounter burnout often experience emotional exhaustion, impaired job performance, relationship difficulties, and poor health, including irritability, sleep disturbances, headaches, depression, and drug addictions.

Increased rates of burnout have been linked to several internal and external factors. Internal factors—management style in a workplace, multiple demands at work, social support from colleagues, lack of control over the work environment—have been illustrated to correlate with higher rates of burnout. The ever-increasing demand on physicians’ time leads to higher rates of dissatisfaction. There are an exponentially increasing number of medications, tests, and procedures to discuss with patients and families. This is complicated by the rise of e-mail and the Internet, as some patients expect immediate responses to their concerns.

Some studies have shown that personality factors can lead to burnout. Compulsiveness, a trait often seen in physicians, is an adaptive behavior for the demands of medical education and practice. However, it can lead to chronic feelings of inadequacy, an exaggerated sense of responsibility, and difficulty setting limits. Furthermore, physicians often are conditioned in the psychology of postponement. It takes root in the early years of medical education and leads to habitually delaying various sources of renewal, such as vacations and relationships.

External factors include payment reductions, managing various insurers, and increasing malpractice cases.^1,2,5 Evaluating the changing landscape of managed-care organizations reveals that while a small fraction of physicians are employed by them, more than 90% contract with them. Commonly cited reasons for dissatisfaction with managed care include “trafficking” of patients in and out of care, administrative paperwork, limitations on referring patients to specialists, financial incentives to curb medical workups, and pressure to evaluate increasing numbers of patients.⁶

Malpractice cases have increased in the past 30 years. The American Medical Association (AMA) has identified 18 states where providers are finding it challenging to purchase affordable insurance.⁷ An additional 26 states have been placed on “orange alert,” indicating a worsening situation in availability and affordability of insurance. Physicians who are not personally burdened by malpractice suits feel its repercussions. They practice “defensive medicine” by ordering increasing numbers of tests and procedures to avoid potential litigation. Physicians involved in lawsuits, regardless of the outcome, describe feeling shame, self-doubt, and disillusionment with medical practice.

What Makes You Happy?

In the December 2006 issue of The Hospitalist (see “Are You Satisfied?” p. 4), Mary Jo Gorman, MD, MBA, FHM, then president of SHM, pointed out five factors that contribute to physician satisfaction:

1. Stimulation and challenge at work. It’s critical to have a job that requires technically difficult tasks, procedures, or intellectual challenges. The ability to interact and collaborate with other physicians further adds depth and richness to hospitalists’ clinical practice. However, it’s important to realize that overstimulation can lead to discomfort and unhappiness.
2. Feeling appreciated. Recog-nition for your performance leads to feeling valued at work and has a strong correlation with overall job satisfaction. It keeps hospitalists interested and motivated. However, recognition should be personalized; otherwise, it can have a detrimental effect.
3. Control over work. Auto-nomy and control over work is important to ensuring job satisfaction. This includes actively participating in the design of your work schedule and other work-related matters. When decisions are imposed on physicians, it creates tension and stress.
4. Work environment. This includes the type of work, support, and opportunities for growth and development, as well as interactions with colleagues and staff.
5. Income. Compensation is often fourth or fifth on the list of priorities for physicians. While all of us seek fair compensation for our work, it often is not the main reason we choose an employment.

Solutions

Burnout prevention is the responsibility of all healthcare professionals. It’s critical to promote well-being on all levels: physical, emotional, psychological, and spiritual. The following recommendations are based on various interventions established nationally to address physician burnout:

Establish realistic goals. Identify realistic goals for your professional and personal life, and actively work on balancing the two. Emphasize these goals throughout your professional career, avoiding the natural tendency for postponement.

Improve your work environment. Involve physicians in the design and management of the practice; build flexible schedules that allow coverage during important life events (i.e., graduations, births, weddings); minimize paperwork and improve efficiency; and establish a committee for open discussion of physician wellness issues.

Take care of yourself. Mentorship programs support junior members in their career development and help them balance the challenges of their personal and professional lives. Mentors can detect dissatisfaction and help physicians re-evaluate their interests and career paths. Require physicians to have their own primary-care physician (PCP) to ensure their physical and mental well-being. Offer memberships to fitness centers.

Provide opportunities to grow. Seek opportunities for medical education; address personal goals and aspirations, such as hobbies and interests; and establish sabbatical programs to gain perspective and broaden your horizons.

Fortunately, medicine has an enthusiastic applicant pool. There is hope that highly motivated and qualified students will continue to apply and enter the medical profession. However, there is concern that the dissatisfaction in medicine might influence the caliber of applicants who apply.

Medical education and training needs to address the challenges of practicing medicine. Students should be taught about the challenges of delivering high-quality care, risk management, cost containment, and utilization review. During the clinical years in medical school and residency, trainees need to experience the fast pace of medicine, the realities of payment dilemmas, and increased paperwork. It ultimately is the responsibility of educators in the medical profession to encourage students and residents to establish more accurate expectations of the practice of medicine. TH

Dr. Afsarmanesh is director of hospital medicine quality initiatives at Ronald Reagan UCLA Medical Center in Los Angeles.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348(23):2281-2284.
2. Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB. Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med. 1992;67:180-190.
3. Harvey LK, Shubat SC. AMA Public Opinion on Healthcare Issues. Chicago: American Medical Association Press; 1988.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
5. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431-1438.
6. Reams HR, Dunstone DC. Professional satisfaction of physicians. Arch Intern Med. 1989;149:1951-1956.
7. McMurray JE, Williams E, Schwartz MD, et al. Developing a model using qualitative data. J Gen Intern Med. 1997;12(11):711–714.

In 1973, a survey was conducted to evaluate physician satisfaction. Less than 15% of physicians reported any doubt that they had made the right career choice, with 3.7% stating that they were “not happy.”¹ Twenty years later, surveys revealed a different story: Forty percent of physicians stated that they would not choose the medical profession if they had to choose a career again.²

Dissatisfaction in medicine has been reported in diverse age groups, different areas of the country, and various medical specialties.³ When dissatisfied, physicians often leave their jobs and, consequently, the patient-physician relationship is disrupted. This turnover is quite costly to the healthcare system. In primary care, the cost of replacing a physician is estimated at $250,000.⁴

Here are some of the factors that contribute to burnout, as well as solutions for ensuring job satisfaction.

Challenges Ahead

Burnout is an interesting phenomenon in the medical profession. Unlike many other professionals, physicians often experience extreme fatigue and emotional exhaustion at an early stage in their careers—during medical school and residency. By midcareer, the momentum is maintained as colleagues recognize their hard work, and they continue to place service to others before themselves. Physicians who encounter burnout often experience emotional exhaustion, impaired job performance, relationship difficulties, and poor health, including irritability, sleep disturbances, headaches, depression, and drug addictions.

Increased rates of burnout have been linked to several internal and external factors. Internal factors—management style in a workplace, multiple demands at work, social support from colleagues, lack of control over the work environment—have been illustrated to correlate with higher rates of burnout. The ever-increasing demand on physicians’ time leads to higher rates of dissatisfaction. There are an exponentially increasing number of medications, tests, and procedures to discuss with patients and families. This is complicated by the rise of e-mail and the Internet, as some patients expect immediate responses to their concerns.

Some studies have shown that personality factors can lead to burnout. Compulsiveness, a trait often seen in physicians, is an adaptive behavior for the demands of medical education and practice. However, it can lead to chronic feelings of inadequacy, an exaggerated sense of responsibility, and difficulty setting limits. Furthermore, physicians often are conditioned in the psychology of postponement. It takes root in the early years of medical education and leads to habitually delaying various sources of renewal, such as vacations and relationships.

External factors include payment reductions, managing various insurers, and increasing malpractice cases.^1,2,5 Evaluating the changing landscape of managed-care organizations reveals that while a small fraction of physicians are employed by them, more than 90% contract with them. Commonly cited reasons for dissatisfaction with managed care include “trafficking” of patients in and out of care, administrative paperwork, limitations on referring patients to specialists, financial incentives to curb medical workups, and pressure to evaluate increasing numbers of patients.⁶

Malpractice cases have increased in the past 30 years. The American Medical Association (AMA) has identified 18 states where providers are finding it challenging to purchase affordable insurance.⁷ An additional 26 states have been placed on “orange alert,” indicating a worsening situation in availability and affordability of insurance. Physicians who are not personally burdened by malpractice suits feel its repercussions. They practice “defensive medicine” by ordering increasing numbers of tests and procedures to avoid potential litigation. Physicians involved in lawsuits, regardless of the outcome, describe feeling shame, self-doubt, and disillusionment with medical practice.

What Makes You Happy?

In the December 2006 issue of The Hospitalist (see “Are You Satisfied?” p. 4), Mary Jo Gorman, MD, MBA, FHM, then president of SHM, pointed out five factors that contribute to physician satisfaction:

1. Stimulation and challenge at work. It’s critical to have a job that requires technically difficult tasks, procedures, or intellectual challenges. The ability to interact and collaborate with other physicians further adds depth and richness to hospitalists’ clinical practice. However, it’s important to realize that overstimulation can lead to discomfort and unhappiness.
2. Feeling appreciated. Recog-nition for your performance leads to feeling valued at work and has a strong correlation with overall job satisfaction. It keeps hospitalists interested and motivated. However, recognition should be personalized; otherwise, it can have a detrimental effect.
3. Control over work. Auto-nomy and control over work is important to ensuring job satisfaction. This includes actively participating in the design of your work schedule and other work-related matters. When decisions are imposed on physicians, it creates tension and stress.
4. Work environment. This includes the type of work, support, and opportunities for growth and development, as well as interactions with colleagues and staff.
5. Income. Compensation is often fourth or fifth on the list of priorities for physicians. While all of us seek fair compensation for our work, it often is not the main reason we choose an employment.

Solutions

Burnout prevention is the responsibility of all healthcare professionals. It’s critical to promote well-being on all levels: physical, emotional, psychological, and spiritual. The following recommendations are based on various interventions established nationally to address physician burnout:

Establish realistic goals. Identify realistic goals for your professional and personal life, and actively work on balancing the two. Emphasize these goals throughout your professional career, avoiding the natural tendency for postponement.

Improve your work environment. Involve physicians in the design and management of the practice; build flexible schedules that allow coverage during important life events (i.e., graduations, births, weddings); minimize paperwork and improve efficiency; and establish a committee for open discussion of physician wellness issues.

Take care of yourself. Mentorship programs support junior members in their career development and help them balance the challenges of their personal and professional lives. Mentors can detect dissatisfaction and help physicians re-evaluate their interests and career paths. Require physicians to have their own primary-care physician (PCP) to ensure their physical and mental well-being. Offer memberships to fitness centers.

Provide opportunities to grow. Seek opportunities for medical education; address personal goals and aspirations, such as hobbies and interests; and establish sabbatical programs to gain perspective and broaden your horizons.

Fortunately, medicine has an enthusiastic applicant pool. There is hope that highly motivated and qualified students will continue to apply and enter the medical profession. However, there is concern that the dissatisfaction in medicine might influence the caliber of applicants who apply.

Medical education and training needs to address the challenges of practicing medicine. Students should be taught about the challenges of delivering high-quality care, risk management, cost containment, and utilization review. During the clinical years in medical school and residency, trainees need to experience the fast pace of medicine, the realities of payment dilemmas, and increased paperwork. It ultimately is the responsibility of educators in the medical profession to encourage students and residents to establish more accurate expectations of the practice of medicine. TH

Dr. Afsarmanesh is director of hospital medicine quality initiatives at Ronald Reagan UCLA Medical Center in Los Angeles.

References

1. Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Engl J Med. 2003;348(23):2281-2284.
2. Hadley J, Cantor JC, Willke RJ, Feder J, Cohen AB. Young physicians most and least likely to have second thoughts about a career in medicine. Acad Med. 1992;67:180-190.
3. Harvey LK, Shubat SC. AMA Public Opinion on Healthcare Issues. Chicago: American Medical Association Press; 1988.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166.
5. Buchbinder SB, Wilson M, Melick CF, Powe NR. Estimates of costs of primary care physician turnover. Am J Manag Care. 1999;5(11):1431-1438.
6. Reams HR, Dunstone DC. Professional satisfaction of physicians. Arch Intern Med. 1989;149:1951-1956.
7. McMurray JE, Williams E, Schwartz MD, et al. Developing a model using qualitative data. J Gen Intern Med. 1997;12(11):711–714.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

Bijo Chacko, MD, FHM, says the varied resources available in the multispecialty medical group in which he practices help to ensure patients receive the best possible care. The structure at Preferred Health Partners in Brooklyn, N.Y., which offers primary and specialty medical services under one roof, requires hospitalists to collaborate frequently with primary-care physicians (PCPs).

That interaction breaks down barriers, fosters communication, promotes the exchange of ideas, and ultimately improves the transition of care from outpatient to inpatient and vice versa, Dr. Chacko says.

His affinity for that environment might explain his passion for the work done by SHM’s Young Physician Task Force, and why “resources” is the word he repeats most often when describing the value of the group’s efforts. Just as experienced hospitalists can learn by interacting with PCPs and other specialists, those who are new to HM can benefit from those who have established themselves in the profession and cleared the hurdles physicians encounter early in a career, he says.

“The advantage of youth is the inherent energy that comes with it,” says Dr. Chacko, hospitalist program medical director with Preferred Health Partners, medical director of the hospitalist program at Good Samaritan Hospital in Suffern, N.Y., and a member of Team Hospitalist. “You really need that energy in your daily work routine, especially early in a career. The disadvantage is, depending on your training, you may not have the experience or been exposed to resources required to take on some of the challenges you’ll face. Hence, expanding the number of resources available to early-career hospitalists—and encouraging them to utilize what is available to them—becomes pivotal.”

Question: Two years after residency, you made the transition to hospitalist program medical director. What advice would you give to an aspiring HM leader?

Answer: Coming out of medical school or residency, you’re not provided all the tools you need to be a successful leader. Some people may achieve those skills during their training or in their first job. But going through some of the unique courses provided by SHM, such as the Leadership Academy, has been invaluable. The information, as well as the connections you make with others throughout the country, really prepares you for a leadership role and some of the challenges you may not have been taught to face in medical school.

Q: What are some of the challenges you aren’t necessarily taught how to handle?

A: Leadership roles take on a complexity of their own. You’re dealing with communications issues; you’re dealing with conflict resolution. Those are unique areas that have to be approached delicately. And one of the fundamental aspects of being a good leader is to define a shared organizational vision and set of shared values for your group that should be supported and promoted.

Q: Can you describe the vision and values you set for your group?

A: Our vision is to be the hospitalist program of choice for patients and physicians in the region. But the key aspect is, we want to provide high-quality patient care with a touch of humility. A physician who demonstrates his or her empathetic side goes a long way in what we do. Research has shown hospitalists provide efficient care—outcomes on cost savings are good. But the other issue is the patient experience, and that’s where the humility factor comes into play.

Q: How do you teach the physicians in your group to be more humble?

A: One thing we emphasize with the team is to imagine themselves or a family member in the patient’s shoes when they are communicating with them. This hits home the importance of bedside manners, and it has to be revisited at times.

Q: Any other techniques?

A: Positive feedback always translates well. We use examples from patients who say they generally had a great experience. In many cases, it amounts to a patient saying, “The doctor was able to explain things to me in a simpler language than anyone has been able to do before, or even attempted to do.” That positive reinforcement resonates well with the doctors. We also share patient scenarios where there were opportunities for improvement.

Q: Considering the demands of your leadership roles at Preferred Health Partners and Good Samaritan Hospital, why is it still a priority for you to provide inpatient clinical care?

A: The old adage is, if you don’t use it, you lose it. Because clinical care is so broad and diverse, and because it is changing so rapidly, it behooves one to stay abreast of it. Also, when you are leading members of a group, I think it’s important to walk in the trenches with them.

Q: You joined SHM’s Young Physician Task Force and served as chairman for two years. What prompted you to participate?

A: When I joined, I had already begun my leadership role as medical director and I was an early-career hospitalist, so I felt it made sense for my professional growth. I wanted an opportunity to collaborate with leading young hospitalists in the country and help shape some of the programs the (group) was working on.

Q: What issues has the group addressed?

A: Initially, the task force was focused on getting information out to early-career hospitalists and providing resources they could utilize. It redefined its section of the SHM website (www.hospitalmedicine .org/youngphysician), which now serves as a portal with information about everything from careers in hospital medicine to how to approach residency. It also introduced the Resident’s Corner (a quarterly column in The Hospitalist, see p. 25), which caters to residents and helps them make a smooth transition to a possible career in hospital medicine. The group has developed programs for early-career hospitalists at the annual SHM meetings.

Q: What major issues are on the agenda now?

A: The group is working on developing a mentorship program for early-career hospitalists, which would be a really valuable resource. The group also is working on projects to reach medical students and residents. The goal is to get them more engaged, and help them realize the diversity and rewards that accompany a career in hospital medicine.

Q: What do you see as the benefit of the mentor program?

A: The beauty of hospital medicine is there is a lot of diversity. If you have an interest in academia, quality initiatives, or research, that’s available. If you have a leadership interest, that can definitely be attained. …

But when you have someone who has had some experience in hospital medicine and can share that experience, and you can get their insights and hear about the challenges they faced and how they faced them, it can make the transition much easier. This will provide young hospitalists with pearls of wisdom and information they may not have been able to access elsewhere.

Q: So it comes back to the idea that there’s still a lot to learn, even after medical school and residency.

A: That’s exactly right. The scope of questions that can be posed or issues that can be addressed is infinite. Beyond that, someone who has already walked that pathway can help establish the fact that hospital medicine should be looked upon as a career with many opportunities, as opposed to a transition point to an alternative career. TH

Mark Leiser is a freelance writer in New Jersey.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.

You’re a what?” he asked over the noise of the passing Mardi Gras parade.

“I’m a hospitalist,” I replied.

“Oh.” There was an extended pause. I could tell he was searching his mental database to determine if he had a family member who was a hospitalist. Nope, nothing there. Then it came: “What is that exactly?” I followed with a general description of “what a hospitalist does,” but his response made it apparent that my description hadn’t stuck: “So you’re like a generalist, but you work in the hospital?”

I let it go. Mardi Gras wasn’t the time to launch into all that a hospitalist truly embodies: quality improvement, systems redesign, patient safety, effective transitions of care. And he probably wouldn’t remember it tomorrow anyway. But my reveler friend’s summary statement stayed with me through the night, for it returned me to a core philosophical tenet: Esse est percipi. We are who we appear to be.

There are 30,000 of us now, all facing the same problem: How do we match who we are perceived to be with who we are? The hospitalist is much more than a “generalist who works in a hospital,” but what is perceived to be is equally as important as what is. At the root of the problem is a question of accountability: How do we hold ourselves out to the public as a specialty that possesses the knowledge and skills necessary to advance quality and safety for the hospitalized patient?

This question of public accountability is not new to the profession. The heterogeneity of physicians in the early 1900s, from the authentic to the snake-oil salesmen, prompted the need for independent validation of physicians’ qualifications. Dr. Derrick Vail introduced the concept of a board certification in 1908, with the goal of “issuing credentials that would assure the public of the specialist’s qualifications.” The American Board of Medical Specialties was formed in 1933, and continues to this day to be the entity responsible for ensuring this accountability.

While there are no “snake-oil salesmen” in HM, there is heterogeneity. There are many of us answering the call to advance quality and patient safety, but there are many more of us who are not yet there. And there are some (i.e., those practicing medicine in the hospital while awaiting a subspecialty fellowship) who, while referred to as “hospitalists,” do not embrace the central tenets of the career hospitalist. Thirty-thousand hospitalists is a spectacular achievement, but with that growth comes the new problem of dilution: Without some measure of distinguishing those who are authentic in the value-added services of quality and patient safety from those who have not embraced these tenets, the perception of us all will be merely “physicians who practice in the hospital.”

To my mind, the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) Focused Practice in Hospital Medicine (FPHM) program answers this question of public accountability. This new MOC process provides an objective way of establishing that hospitalists who claim to be competent in their field have, in fact, demonstrated this competence. Paradoxically, it is even more compelling than a board certification following a residency or fellowship; skills and knowledge fade over time, and new knowledge consistently is added. The MOC certification assures the public that despite these challenges, the certified hospitalist has continued to maintain competence in the field.

Further, the components of the FPHM (www.abim.org/specialty/fphm.aspx) provide assurance that the certified hospitalist has the expertise to practice HM, and has the knowledge and skills necessary to offer the value-added services of quality, patient safety, and performance improvement.

Why Is It Important to Recertify?

Registration for the MOC in FPHM opened March 15, and more than 100 hospitalists enrolled in the program in the first two weeks. While exciting, this number is not enough; here I share with you my reflections on why this MOC is so important to our field.

As with all things SHM, the rationale begins with, “What is the best thing for the patient?” I completed my first recertification in 2008, and I can honestly say that this was the first “test” in my career that actually made me a better physician for my patients. I was skeptical at first, seeing the MOC as another bureaucratic hurdle for which I would have the opportunity to pay $1,000. But the reality was that it was much more than that; it made me a better physician. It alerted me to blind spots in my clinical repertoire: some topics I had never learned, some I had forgotten, and some that were new knowledge.

Preparing for the examination isn’t onerous, perhaps a couple extra hours a week of reading. Since the examination focused on the practical aspects of diagnosis and management, and not the basic- science minutiae that had characterized the earlier examinations in my career, I found that the preparation for the MOC exam improved my practice of medicine. The only downside was that I did not have the luxury of an HM-focused exam in 2008, and there were content areas on the standard internal medicine (IM) MOC that were not a part of my inpatient practice.

But it was the Practice Improvement Module (PIM) component of the MOC process, a shared feature of both the FPHM and the IM MOC processes, that most benefited my patients. As a hospitalist, this too was not onerous, as practice improvement is what I do on a daily basis. Moreover, it was the external discipline of completing the PIM that made it truly valuable: collecting data, reflecting on methods of improvement, enacting an intervention, and then reassessing the results. The process forced me to reflect on my practice, and it heightened my sensitivity to other parts of my practice, and the hospital system, that needed to be improved.

Further benefit came through collaboration with other physicians in my group, as encouraged by the ABIM, to complete the PIM. This teamwork fostered a heightened spirit of QI within our team, further augmenting quality of care and sensitivity to needed systems improvements. True, at the end of the process, I was $1,000 lighter … but my conscience was richer. I had improved as a physician, and I think it has translated into a benefit for my patients.

What Recertification Means to HM

Although the virtue of improving patient care is sufficient to justify participation in the MOC in FPHM, the passage of healthcare reform legislation raises the stakes for hospitalists. The Physician Quality Reporting Initiative (PQRI) is an ongoing reality, further voicing the public’s need for accountability.

The final impact will hinge on the Center for Medicare & Medicaid Services’ (CMS) interpretation and execution of the language in the final bill, but it is clear that physicians who participate in the PQRI (through claims-based or registry reporting) have the opportunity to receive an additional 0.5% bonus on their total allowable Medicare charges in 2011 through 2014, if they also meet MOC program requirements. (The health reform bill provides a 1.0% bonus in 2011 for PQRI participation and a 0.5% bonus through 2014.)

Subsequently, physicians who do not participate in the PQRI will face a 1.5% payment penalty in 2015, and a 2% payment penalty in 2016 and thereafter. With these incentives, it appears the day-to-day finances of practice will offset the cost of MOC participation.

The importance of FPHM extends to the remainder of the PQRI as well. Currently, HM is not recognized by CMS as its own specialty, which means that it does not have its own CMS specialty code. In turn, this means that the core measures CMS will apply to the hospitalist in fulfilling the PQRI standards will be those of the general internist, and these might or might not apply to HM practice. For those to whom the standards do not apply, PQRI becomes a practical impossibility, though the financial penalty remains an unfortunate reality.

The extent to which the core measures for general medicine do not apply to the inpatient environment is the extent to which PQRI will be less effective in incentivizing the advancement of inpatient healthcare quality. This is an opportunity missed. Preventing this systematic exclusion begins with recognizing HM as a specialty. In convincing CMS that HM is its own specialty, deserving of its own code and its own PQRI indices, I can think of no argument as compelling as pointing to 10,000 hospitalists certified in the MOC in FPHM program.

Financial incentives aside, the ultimate success of HM will be in our ability to change the healthcare system such that it provides safe, timely, equitable, efficient, and patient-centered care. We’ve spent more than 10 years trying to get into the conversation, and now we have a seat at the table. But to be effective in this audacious goal, we must speak with a stentorian voice—a timbre that comes only from the chords of the sincere. Society must know of our sincerity—not by our words, but by our actions.

As president of SHM, I am calling on you to join me in meeting this standard of public accountability. Let us prove to the world that our talk of quality and patient safety is much more than talk. Let us establish that we are willing to engage in the ongoing self-improvement necessary to reach this wished-for goal.

Esse est percipi. We are as we are perceived. Now is our time to make one with the other—fulfilling a covenant that promises that we will, eventually, close this quality chasm. TH

Dr. Wiese is president of SHM.

As I write, I’m fighting the jet stream from Washington, D.C., to Denver, midflight on my return from HM10. I’m 30,000 feet above the ground—literally and figuratively—my mind spinning with the thoughts, ideas, and memories from the largest gathering of hospitalists ever. In the end, 2,500 hospitalists descended on our nation’s capital. Shrouded by the din of healthcare reform, we discussed, deliberated, and discovered what’s new in the clinical, political, and programmatic world of HM. Out of this churn, I learned a lot. Here’s but a small sample.

Smart People = Smart Solutions

I learned that if you put really smart people in a room and give them a problem to grapple with, they come up with really smart solutions. At the inaugural Academic Hospital Medicine Leadership Summit, 100 of the brightest, most influential academic hospitalists convened to tackle the problems facing our field.

The output was an amazing crop of inventive ideas aimed at taming the vexing issues surrounding clinical sustainability, academic viability, and career satisfaction. SHM leadership has heard the cry and promises to work closely with the academic community to transform these smart solutions into future initiatives.

Hospitalists Support Healthcare Reform, Should Collude with Hospitals

I learned that most of us support the recently passed healthcare reform legislation, with a few notable dissenters. In response to a question from the chair of SHM’s Public Policy Committee, the vast majority of attendees at the opening plenary session raised their hands affirmatively in response to the question of whether they support the reform bill. Meanwhile, nearly everyone in the crowd felt it is important that SHM have an opinion regarding the legislation and continue to work closely with Congress to ensure its implementation helps our most important constituent—our patients.

Finally, I learned that Ron Greeno, CMO of Brentwood, Tenn.-based Cogent Healthcare, believes that the development of accountable-care organizations might lead hospitalists to align with hospitals to keep costs down. In fact, he saw this as a welcome, intended consequence. In his opinion, this “collusion” promises to raise the quality of care and reduce waste in the system—a statement that was met with applause from the plenary crowd.

The Healthcare Paradox

I learned that blogs save lives. Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, roused the crowd during his keynote address by relating the power of transparency. Bothered by the paradox that the medical profession, comprising the most well-intentioned people in the world, could kill so many people through errors (ranked the No. 4 public health hazard in the U.S.), Levy decided to make his hospital’s struggles public.

On his blog, Running a Hospital (runningahospital.blogspot.com), he took the extraordinary step of publically documenting the rates of harm caused at his medical center for the world to see. Additionally, he set audacious goals to reduce the amount of harm to zero. He encouraged hospital staff to raise issues of safety and efficiency as a way to avoid the workarounds—shortcuts—that ultimately increase variability and reduce quality without addressing the core problem.

In response, the staff swarms the problem to rapidly improve the process and ultimately return the system back to homeostasis. The results of this effort can be viewed at Levy’s hospital’s website (www.bidmc.org/QualityandSafety.aspx).

Which Hill Will You Climb?

I learned that leadership is the ability to help people address problems that make the world better. At a much-anticipated presentation, Peter Pronovost, MD, of Johns Hopkins Hospital in Baltimore related a transformative story from his youth. At a summer camp, each boy was assigned to one of three groups and tasked with climbing a seemingly insurmountable hill. The first camp counselor pummeled the group with overbearing directions, directives, and derision, and in the end the group failed to conquer the hill. The second counselor took a more relaxed approach, giving the group essentially no direction. They, too, failed.

The final counselor offered nothing but the inspiration of how marvelous the view from the top of the hill would be and how they’d all have to pull together and work as a team if they wanted to attain that greatness. Dr. Pronovost was in this last group, and has been summiting insurmountable peaks ever since.

You likely are familiar with Dr. Pronovost’s work on ICU line infections. He elaborated on how he accomplished a rate of zero line infections, first at his hospital and then throughout the entire state of Michigan. The key was an inspiring vision and, once again, removal of workarounds. After compiling a checklist of the five most crucial components of line placement and management, Hopkins personnel discovered they were only compliant with the checklist 30% of the time—mostly due to shortcuts caused by inefficient systems that placed supplies too far from the clinical-care setting. After removing those barriers, the compliance rate went to 70%. It was only after empowering the nursing staff to stop physicians from proceeding with line placement unless the checklist was followed that the team was able to achieve 100% compliance.

Today, patients in the Johns Hopkins cardiovascular unit have not suffered a line infection for 87 consecutive weeks. That’s a hill worth climbing.

Saving Lives and Canine Castaways

I learned that the SHM annual meeting is attracting the highest echelon of clinical speakers. Whether it was Dr. Pronovost speaking about line infections, Dr. Greg Fonarow discussing congestive heart failure, or Dr. John Bartlett presenting on Clostrium difficile infections, HM10 featured world-class speakers.

For example, Dr. Bartlett’s work has defined the C. diff field, and the opportunity to hear him was incredible. I learned from him that severe C. diff infections are on the rise and that recurrences are tougher than ever to treat. I also learned that there are mixed data on whether nurses can detect C. diff based on stool smell alone; that up to 10% of dogs carry C. diff (out of the bed, Hogan and Grady!); and that stool transplants are becoming a quality- and quantity-of-life-saving treatment for those with severe bouts of recurrent C. diff.

To quote Dr. Bartlett, “pathophysiologically, it’s a dream; aesthetically, it sucks.”

Homeward Bound

Finally, I learned that every year, SHM feels more and more like my second family, with the annual meeting its family reunion. I saw tons of friends, made dozens more, and look forward to next year in Dallas.

Mostly, however, I was reminded of the emotional tug of being away from home, the emotive power of a few e-mailed photos of your kids, and how great if feels to turn off your electronic devices and return your folding tray and seat back to the upright and locked position. 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.

As I write, I’m fighting the jet stream from Washington, D.C., to Denver, midflight on my return from HM10. I’m 30,000 feet above the ground—literally and figuratively—my mind spinning with the thoughts, ideas, and memories from the largest gathering of hospitalists ever. In the end, 2,500 hospitalists descended on our nation’s capital. Shrouded by the din of healthcare reform, we discussed, deliberated, and discovered what’s new in the clinical, political, and programmatic world of HM. Out of this churn, I learned a lot. Here’s but a small sample.

Smart People = Smart Solutions

I learned that if you put really smart people in a room and give them a problem to grapple with, they come up with really smart solutions. At the inaugural Academic Hospital Medicine Leadership Summit, 100 of the brightest, most influential academic hospitalists convened to tackle the problems facing our field.

The output was an amazing crop of inventive ideas aimed at taming the vexing issues surrounding clinical sustainability, academic viability, and career satisfaction. SHM leadership has heard the cry and promises to work closely with the academic community to transform these smart solutions into future initiatives.

Hospitalists Support Healthcare Reform, Should Collude with Hospitals

I learned that most of us support the recently passed healthcare reform legislation, with a few notable dissenters. In response to a question from the chair of SHM’s Public Policy Committee, the vast majority of attendees at the opening plenary session raised their hands affirmatively in response to the question of whether they support the reform bill. Meanwhile, nearly everyone in the crowd felt it is important that SHM have an opinion regarding the legislation and continue to work closely with Congress to ensure its implementation helps our most important constituent—our patients.

Finally, I learned that Ron Greeno, CMO of Brentwood, Tenn.-based Cogent Healthcare, believes that the development of accountable-care organizations might lead hospitalists to align with hospitals to keep costs down. In fact, he saw this as a welcome, intended consequence. In his opinion, this “collusion” promises to raise the quality of care and reduce waste in the system—a statement that was met with applause from the plenary crowd.

The Healthcare Paradox

I learned that blogs save lives. Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, roused the crowd during his keynote address by relating the power of transparency. Bothered by the paradox that the medical profession, comprising the most well-intentioned people in the world, could kill so many people through errors (ranked the No. 4 public health hazard in the U.S.), Levy decided to make his hospital’s struggles public.

On his blog, Running a Hospital (runningahospital.blogspot.com), he took the extraordinary step of publically documenting the rates of harm caused at his medical center for the world to see. Additionally, he set audacious goals to reduce the amount of harm to zero. He encouraged hospital staff to raise issues of safety and efficiency as a way to avoid the workarounds—shortcuts—that ultimately increase variability and reduce quality without addressing the core problem.

In response, the staff swarms the problem to rapidly improve the process and ultimately return the system back to homeostasis. The results of this effort can be viewed at Levy’s hospital’s website (www.bidmc.org/QualityandSafety.aspx).

Which Hill Will You Climb?

I learned that leadership is the ability to help people address problems that make the world better. At a much-anticipated presentation, Peter Pronovost, MD, of Johns Hopkins Hospital in Baltimore related a transformative story from his youth. At a summer camp, each boy was assigned to one of three groups and tasked with climbing a seemingly insurmountable hill. The first camp counselor pummeled the group with overbearing directions, directives, and derision, and in the end the group failed to conquer the hill. The second counselor took a more relaxed approach, giving the group essentially no direction. They, too, failed.

The final counselor offered nothing but the inspiration of how marvelous the view from the top of the hill would be and how they’d all have to pull together and work as a team if they wanted to attain that greatness. Dr. Pronovost was in this last group, and has been summiting insurmountable peaks ever since.

You likely are familiar with Dr. Pronovost’s work on ICU line infections. He elaborated on how he accomplished a rate of zero line infections, first at his hospital and then throughout the entire state of Michigan. The key was an inspiring vision and, once again, removal of workarounds. After compiling a checklist of the five most crucial components of line placement and management, Hopkins personnel discovered they were only compliant with the checklist 30% of the time—mostly due to shortcuts caused by inefficient systems that placed supplies too far from the clinical-care setting. After removing those barriers, the compliance rate went to 70%. It was only after empowering the nursing staff to stop physicians from proceeding with line placement unless the checklist was followed that the team was able to achieve 100% compliance.

Today, patients in the Johns Hopkins cardiovascular unit have not suffered a line infection for 87 consecutive weeks. That’s a hill worth climbing.

Saving Lives and Canine Castaways

I learned that the SHM annual meeting is attracting the highest echelon of clinical speakers. Whether it was Dr. Pronovost speaking about line infections, Dr. Greg Fonarow discussing congestive heart failure, or Dr. John Bartlett presenting on Clostrium difficile infections, HM10 featured world-class speakers.

For example, Dr. Bartlett’s work has defined the C. diff field, and the opportunity to hear him was incredible. I learned from him that severe C. diff infections are on the rise and that recurrences are tougher than ever to treat. I also learned that there are mixed data on whether nurses can detect C. diff based on stool smell alone; that up to 10% of dogs carry C. diff (out of the bed, Hogan and Grady!); and that stool transplants are becoming a quality- and quantity-of-life-saving treatment for those with severe bouts of recurrent C. diff.

To quote Dr. Bartlett, “pathophysiologically, it’s a dream; aesthetically, it sucks.”

Homeward Bound

Finally, I learned that every year, SHM feels more and more like my second family, with the annual meeting its family reunion. I saw tons of friends, made dozens more, and look forward to next year in Dallas.

Mostly, however, I was reminded of the emotional tug of being away from home, the emotive power of a few e-mailed photos of your kids, and how great if feels to turn off your electronic devices and return your folding tray and seat back to the upright and locked position. 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.

As I write, I’m fighting the jet stream from Washington, D.C., to Denver, midflight on my return from HM10. I’m 30,000 feet above the ground—literally and figuratively—my mind spinning with the thoughts, ideas, and memories from the largest gathering of hospitalists ever. In the end, 2,500 hospitalists descended on our nation’s capital. Shrouded by the din of healthcare reform, we discussed, deliberated, and discovered what’s new in the clinical, political, and programmatic world of HM. Out of this churn, I learned a lot. Here’s but a small sample.

Smart People = Smart Solutions

I learned that if you put really smart people in a room and give them a problem to grapple with, they come up with really smart solutions. At the inaugural Academic Hospital Medicine Leadership Summit, 100 of the brightest, most influential academic hospitalists convened to tackle the problems facing our field.

The output was an amazing crop of inventive ideas aimed at taming the vexing issues surrounding clinical sustainability, academic viability, and career satisfaction. SHM leadership has heard the cry and promises to work closely with the academic community to transform these smart solutions into future initiatives.

Hospitalists Support Healthcare Reform, Should Collude with Hospitals

I learned that most of us support the recently passed healthcare reform legislation, with a few notable dissenters. In response to a question from the chair of SHM’s Public Policy Committee, the vast majority of attendees at the opening plenary session raised their hands affirmatively in response to the question of whether they support the reform bill. Meanwhile, nearly everyone in the crowd felt it is important that SHM have an opinion regarding the legislation and continue to work closely with Congress to ensure its implementation helps our most important constituent—our patients.

Finally, I learned that Ron Greeno, CMO of Brentwood, Tenn.-based Cogent Healthcare, believes that the development of accountable-care organizations might lead hospitalists to align with hospitals to keep costs down. In fact, he saw this as a welcome, intended consequence. In his opinion, this “collusion” promises to raise the quality of care and reduce waste in the system—a statement that was met with applause from the plenary crowd.

The Healthcare Paradox

I learned that blogs save lives. Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston, roused the crowd during his keynote address by relating the power of transparency. Bothered by the paradox that the medical profession, comprising the most well-intentioned people in the world, could kill so many people through errors (ranked the No. 4 public health hazard in the U.S.), Levy decided to make his hospital’s struggles public.

On his blog, Running a Hospital (runningahospital.blogspot.com), he took the extraordinary step of publically documenting the rates of harm caused at his medical center for the world to see. Additionally, he set audacious goals to reduce the amount of harm to zero. He encouraged hospital staff to raise issues of safety and efficiency as a way to avoid the workarounds—shortcuts—that ultimately increase variability and reduce quality without addressing the core problem.

In response, the staff swarms the problem to rapidly improve the process and ultimately return the system back to homeostasis. The results of this effort can be viewed at Levy’s hospital’s website (www.bidmc.org/QualityandSafety.aspx).

Which Hill Will You Climb?

I learned that leadership is the ability to help people address problems that make the world better. At a much-anticipated presentation, Peter Pronovost, MD, of Johns Hopkins Hospital in Baltimore related a transformative story from his youth. At a summer camp, each boy was assigned to one of three groups and tasked with climbing a seemingly insurmountable hill. The first camp counselor pummeled the group with overbearing directions, directives, and derision, and in the end the group failed to conquer the hill. The second counselor took a more relaxed approach, giving the group essentially no direction. They, too, failed.

The final counselor offered nothing but the inspiration of how marvelous the view from the top of the hill would be and how they’d all have to pull together and work as a team if they wanted to attain that greatness. Dr. Pronovost was in this last group, and has been summiting insurmountable peaks ever since.

You likely are familiar with Dr. Pronovost’s work on ICU line infections. He elaborated on how he accomplished a rate of zero line infections, first at his hospital and then throughout the entire state of Michigan. The key was an inspiring vision and, once again, removal of workarounds. After compiling a checklist of the five most crucial components of line placement and management, Hopkins personnel discovered they were only compliant with the checklist 30% of the time—mostly due to shortcuts caused by inefficient systems that placed supplies too far from the clinical-care setting. After removing those barriers, the compliance rate went to 70%. It was only after empowering the nursing staff to stop physicians from proceeding with line placement unless the checklist was followed that the team was able to achieve 100% compliance.

Today, patients in the Johns Hopkins cardiovascular unit have not suffered a line infection for 87 consecutive weeks. That’s a hill worth climbing.

Saving Lives and Canine Castaways

I learned that the SHM annual meeting is attracting the highest echelon of clinical speakers. Whether it was Dr. Pronovost speaking about line infections, Dr. Greg Fonarow discussing congestive heart failure, or Dr. John Bartlett presenting on Clostrium difficile infections, HM10 featured world-class speakers.

For example, Dr. Bartlett’s work has defined the C. diff field, and the opportunity to hear him was incredible. I learned from him that severe C. diff infections are on the rise and that recurrences are tougher than ever to treat. I also learned that there are mixed data on whether nurses can detect C. diff based on stool smell alone; that up to 10% of dogs carry C. diff (out of the bed, Hogan and Grady!); and that stool transplants are becoming a quality- and quantity-of-life-saving treatment for those with severe bouts of recurrent C. diff.

To quote Dr. Bartlett, “pathophysiologically, it’s a dream; aesthetically, it sucks.”

Homeward Bound

Finally, I learned that every year, SHM feels more and more like my second family, with the annual meeting its family reunion. I saw tons of friends, made dozens more, and look forward to next year in Dallas.

Mostly, however, I was reminded of the emotional tug of being away from home, the emotive power of a few e-mailed photos of your kids, and how great if feels to turn off your electronic devices and return your folding tray and seat back to the upright and locked position. 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.

Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.

In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.

But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.

It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.

Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.

Write “Probable Discharge Tomorrow” Orders

Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.

Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.

Prepare the Day Prior

Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:

On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).

Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.

On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.

I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.

Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.

The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:

“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”

Start Rounds Earlier

This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 also 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.

Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.

In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.

But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.

It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.

Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.

Write “Probable Discharge Tomorrow” Orders

Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.

Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.

Prepare the Day Prior

Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:

On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).

Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.

On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.

I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.

Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.

The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:

“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”

Start Rounds Earlier

This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 also 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.

Most hospitals work hard to increase the portion of discharges that occur early in the workday and decrease the number that occur in the afternoon or evening. In every case, hospitalists have an important role in making this happen.

In my April 2009 column (“Top O’ the Morning,” p. 53), I wrote about why this is important to hospitals and which strategies hospitalists could adopt. But this is still such a big issue for hospitalists that I thought I would elaborate on a few of the really simple ideas. Your HM group could implement most of the following strategies beginning next week, and you wouldn’t need months of meetings with other hospital departments.

But before I get to the ideas, I want to mention a couple of other things. First, I can’t resist pointing out that giving hospitalists a financial incentive for writing the majority of discharge orders by a certain time in the morning has met with mixed results, despite the fact that some institutions believe this approach is valuable. In the absence of computerized physician order entry (CPOE), it can be really difficult to track exactly when the doctor wrote the discharge order. And, more importantly, a financial incentive might discourage a hospitalist from discharging a patient this afternoon, and they might instead wait to discharge tomorrow morning—adding to length of stay and defeating the goal of the incentive.

It turns out that a lot has been written about throughput; just do an Internet search and pair “throughput” with terms like “hospital,” “hospitalist,” “ED,” etc. Remarkably, I haven’t been able to dig up much material that specifically addresses early-morning discharges, which is an important component of throughput.

Let’s turn our attention to some specific recommendations for increasing morning discharges. Remember, I’ve selected these because they’re easy to implement and won’t require HM groups to negotiate with others at the hospital.

Write “Probable Discharge Tomorrow” Orders

Letting other staff know the anticipated discharge date via an order in the chart typically is more effective than writing the same information in the progress note section of the chart. Although a hospitalist should verbally communicate the anticipated discharge date with the patient’s nurse and discharge planner, it still is worthwhile to write an order, because it increases the chance all, or nearly all, staff (e.g., night nurses) will be aware of the plan and communicate the same message to the family.

Your group could establish a rule or financial incentive, such that all charts will be reviewed after discharge, and a certain portion (e.g., 85%) must have such an order written sometime prior to discharge. It doesn’t always need to be written on the day prior to discharge; instead, an order written on Monday could say “likely discharge on Wednesday or Thursday.” And, of course, there shouldn’t be a requirement that the patient actually be discharged on the day that was forecast.

Prepare the Day Prior

Typically, hospitalized-patient discharges are very time-consuming. Most discharges are complicated by last-minute medical or social loose ends that require attention. Routinely trying to uncover and address these on the evening prior to discharge will ensure that a larger percentage of patients will be discharged—and vacate their room—earlier the next day. Here is what this might look like:

On Tuesday, Dr. Guaraldi is wrapping up most work for the day. He stops by to see his patient, Mr. Schultz, to see if he is improving as expected. Indeed, Mr. Schultz is looking better and probably will be ready for discharge Wednesday morning. So, Dr. Guaraldi talks with Mr. Schultz and calls the patient’s daughter to answer any questions and concerns, ensuring no surprises by the Wednesday-morning discharge. When the daughter asks (as nearly all family members do) what time she should plan to pick up her dad, Dr. Guaraldi can suggest a time based on when he will be able to round in the morning. He also can arrange to have the discharge planning staff alerted if there are more complicated issues (e.g., arranging for professional transport home).

Dr. Guaraldi then dictates the discharge summary, addresses the discharge medicine reconciliation, and writes the prescriptions. In doing so, he might uncover some loose ends and might end up ordering a lab or imaging test to be done in the evening so the results will be available early Wednesday morning and won’t delay the routine discharge.

On Wednesday morning, Dr. Guaraldi rounds on Mr. Schultz early, finds the patient is improving as expected, and writes the discharge order. The whole visit takes only a few minutes, as most of the time-consuming work was completed the prior evening. In fact, because it is a relatively short visit, it is a lot easier for Dr. Guaraldi to arrange to round on Mr. Schultz early in the day (e.g., even on the way to see ICU patients), as the hospital’s chief medical officer is always asking him to do.

I hope this scenario doesn’t sound too difficult. (Another benefit of dictating discharge summaries the evening before discharge is that the typed document should be available the next morning, so the patient can have a copy to take with him at discharge.) Of course, it won’t apply to all patients, such as those patients whose discharges can’t be predicted.

Many hospitalists think arranging for discharge the evening before is impossible because “I’m just too spent at the end of a long day to stay late getting patients ready for discharge tomorrow!” But realize you won’t be doing any more work; you’re rearranging when you do the work. The time you spend arranging for discharge in advance will save you time and stress tomorrow. My own experience is that it is much easier to do all the discharge work the evening before than in the morning when I’m so busy and am being pulled in 10 different directions. Most morning discharge visits are relatively quick and painless, which is really valuable for increasing the efficiency and decreasing the stress of morning rounds.

The alert reader already has figured out there is a pretty big cost to doing the discharge work the evening before. Some patients won’t be able to discharge as planned (e.g., they have a fever overnight) and the preparations will have been in vain. My experience is that such “failed” discharges are reasonably common, but even when they occur, it is usually reasonable to use most of the original prescriptions and discharge summary, with an addendum as required. For example, Dr. Guaraldi could dictate an addendum stating:

“The patient originally was planned for discharge on Wednesday but had a temperature of 38.6 degrees Celsius the night before, so stayed in the hospital for two more days for … ”

Start Rounds Earlier

This strategy might be the most difficult for you and your HM group to arrange, but I propose it because you could do it without having to negotiate with a lot of other departments in the hospital. If your group currently has a day shift that starts at 8 a.m. with a team conference, you could instead start at 7 a.m. Your group could try to shorten the duration of the morning team conference, or eliminate it. Whether the need to get patients discharged early in the day is worth the complexity of rearranging your schedule will depend on the circumstances of your hospital and your group. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 also 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.

Physicians Could Be Eligible to Receive IRS Refund

I heard the Internal Revenue Service is going to refund the employment taxes physicians paid when they were residents. Is this true? If so, how do I go about filing for this?

J. Byrne, MD

New YorkRe

Dr. Hospitalist responds: On March 2, the IRS announced that it had “made an administrative determination to accept the position that medical residents are excepted from FICA taxes based on the student exception for tax periods ending before April 1, 2005, when new IRS regulations went into effect.”¹ For folks like me, who have a hard time understanding the different numbers on my paycheck, here is an explanation. (I am neither an attorney nor an accountant; for any such counsel, I suggest you visit a professional.)

Federal Insurance Contributions Act, or FICA, taxes are the payroll taxes collected for Medicare and Social Security programs. These taxes fund insurance programs for the elderly, disabled, survivors (Social Security), and for healthcare (Medicare). This tax originated in 1935. Employees and employers are required to make regular contributions to FICA through payroll deductions. For 2010, the FICA tax rate is 7.65% (6.2% for Social Security and 1.45% for Medicare) on gross earnings (earnings before any deductions). The individual contribution limit for the Social Security program is 6.2% of wages up to $106,800 (a $6,621.60 cap per individual). Unlike Social Security, there is no cap on contributions to the Medicare program. Individuals and employers each contribute 1.45% of wages earned (for a total of 2.9%) to fund the Medicare program.

House staff traditionally participate in this government insurance program by contributing FICA taxes. But in the 1990s, employers and individuals began filing FICA refund claims to the IRS based on the student exception (Internal Revenue Code section 3121(b)(10)). It is my understanding that this section of the IRS code exempts students from the FICA tax.

So are house staff recognized as students under the eyes of the law? In the 1998 court case State of Minnesota vs. Apfel, the court opined that University of Minnesota house staff exist for the primary purpose of education, rather than for earning a livelihood. Based on that ruling, the IRS chief counsel issued a memorandum in July 2000 that stated house staff could meet the FICA student exemption if 1) the house staff’s employer is a school, and 2) the house staffer is considered a student by the employer.

So why has it taken so long for the IRS to decide to refund these dollars? Over the past decade, there have been other court cases with conflicting interpretations of the IRS code. In January 2005, the IRS implemented new regulations that did not require house staff to contribute FICA taxes. But this new regulation did nothing about past house-staff contributions. Last year, in another Minnesota case, Mayo Foundation for Medical Education and Research vs. the United States, the court again interpreted the IRS regulations as limiting the student FICA exception to students who are not full-time employees. Despite other ongoing lawsuits, the IRS has decided that individuals who were house staff prior to April 2005 and meet the criteria are excepted from FICA taxes.

So who is eligible to receive these FICA taxes refund? It is my understanding that if you are a house officer who contributed to FICA taxes prior to April 2005, you are eligible for a refund only if you or the institution where you trained filed a claim in a timely fashion. The period of limitation for filing a claim has expired. If you think that you are covered by a claim, the IRS states that you should expect to hear from the institution where you trained about the refund process. You will not be hearing from the IRS directly.

For more information, call 800-919-1703 or visit www.irs.gov/charities and click on “Medical Resident FICA Refund.”

Is the Economy Having a Negative Effect on Hospitalist Jobs?

I will start my senior year as a medical resident in a few months. I am interested in a career as a hospitalist. While I hear that there are a lot of hospitalists out there, one of my friends has been looking for a hospitalist job in the Northeast and has had some difficulty landing a position. Is the problem the area or the economy? Is there anything I can do to make myself a more attractive candidate?

Reza Mohan, MD

Seattle

Dr. Hospitalist responds: Congratul-ations on reaching this stage in your training as a physician; this is the time you can start thinking about your career as a hospitalist. While I understand your desire to land a plum job upon completion of training, I want to encourage you to focus your efforts during your last year of training. Becoming the best doctor possible might be the best preparation to land the ideal HM job.

It is true that since 1996, when the term “hospitalist” was first coined, it has been easy to land HM jobs. The field exploded out of nowhere, and now boasts more than 30,000 hospitalists after little more than a decade. Atlanta, Boston, San Diego, Seattle … hospitalist jobs were plentiful.

While it has been good for physicians looking for jobs, I am not sure it has been ideal for patients. I would argue that the easy availability of jobs has attracted people to our profession who probably are not ideally suited to be hospitalists. From a quality perspective, wouldn’t we be better off if there were more competition for hospitalist jobs? In fact, I am hearing talk from colleagues around the country that there are a few places where it is increasingly more difficult to land a hospitalist job. Seattle and Boston are two such places.

That said, one only has to look at the job ads in the preceding pages of The Hospitalist and the SHM Career Center (www.hospitalmedicine.org/careers) to see that HM jobs are still plentiful in most parts of the country. I would not worry about not being able to land a job as a hospitalist when you finish training. However, you might not be able to find a great job in the city of your choice.

If you are interested in networking, I encourage you to speak with HM physicians at your hospital and in your community. Don’t pass up the opportunity to attend a local SHM chapter meeting or a regional conference; both are great for connecting with hospitalists and hiring managers. Another option is to sign up with an SHM e-mail listserv, so you have the opportunity to participate in online discussions with hospitalists. TH

Reference

1. IRS to honor medical resident FICA refund claims. IRS Web site. Available at www.irs.gov/charities/article/ 0,,id=219548,00.html. Published March 2, 2010. Accessed April 14, 2010.

Physicians Could Be Eligible to Receive IRS Refund

I heard the Internal Revenue Service is going to refund the employment taxes physicians paid when they were residents. Is this true? If so, how do I go about filing for this?

J. Byrne, MD

New YorkRe

Dr. Hospitalist responds: On March 2, the IRS announced that it had “made an administrative determination to accept the position that medical residents are excepted from FICA taxes based on the student exception for tax periods ending before April 1, 2005, when new IRS regulations went into effect.”¹ For folks like me, who have a hard time understanding the different numbers on my paycheck, here is an explanation. (I am neither an attorney nor an accountant; for any such counsel, I suggest you visit a professional.)

Federal Insurance Contributions Act, or FICA, taxes are the payroll taxes collected for Medicare and Social Security programs. These taxes fund insurance programs for the elderly, disabled, survivors (Social Security), and for healthcare (Medicare). This tax originated in 1935. Employees and employers are required to make regular contributions to FICA through payroll deductions. For 2010, the FICA tax rate is 7.65% (6.2% for Social Security and 1.45% for Medicare) on gross earnings (earnings before any deductions). The individual contribution limit for the Social Security program is 6.2% of wages up to $106,800 (a $6,621.60 cap per individual). Unlike Social Security, there is no cap on contributions to the Medicare program. Individuals and employers each contribute 1.45% of wages earned (for a total of 2.9%) to fund the Medicare program.

House staff traditionally participate in this government insurance program by contributing FICA taxes. But in the 1990s, employers and individuals began filing FICA refund claims to the IRS based on the student exception (Internal Revenue Code section 3121(b)(10)). It is my understanding that this section of the IRS code exempts students from the FICA tax.

So are house staff recognized as students under the eyes of the law? In the 1998 court case State of Minnesota vs. Apfel, the court opined that University of Minnesota house staff exist for the primary purpose of education, rather than for earning a livelihood. Based on that ruling, the IRS chief counsel issued a memorandum in July 2000 that stated house staff could meet the FICA student exemption if 1) the house staff’s employer is a school, and 2) the house staffer is considered a student by the employer.

So why has it taken so long for the IRS to decide to refund these dollars? Over the past decade, there have been other court cases with conflicting interpretations of the IRS code. In January 2005, the IRS implemented new regulations that did not require house staff to contribute FICA taxes. But this new regulation did nothing about past house-staff contributions. Last year, in another Minnesota case, Mayo Foundation for Medical Education and Research vs. the United States, the court again interpreted the IRS regulations as limiting the student FICA exception to students who are not full-time employees. Despite other ongoing lawsuits, the IRS has decided that individuals who were house staff prior to April 2005 and meet the criteria are excepted from FICA taxes.

So who is eligible to receive these FICA taxes refund? It is my understanding that if you are a house officer who contributed to FICA taxes prior to April 2005, you are eligible for a refund only if you or the institution where you trained filed a claim in a timely fashion. The period of limitation for filing a claim has expired. If you think that you are covered by a claim, the IRS states that you should expect to hear from the institution where you trained about the refund process. You will not be hearing from the IRS directly.

For more information, call 800-919-1703 or visit www.irs.gov/charities and click on “Medical Resident FICA Refund.”

Is the Economy Having a Negative Effect on Hospitalist Jobs?

I will start my senior year as a medical resident in a few months. I am interested in a career as a hospitalist. While I hear that there are a lot of hospitalists out there, one of my friends has been looking for a hospitalist job in the Northeast and has had some difficulty landing a position. Is the problem the area or the economy? Is there anything I can do to make myself a more attractive candidate?

Reza Mohan, MD

Seattle

Dr. Hospitalist responds: Congratul-ations on reaching this stage in your training as a physician; this is the time you can start thinking about your career as a hospitalist. While I understand your desire to land a plum job upon completion of training, I want to encourage you to focus your efforts during your last year of training. Becoming the best doctor possible might be the best preparation to land the ideal HM job.

It is true that since 1996, when the term “hospitalist” was first coined, it has been easy to land HM jobs. The field exploded out of nowhere, and now boasts more than 30,000 hospitalists after little more than a decade. Atlanta, Boston, San Diego, Seattle … hospitalist jobs were plentiful.

While it has been good for physicians looking for jobs, I am not sure it has been ideal for patients. I would argue that the easy availability of jobs has attracted people to our profession who probably are not ideally suited to be hospitalists. From a quality perspective, wouldn’t we be better off if there were more competition for hospitalist jobs? In fact, I am hearing talk from colleagues around the country that there are a few places where it is increasingly more difficult to land a hospitalist job. Seattle and Boston are two such places.

That said, one only has to look at the job ads in the preceding pages of The Hospitalist and the SHM Career Center (www.hospitalmedicine.org/careers) to see that HM jobs are still plentiful in most parts of the country. I would not worry about not being able to land a job as a hospitalist when you finish training. However, you might not be able to find a great job in the city of your choice.

If you are interested in networking, I encourage you to speak with HM physicians at your hospital and in your community. Don’t pass up the opportunity to attend a local SHM chapter meeting or a regional conference; both are great for connecting with hospitalists and hiring managers. Another option is to sign up with an SHM e-mail listserv, so you have the opportunity to participate in online discussions with hospitalists. TH

Reference

1. IRS to honor medical resident FICA refund claims. IRS Web site. Available at www.irs.gov/charities/article/ 0,,id=219548,00.html. Published March 2, 2010. Accessed April 14, 2010.

Physicians Could Be Eligible to Receive IRS Refund

I heard the Internal Revenue Service is going to refund the employment taxes physicians paid when they were residents. Is this true? If so, how do I go about filing for this?

J. Byrne, MD

New YorkRe

Dr. Hospitalist responds: On March 2, the IRS announced that it had “made an administrative determination to accept the position that medical residents are excepted from FICA taxes based on the student exception for tax periods ending before April 1, 2005, when new IRS regulations went into effect.”¹ For folks like me, who have a hard time understanding the different numbers on my paycheck, here is an explanation. (I am neither an attorney nor an accountant; for any such counsel, I suggest you visit a professional.)

Federal Insurance Contributions Act, or FICA, taxes are the payroll taxes collected for Medicare and Social Security programs. These taxes fund insurance programs for the elderly, disabled, survivors (Social Security), and for healthcare (Medicare). This tax originated in 1935. Employees and employers are required to make regular contributions to FICA through payroll deductions. For 2010, the FICA tax rate is 7.65% (6.2% for Social Security and 1.45% for Medicare) on gross earnings (earnings before any deductions). The individual contribution limit for the Social Security program is 6.2% of wages up to $106,800 (a $6,621.60 cap per individual). Unlike Social Security, there is no cap on contributions to the Medicare program. Individuals and employers each contribute 1.45% of wages earned (for a total of 2.9%) to fund the Medicare program.

House staff traditionally participate in this government insurance program by contributing FICA taxes. But in the 1990s, employers and individuals began filing FICA refund claims to the IRS based on the student exception (Internal Revenue Code section 3121(b)(10)). It is my understanding that this section of the IRS code exempts students from the FICA tax.

So are house staff recognized as students under the eyes of the law? In the 1998 court case State of Minnesota vs. Apfel, the court opined that University of Minnesota house staff exist for the primary purpose of education, rather than for earning a livelihood. Based on that ruling, the IRS chief counsel issued a memorandum in July 2000 that stated house staff could meet the FICA student exemption if 1) the house staff’s employer is a school, and 2) the house staffer is considered a student by the employer.

So why has it taken so long for the IRS to decide to refund these dollars? Over the past decade, there have been other court cases with conflicting interpretations of the IRS code. In January 2005, the IRS implemented new regulations that did not require house staff to contribute FICA taxes. But this new regulation did nothing about past house-staff contributions. Last year, in another Minnesota case, Mayo Foundation for Medical Education and Research vs. the United States, the court again interpreted the IRS regulations as limiting the student FICA exception to students who are not full-time employees. Despite other ongoing lawsuits, the IRS has decided that individuals who were house staff prior to April 2005 and meet the criteria are excepted from FICA taxes.

So who is eligible to receive these FICA taxes refund? It is my understanding that if you are a house officer who contributed to FICA taxes prior to April 2005, you are eligible for a refund only if you or the institution where you trained filed a claim in a timely fashion. The period of limitation for filing a claim has expired. If you think that you are covered by a claim, the IRS states that you should expect to hear from the institution where you trained about the refund process. You will not be hearing from the IRS directly.

For more information, call 800-919-1703 or visit www.irs.gov/charities and click on “Medical Resident FICA Refund.”

Is the Economy Having a Negative Effect on Hospitalist Jobs?

I will start my senior year as a medical resident in a few months. I am interested in a career as a hospitalist. While I hear that there are a lot of hospitalists out there, one of my friends has been looking for a hospitalist job in the Northeast and has had some difficulty landing a position. Is the problem the area or the economy? Is there anything I can do to make myself a more attractive candidate?

Reza Mohan, MD

Seattle

Dr. Hospitalist responds: Congratul-ations on reaching this stage in your training as a physician; this is the time you can start thinking about your career as a hospitalist. While I understand your desire to land a plum job upon completion of training, I want to encourage you to focus your efforts during your last year of training. Becoming the best doctor possible might be the best preparation to land the ideal HM job.

It is true that since 1996, when the term “hospitalist” was first coined, it has been easy to land HM jobs. The field exploded out of nowhere, and now boasts more than 30,000 hospitalists after little more than a decade. Atlanta, Boston, San Diego, Seattle … hospitalist jobs were plentiful.

While it has been good for physicians looking for jobs, I am not sure it has been ideal for patients. I would argue that the easy availability of jobs has attracted people to our profession who probably are not ideally suited to be hospitalists. From a quality perspective, wouldn’t we be better off if there were more competition for hospitalist jobs? In fact, I am hearing talk from colleagues around the country that there are a few places where it is increasingly more difficult to land a hospitalist job. Seattle and Boston are two such places.

That said, one only has to look at the job ads in the preceding pages of The Hospitalist and the SHM Career Center (www.hospitalmedicine.org/careers) to see that HM jobs are still plentiful in most parts of the country. I would not worry about not being able to land a job as a hospitalist when you finish training. However, you might not be able to find a great job in the city of your choice.

If you are interested in networking, I encourage you to speak with HM physicians at your hospital and in your community. Don’t pass up the opportunity to attend a local SHM chapter meeting or a regional conference; both are great for connecting with hospitalists and hiring managers. Another option is to sign up with an SHM e-mail listserv, so you have the opportunity to participate in online discussions with hospitalists. TH

Reference

1. IRS to honor medical resident FICA refund claims. IRS Web site. Available at www.irs.gov/charities/article/ 0,,id=219548,00.html. Published March 2, 2010. Accessed April 14, 2010.

Awards of Excellence

Award for Excellence in Teamwork in Quality Improvement

The Emory University Hospital Healthcare Team, co-led by Jason Stein, MD, FHM, Carolyn Hill, RN, Laura Phillips, and Dee Cantrell, received the award for excellence in QI teamwork for their groundbreaking work on VTE prophylaxis, a key indicator of hospital quality.

Award for Clinical Excellence

Jennifer Myers, MD, FHM, for leading the “rapid root cause analysis” process that convenes medical error reviews with front-line clinicians and staff.

Award for Excellence in Teaching

Amir Jaffer, MD, FHM

Dr. Kangelaris

Award for Outstanding Service in Hospital Medicine

Mitchell Wilson, MD, FHM

Award for Excellence in Research

Margaret C. Fang MD, MPH, FHM

Research, Innovation, and Clinical Vignettes Winners

2010 Innovation Poster Winner: Aaron Farberg, BS, Andrew Lin, BS, Latoya Kuhn, MPH, Scott Flanders, MD, SFHM, Christopher Kim, MD, MBA, University of Michigan Medical School, “Dear Doctor: A Tool to Facilitate Patient-Centered Care and Enhance Communication.”

Dr. Kangelaris

2010 Adult Vignette Winner: Jennie Wei, MD, and Patrick Kneeland, MD, University of California at San Francisco, “A Case of Skin Ulcers and Neutropenia: Definitely Not a Helminth Problem.”

2010 Research Winner: Will Southern, MD, MS, and Julia Arnsten, MD, MPH, Montefiore Medical Center, Bronx, N.Y.: “Increased Mortality and Readmission Among Patients Discharged against Medical Advice.”

2010 Pediatric Vignette Winner: Harry Hoar, MD, Baystate Children’s Hospitalist, Springfield, Mass., “A Teen with Varices: An Uncommon Presentation of a Familiar Disease.”

Researchers Earn First SHM Junior Faculty Development Awards

Two-year, $50,000 commitment bolsters academic pursuits for young hospitalists

By Jason Carris

Dr. Kangelaris

NATIONAL HARBOR, Md.– Kirsten Kangelaris, MD, and Evan Fieldston, MD, MBA, MSHP, were presented $50,000 Junior Faculty Development Awards at HM10. The first-year awards are part of SHM’s commitment to helping the “generation of new knowledge,” said Scott Flanders, SHM’s outgoing president.

Dr. Kangelaris, a fellow in internal medicine at the University of California at San Francisco, focuses her research on continued clinical and biologic genetic risk-prediction algorithms that will improve the triage and early-management strategies for hospitalized patients with inflammatory illness.

Dr. Fieldston

Dr. Fieldston, an assistant professor in pediatrics at the University of Pennsylvania School of Medicine and Children’s Hospital of Philadelphia, plans to use his award to examine the association between dynamic aspects of workload, workforce, and quality of care at children’s hospitals.

SHM also handed out its annual Awards of Excellence (above left) and announced winners from the Research, Innovation, and Clinical Vignette competition (below left). Judges scored more than 400 posters; some of the winning project teams included medical students.

“I am particularly proud to see that we had medical students as award winners,” said Flanders, chief of the hospital medicine division at the University of Michigan Health System in Ann Arbor. “That gives me great hope for the future of HM.”

Awards of Excellence

Award for Excellence in Teamwork in Quality Improvement

The Emory University Hospital Healthcare Team, co-led by Jason Stein, MD, FHM, Carolyn Hill, RN, Laura Phillips, and Dee Cantrell, received the award for excellence in QI teamwork for their groundbreaking work on VTE prophylaxis, a key indicator of hospital quality.

Award for Clinical Excellence

Jennifer Myers, MD, FHM, for leading the “rapid root cause analysis” process that convenes medical error reviews with front-line clinicians and staff.

Award for Excellence in Teaching

Amir Jaffer, MD, FHM

Dr. Kangelaris

Award for Outstanding Service in Hospital Medicine

Mitchell Wilson, MD, FHM

Award for Excellence in Research

Margaret C. Fang MD, MPH, FHM

Research, Innovation, and Clinical Vignettes Winners

2010 Innovation Poster Winner: Aaron Farberg, BS, Andrew Lin, BS, Latoya Kuhn, MPH, Scott Flanders, MD, SFHM, Christopher Kim, MD, MBA, University of Michigan Medical School, “Dear Doctor: A Tool to Facilitate Patient-Centered Care and Enhance Communication.”

Dr. Kangelaris

2010 Adult Vignette Winner: Jennie Wei, MD, and Patrick Kneeland, MD, University of California at San Francisco, “A Case of Skin Ulcers and Neutropenia: Definitely Not a Helminth Problem.”

2010 Research Winner: Will Southern, MD, MS, and Julia Arnsten, MD, MPH, Montefiore Medical Center, Bronx, N.Y.: “Increased Mortality and Readmission Among Patients Discharged against Medical Advice.”

2010 Pediatric Vignette Winner: Harry Hoar, MD, Baystate Children’s Hospitalist, Springfield, Mass., “A Teen with Varices: An Uncommon Presentation of a Familiar Disease.”

Researchers Earn First SHM Junior Faculty Development Awards

Two-year, $50,000 commitment bolsters academic pursuits for young hospitalists

By Jason Carris

Dr. Kangelaris

NATIONAL HARBOR, Md.– Kirsten Kangelaris, MD, and Evan Fieldston, MD, MBA, MSHP, were presented $50,000 Junior Faculty Development Awards at HM10. The first-year awards are part of SHM’s commitment to helping the “generation of new knowledge,” said Scott Flanders, SHM’s outgoing president.

Dr. Kangelaris, a fellow in internal medicine at the University of California at San Francisco, focuses her research on continued clinical and biologic genetic risk-prediction algorithms that will improve the triage and early-management strategies for hospitalized patients with inflammatory illness.

Dr. Fieldston

Dr. Fieldston, an assistant professor in pediatrics at the University of Pennsylvania School of Medicine and Children’s Hospital of Philadelphia, plans to use his award to examine the association between dynamic aspects of workload, workforce, and quality of care at children’s hospitals.

SHM also handed out its annual Awards of Excellence (above left) and announced winners from the Research, Innovation, and Clinical Vignette competition (below left). Judges scored more than 400 posters; some of the winning project teams included medical students.

“I am particularly proud to see that we had medical students as award winners,” said Flanders, chief of the hospital medicine division at the University of Michigan Health System in Ann Arbor. “That gives me great hope for the future of HM.”

Awards of Excellence

Award for Excellence in Teamwork in Quality Improvement

The Emory University Hospital Healthcare Team, co-led by Jason Stein, MD, FHM, Carolyn Hill, RN, Laura Phillips, and Dee Cantrell, received the award for excellence in QI teamwork for their groundbreaking work on VTE prophylaxis, a key indicator of hospital quality.

Award for Clinical Excellence

Jennifer Myers, MD, FHM, for leading the “rapid root cause analysis” process that convenes medical error reviews with front-line clinicians and staff.

Award for Excellence in Teaching

Amir Jaffer, MD, FHM

Dr. Kangelaris

Award for Outstanding Service in Hospital Medicine

Mitchell Wilson, MD, FHM

Award for Excellence in Research

Margaret C. Fang MD, MPH, FHM

Research, Innovation, and Clinical Vignettes Winners

2010 Innovation Poster Winner: Aaron Farberg, BS, Andrew Lin, BS, Latoya Kuhn, MPH, Scott Flanders, MD, SFHM, Christopher Kim, MD, MBA, University of Michigan Medical School, “Dear Doctor: A Tool to Facilitate Patient-Centered Care and Enhance Communication.”

Dr. Kangelaris

2010 Adult Vignette Winner: Jennie Wei, MD, and Patrick Kneeland, MD, University of California at San Francisco, “A Case of Skin Ulcers and Neutropenia: Definitely Not a Helminth Problem.”

2010 Research Winner: Will Southern, MD, MS, and Julia Arnsten, MD, MPH, Montefiore Medical Center, Bronx, N.Y.: “Increased Mortality and Readmission Among Patients Discharged against Medical Advice.”

2010 Pediatric Vignette Winner: Harry Hoar, MD, Baystate Children’s Hospitalist, Springfield, Mass., “A Teen with Varices: An Uncommon Presentation of a Familiar Disease.”

Researchers Earn First SHM Junior Faculty Development Awards

Two-year, $50,000 commitment bolsters academic pursuits for young hospitalists

By Jason Carris

Dr. Kangelaris

NATIONAL HARBOR, Md.– Kirsten Kangelaris, MD, and Evan Fieldston, MD, MBA, MSHP, were presented $50,000 Junior Faculty Development Awards at HM10. The first-year awards are part of SHM’s commitment to helping the “generation of new knowledge,” said Scott Flanders, SHM’s outgoing president.

Dr. Kangelaris, a fellow in internal medicine at the University of California at San Francisco, focuses her research on continued clinical and biologic genetic risk-prediction algorithms that will improve the triage and early-management strategies for hospitalized patients with inflammatory illness.

Dr. Fieldston

Dr. Fieldston, an assistant professor in pediatrics at the University of Pennsylvania School of Medicine and Children’s Hospital of Philadelphia, plans to use his award to examine the association between dynamic aspects of workload, workforce, and quality of care at children’s hospitals.

SHM also handed out its annual Awards of Excellence (above left) and announced winners from the Research, Innovation, and Clinical Vignette competition (below left). Judges scored more than 400 posters; some of the winning project teams included medical students.

“I am particularly proud to see that we had medical students as award winners,” said Flanders, chief of the hospital medicine division at the University of Michigan Health System in Ann Arbor. “That gives me great hope for the future of HM.”

Last month, more than 2,500 hospitalists and experts in HM gathered just outside Washington, D.C., to share the very best the specialty has to offer. The record-setting attendance surpassed the previous record—set at HM09 in Chicago—by more than 20%.

For hospitalists across the country, the meeting provided the perfect venue for continued education, professional development, and networking with friends and colleagues. To SHM CEO Larry Wellikson, MD, FHM, that is exactly what makes the annual meeting important.

“Hospital medicine is growing and evolving at a breakneck pace, and individual hospitalists are expected to keep up on a daily basis,” he says. “Our annual meeting is an opportunity to recognize the leaders in our field and identify the opportunities and challenges on the horizon for hospitalists.”

SHM Inducts First Senior Fellows and Masters in Hospital Medicine

The current and future leaders of HM were inducted as Fellows in Hospital Medicine at HM10 (see “Fellows in Hospital Medicine Class of 2010,” p.10). This year, SHM introduced the inaugural class of nearly 200 Senior Fellows in Hospital Medicine (SFHM) and three Masters in Hospital Medicine (MHM).

The three MHM designees—Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM—were recognized by SHM leadership for the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.”

Great Hospital Care? There’s an App for That

The Hospitalist Connection, a new, free handheld application developed specifically for hospitalists, is available at www.hospitalmedicine.org/epocrates.

Available for iPhone, Windows Mobile, and Palm devices, Hospitalist Connection puts the best in practice-management resources at hospitalists’ fingertips. Each article in Hospitalist Connection is selected by hospitalist Chad Whelan, MD, FHM, who adds his expert commentary on the topic.

“Staying up to date with the latest advances in hospital medicine is a key component of any hospitalist’s job, but they rarely find themselves with time at a desk behind a computer,” Dr. Whelan says. “That’s what makes this combination of format and content so powerful.”

In addition to exclusive content from Dr. Whelan, Hospitalist Connection presents excerpts of articles from the most trusted sources in HM. Topics range from management and care transitions to quality improvement (QI) and patient safety.

Hospitalist Connection is a joint collaboration between SHM and Epocrates, which develops Web-based and mobile applications for the healthcare sector. Epocrates estimates that more than 900,000 healthcare professionals—including 1 in 3 U.S. physicians—use Epocrates products.

The response to the Hospitalist Connection launch has been enthusiastic, according to SHM officials.

“Making great information more accessible empowers hospitalists to truly bring the best to their hospitals and patients,” says Todd Von Deak, SHM vice president and general manager. “We’re thrilled that so many hospitalists have shown such an interest in Hospitalist Connection. This is an extension of our commitment to bring the best resources to hospital medicine and our members.”

“This is a true milestone for the hospital medicine specialty,” said Dr. Wellikson. “The Masters in Hospital Medicine designation is the Hall of Fame of hospital medicine. We are honored to acknowledge Drs. Nelson, Wachter, and Whitcomb. We’re also thrilled to induct hundreds of new Fellows and Senior Fellows into the program. Their demonstrated commitment to improving patient care is one of the hallmarks of hospital medicine.”

The new SFHM designees represent the field’s experienced leaders and the next level of credentialing beyond the original Fellow in Hospital Medicine (FHM). Senior Fellows must have at least five years of HM practice and have been a society member for at least five years.

SHM also inducted 190 new FHM designees. As the second class of Fellows, they join more than 500 other hospitalists who have practiced HM for five years and been a member of SHM for at least three years.

For more information about the SHM Fellowship program, visit www.hospitalmedicine.org/fellows.

Featured Speakers Bring Focus to HM, Healthcare Policy

It’s no coincidence that SHM brought hospitalists to the nation’s capital for the annual meeting. The ongoing public debate over delivering patient care safely, effectively, and efficiently remains at the fore in the nation’s capital.

That was the point driven home by Dr. Wachter in his featured presentation on the final day of the conference. While the recently passed healthcare reform legislation addressed such issues as access to health insurance and costs, the legislation “kicked the can down the road,” he said.

For perspective from a hospital administrator who already has put into practice many of the reform recommendations, HM10 turned to Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston. Too much attention on political debate could be a distraction, Levy warned. Instead of getting too caught up in national political drama, Levy cautioned, hospitalists would do well to focus on their own practices and identify ways to reduce preventable errors in the hospital.

Levy’s speech was preceded by a panel discussion led by Public Policy Committee Chair Eric Siegal, MD, SFHM, one of the newest members of the SHM board. Leslie Norwalk, a former Centers for Medicare and Medicaid Services (CMS) administrator, participated in the panel and was interviewed later that day by CNN Money about young, healthy individuals and the role they play in reducing health insurance costs.

Hospitalists Bone Up on Career and Clinical Skills

More than 900 hospitalists used the pre-courses at HM10 as an opportunity for continued professional education.

Presented on the day before the formal kickoff of HM10, each pre-course presented an in-depth look at some of the most pressing issues in HM. This year introduced two new pre-courses that characterized the wide range of topics: “Early Career Hospitalist: Skills for Success” and “Essential Neurology for the Hospitalist.”

All told, HM10 was a resounding success that reflected the continued energy and enthusiasm of HM and its impact on healthcare. To SHM Vice President and General Manager Todd Von Deak, that momentum means looking to the future.

“We received great feedback from our attendees this year, and we’re looking forward to using that information to make an even stronger—and record-breaking—annual meeting in Dallas next year,” he said. “See you in 2011!” TH

Brendon Shank is a freelance writer based in Philadelphia.

Last month, more than 2,500 hospitalists and experts in HM gathered just outside Washington, D.C., to share the very best the specialty has to offer. The record-setting attendance surpassed the previous record—set at HM09 in Chicago—by more than 20%.

For hospitalists across the country, the meeting provided the perfect venue for continued education, professional development, and networking with friends and colleagues. To SHM CEO Larry Wellikson, MD, FHM, that is exactly what makes the annual meeting important.

“Hospital medicine is growing and evolving at a breakneck pace, and individual hospitalists are expected to keep up on a daily basis,” he says. “Our annual meeting is an opportunity to recognize the leaders in our field and identify the opportunities and challenges on the horizon for hospitalists.”

SHM Inducts First Senior Fellows and Masters in Hospital Medicine

The current and future leaders of HM were inducted as Fellows in Hospital Medicine at HM10 (see “Fellows in Hospital Medicine Class of 2010,” p.10). This year, SHM introduced the inaugural class of nearly 200 Senior Fellows in Hospital Medicine (SFHM) and three Masters in Hospital Medicine (MHM).

The three MHM designees—Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM—were recognized by SHM leadership for the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.”

Great Hospital Care? There’s an App for That

The Hospitalist Connection, a new, free handheld application developed specifically for hospitalists, is available at www.hospitalmedicine.org/epocrates.

Available for iPhone, Windows Mobile, and Palm devices, Hospitalist Connection puts the best in practice-management resources at hospitalists’ fingertips. Each article in Hospitalist Connection is selected by hospitalist Chad Whelan, MD, FHM, who adds his expert commentary on the topic.

“Staying up to date with the latest advances in hospital medicine is a key component of any hospitalist’s job, but they rarely find themselves with time at a desk behind a computer,” Dr. Whelan says. “That’s what makes this combination of format and content so powerful.”

In addition to exclusive content from Dr. Whelan, Hospitalist Connection presents excerpts of articles from the most trusted sources in HM. Topics range from management and care transitions to quality improvement (QI) and patient safety.

Hospitalist Connection is a joint collaboration between SHM and Epocrates, which develops Web-based and mobile applications for the healthcare sector. Epocrates estimates that more than 900,000 healthcare professionals—including 1 in 3 U.S. physicians—use Epocrates products.

The response to the Hospitalist Connection launch has been enthusiastic, according to SHM officials.

“Making great information more accessible empowers hospitalists to truly bring the best to their hospitals and patients,” says Todd Von Deak, SHM vice president and general manager. “We’re thrilled that so many hospitalists have shown such an interest in Hospitalist Connection. This is an extension of our commitment to bring the best resources to hospital medicine and our members.”

“This is a true milestone for the hospital medicine specialty,” said Dr. Wellikson. “The Masters in Hospital Medicine designation is the Hall of Fame of hospital medicine. We are honored to acknowledge Drs. Nelson, Wachter, and Whitcomb. We’re also thrilled to induct hundreds of new Fellows and Senior Fellows into the program. Their demonstrated commitment to improving patient care is one of the hallmarks of hospital medicine.”

The new SFHM designees represent the field’s experienced leaders and the next level of credentialing beyond the original Fellow in Hospital Medicine (FHM). Senior Fellows must have at least five years of HM practice and have been a society member for at least five years.

SHM also inducted 190 new FHM designees. As the second class of Fellows, they join more than 500 other hospitalists who have practiced HM for five years and been a member of SHM for at least three years.

For more information about the SHM Fellowship program, visit www.hospitalmedicine.org/fellows.

Featured Speakers Bring Focus to HM, Healthcare Policy

It’s no coincidence that SHM brought hospitalists to the nation’s capital for the annual meeting. The ongoing public debate over delivering patient care safely, effectively, and efficiently remains at the fore in the nation’s capital.

That was the point driven home by Dr. Wachter in his featured presentation on the final day of the conference. While the recently passed healthcare reform legislation addressed such issues as access to health insurance and costs, the legislation “kicked the can down the road,” he said.

For perspective from a hospital administrator who already has put into practice many of the reform recommendations, HM10 turned to Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston. Too much attention on political debate could be a distraction, Levy warned. Instead of getting too caught up in national political drama, Levy cautioned, hospitalists would do well to focus on their own practices and identify ways to reduce preventable errors in the hospital.

Levy’s speech was preceded by a panel discussion led by Public Policy Committee Chair Eric Siegal, MD, SFHM, one of the newest members of the SHM board. Leslie Norwalk, a former Centers for Medicare and Medicaid Services (CMS) administrator, participated in the panel and was interviewed later that day by CNN Money about young, healthy individuals and the role they play in reducing health insurance costs.

Hospitalists Bone Up on Career and Clinical Skills

More than 900 hospitalists used the pre-courses at HM10 as an opportunity for continued professional education.

Presented on the day before the formal kickoff of HM10, each pre-course presented an in-depth look at some of the most pressing issues in HM. This year introduced two new pre-courses that characterized the wide range of topics: “Early Career Hospitalist: Skills for Success” and “Essential Neurology for the Hospitalist.”

All told, HM10 was a resounding success that reflected the continued energy and enthusiasm of HM and its impact on healthcare. To SHM Vice President and General Manager Todd Von Deak, that momentum means looking to the future.

“We received great feedback from our attendees this year, and we’re looking forward to using that information to make an even stronger—and record-breaking—annual meeting in Dallas next year,” he said. “See you in 2011!” TH

Brendon Shank is a freelance writer based in Philadelphia.

Last month, more than 2,500 hospitalists and experts in HM gathered just outside Washington, D.C., to share the very best the specialty has to offer. The record-setting attendance surpassed the previous record—set at HM09 in Chicago—by more than 20%.

For hospitalists across the country, the meeting provided the perfect venue for continued education, professional development, and networking with friends and colleagues. To SHM CEO Larry Wellikson, MD, FHM, that is exactly what makes the annual meeting important.

“Hospital medicine is growing and evolving at a breakneck pace, and individual hospitalists are expected to keep up on a daily basis,” he says. “Our annual meeting is an opportunity to recognize the leaders in our field and identify the opportunities and challenges on the horizon for hospitalists.”

SHM Inducts First Senior Fellows and Masters in Hospital Medicine

The current and future leaders of HM were inducted as Fellows in Hospital Medicine at HM10 (see “Fellows in Hospital Medicine Class of 2010,” p.10). This year, SHM introduced the inaugural class of nearly 200 Senior Fellows in Hospital Medicine (SFHM) and three Masters in Hospital Medicine (MHM).

The three MHM designees—Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM—were recognized by SHM leadership for the “utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession.”

Great Hospital Care? There’s an App for That

The Hospitalist Connection, a new, free handheld application developed specifically for hospitalists, is available at www.hospitalmedicine.org/epocrates.

Available for iPhone, Windows Mobile, and Palm devices, Hospitalist Connection puts the best in practice-management resources at hospitalists’ fingertips. Each article in Hospitalist Connection is selected by hospitalist Chad Whelan, MD, FHM, who adds his expert commentary on the topic.

“Staying up to date with the latest advances in hospital medicine is a key component of any hospitalist’s job, but they rarely find themselves with time at a desk behind a computer,” Dr. Whelan says. “That’s what makes this combination of format and content so powerful.”

In addition to exclusive content from Dr. Whelan, Hospitalist Connection presents excerpts of articles from the most trusted sources in HM. Topics range from management and care transitions to quality improvement (QI) and patient safety.

Hospitalist Connection is a joint collaboration between SHM and Epocrates, which develops Web-based and mobile applications for the healthcare sector. Epocrates estimates that more than 900,000 healthcare professionals—including 1 in 3 U.S. physicians—use Epocrates products.

The response to the Hospitalist Connection launch has been enthusiastic, according to SHM officials.

“Making great information more accessible empowers hospitalists to truly bring the best to their hospitals and patients,” says Todd Von Deak, SHM vice president and general manager. “We’re thrilled that so many hospitalists have shown such an interest in Hospitalist Connection. This is an extension of our commitment to bring the best resources to hospital medicine and our members.”

“This is a true milestone for the hospital medicine specialty,” said Dr. Wellikson. “The Masters in Hospital Medicine designation is the Hall of Fame of hospital medicine. We are honored to acknowledge Drs. Nelson, Wachter, and Whitcomb. We’re also thrilled to induct hundreds of new Fellows and Senior Fellows into the program. Their demonstrated commitment to improving patient care is one of the hallmarks of hospital medicine.”

The new SFHM designees represent the field’s experienced leaders and the next level of credentialing beyond the original Fellow in Hospital Medicine (FHM). Senior Fellows must have at least five years of HM practice and have been a society member for at least five years.

SHM also inducted 190 new FHM designees. As the second class of Fellows, they join more than 500 other hospitalists who have practiced HM for five years and been a member of SHM for at least three years.

For more information about the SHM Fellowship program, visit www.hospitalmedicine.org/fellows.

Featured Speakers Bring Focus to HM, Healthcare Policy

It’s no coincidence that SHM brought hospitalists to the nation’s capital for the annual meeting. The ongoing public debate over delivering patient care safely, effectively, and efficiently remains at the fore in the nation’s capital.

That was the point driven home by Dr. Wachter in his featured presentation on the final day of the conference. While the recently passed healthcare reform legislation addressed such issues as access to health insurance and costs, the legislation “kicked the can down the road,” he said.

For perspective from a hospital administrator who already has put into practice many of the reform recommendations, HM10 turned to Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston. Too much attention on political debate could be a distraction, Levy warned. Instead of getting too caught up in national political drama, Levy cautioned, hospitalists would do well to focus on their own practices and identify ways to reduce preventable errors in the hospital.

Levy’s speech was preceded by a panel discussion led by Public Policy Committee Chair Eric Siegal, MD, SFHM, one of the newest members of the SHM board. Leslie Norwalk, a former Centers for Medicare and Medicaid Services (CMS) administrator, participated in the panel and was interviewed later that day by CNN Money about young, healthy individuals and the role they play in reducing health insurance costs.

Hospitalists Bone Up on Career and Clinical Skills

More than 900 hospitalists used the pre-courses at HM10 as an opportunity for continued professional education.

Presented on the day before the formal kickoff of HM10, each pre-course presented an in-depth look at some of the most pressing issues in HM. This year introduced two new pre-courses that characterized the wide range of topics: “Early Career Hospitalist: Skills for Success” and “Essential Neurology for the Hospitalist.”

All told, HM10 was a resounding success that reflected the continued energy and enthusiasm of HM and its impact on healthcare. To SHM Vice President and General Manager Todd Von Deak, that momentum means looking to the future.

“We received great feedback from our attendees this year, and we’re looking forward to using that information to make an even stronger—and record-breaking—annual meeting in Dallas next year,” he said. “See you in 2011!” TH

Brendon Shank is a freelance writer based in Philadelphia.