User login
The Hospitalist only
NEW MEMBERS
Enter text here
Enter text here
Enter text here
The Laborist Movement
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
Health IT Hurdles
I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.
The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.
Levels of Complexity
Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.
While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.
The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.
EHR: A Tipping Point
The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.
I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.
The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.
I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.
Rethink New Employee Orientation
I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.
My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.
And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.
Hospital-Certified?
If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?
Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.
Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.
It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.
But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is 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.
I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.
The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.
Levels of Complexity
Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.
While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.
The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.
EHR: A Tipping Point
The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.
I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.
The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.
I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.
Rethink New Employee Orientation
I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.
My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.
And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.
Hospital-Certified?
If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?
Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.
Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.
It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.
But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is 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.
I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.
The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.
Levels of Complexity
Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.
While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.
The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.
EHR: A Tipping Point
The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.
I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.
The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.
I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.
Rethink New Employee Orientation
I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.
My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.
And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.
Hospital-Certified?
If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?
Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.
Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.
It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.
But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is 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.
ONLINE EXCLUSIVE: Listen to HM program directors and hospital execs discuss strategies for negotiating your group's next contract
Business Blueprint
Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Perhaps you’ve put in a few years of clinical practice in an HM group. Suddenly, your group needs a director—and everybody stepped back, except you. You now find yourself thrust into an unfamiliar world of bottom-line thinking, budgets, schedules, spreadsheets, decision-making, conflict resolution, recruiting, contract negotiations, and other managerial responsibilities. You’ve tried to learn how to perform most of these duties on the job. But you’ve learned that assuming direct responsibility for the fate of a hospitalist group with millions in annual billing requires skills that weren’t taught in medical school. And you’re struggling.
Maybe you’re a hospitalist residency program director in a teaching hospital setting, and you would like to transition into other hospital administrative leadership roles, such as chair of a medical staff or credentials committee, department chair, vice president of medical affairs, chief medical officer—maybe even CEO. But where do you begin?
The good news is that hospitalists are well positioned for such advancements, there is a core set of skills required for these various leadership positions that you can learn, and there are several places you can turn to for training. The trick is figuring out which skills and aptitudes you already possess, identifying those you need to strengthen, and selecting the training venues that best meet your goals. Your options vary widely, and include simply reading books on management to get up to speed quickly, investing in leadership training seminars and short courses, and pursuing advanced-degree programs in business leadership.
“Over the next 10 years, the single largest source of new CMOs might be hospitalists,” says John Nelson, MD, FACP, MHM, medical director of Overlake Hospital in Bellevue, Wash., and cofounder, past president, and past board member of SHM. “As many specialties focus more of their practice in the ambulatory care setting, that leaves behind those of us who will stay—e.g., hospitalists, radiologists, ER doctors, anesthesiologists—and who think of the hospital as their principal place of work. Of those doctors, hospitalists are probably the most interconnected and networked with all other doctors and all levels of hospital staff. That’s why hospitals are looking toward hospitalists for leadership.”
There is a growing need for HM to develop leaders, Dr. Nelson says, “not just for their own practice, but for various leadership activities within their hospital.”
Start at Self-Assessment
Hospitalist leadership is not for everyone, and you need to find out if you’re making the right decision by pursuing it. For one thing, you’ll need to facilitate consensus among physicians—a notoriously challenging group of professionals who are autonomous by training, conditioned to believe that they always wield veto power and that they don’t have to play by the rules established for everyone else, Dr. Nelson says.
Most daily leadership activities are much more open-ended and far less structured than physicians are used to, entailing simultaneous projects that need to be prioritized, says Dr. Nelson, who splits his time about 30% clinical and 70% administrative. He is a champion for his hospital’s technology initiative, medical director of his institution’s hospitalist practice, physician lead of its palliative-care program, principal of Nelson Flores Hospital Medicine Consultants, and a columnist for The Hospitalist.
How can you find out what you’re good at, what your weaknesses are, and what skills you need to build? There are several personality assessment instruments with which you can appraise your compatibility with leadership culture, says Julia S. Wright, MD, SFHM, FACP, senior medical officer for Canton, Ohio-based Hospitalists Management Group. And there are good self-assessment workbooks to test whether you have an inclination toward leadership, says Mary Jane Kornacki, MS, a partner in the Boston-based consulting firm Amicus Inc. You also can have a personal leadership assessment performed professionally (see “Leadership Self-Assessment,” p. 27).
Identify Core Leadership Requirements
There are various ways to categorize the leadership skills that a hospitalist needs, including these: financial and business literacy, technical savvy for projects like quality and patient safety improvement, planning acumen to identify external trends and implement appropriate change in one’s department or group, and emotional intelligence to engineer cooperative relationships, says Jack Silversin, DMD, DrPH, president of Amicus.
Indeed, the ability to manage the relationships with myriad stakeholders is a hospitalist leader’s central requirement, according to “Hospitalists: A Guide to Building and Sustaining a Successful Program.”1 Stakeholders include patients, families, referring physicians, medical subspecialists and surgeons, the hospital executive team (C-suite), the clinical team (nurses, case management, therapy departments, and others), the HM group itself, and the public.
The hospitalist leader is responsible for many tasks, the authors write, including:
- Blending marketplace needs with those of these various stakeholders;
- Managing budgets, billing and revenue cycles, resources, and performance metrics; and
- Overseeing such operational issues as scheduling, workload, census, staffing, and recruitment.
These duties will likely be time-consuming, but a hospitalist leader should nevertheless maintain a portion of his or her clinical practice to continue to be connected to the core work. “The foundation of your credibility as a leader is that you have excellent clinical skills,” says Winthrop F. Whitcomb, MD, MHM, medical director of healthcare quality at Baystate Medical Center in Springfield, Mass., and SHM cofounder and past president.
Clinical excellence is the foundation of successful leadership because the best quality and safety practices will drive successful hospitalist business practices, according to Lakshmi K. Halasyamani, MD, SFHM, SHM board member and vice president for Quality and Systems Improvement at Saint Joseph Mercy Hospital in Ann Arbor, Mich. “As healthcare reform begins to financially incentivize things like safe patient handoffs and more evidence-based medicine,” she says, “the business part of running a practice is going to quickly align with quality and safety outcomes. That’s what hospital medicine leaders should be focusing on.”
Empathy and communication skills are essential for a leader, who must continually translate messages from hospital administration to rank-and-file physicians, and vice versa, Dr. Whitcomb says. For example, he says, the message that hospitalists want better work conditions and more staff should be presented so that administration hears something like this: “We don’t want care to be unsafe; that would hurt the hospital’s reputation. Some of the hospitalists are burning out, creating the risk of increasing turnover. In fact, length of stay would be lower if the group has better staffing, because they could get the patients earlier in the day and send them home sooner.”
Such “situational awareness” is necessary to win the trust and cooperation of others and avoid becoming marginalized by important allies, says Eric Howell, MD, SFHM, director of the Hospital Medicine Division at Johns Hopkins Bayview Medical Center in Baltimore. “I’ve seen very successful advocates of hospital medicine groups who were not very good leaders,” the SHM board member says, “because they could not see what the leadership above them needed.”
Leadership Self-Assessment
The best way to examine your leadership skills is to take a test, such as the Leadership Effectiveness Analysis (LEA), which scores you on six leadership dimensions: creating a vision, developing followership, implementing the vision, following through, and achieving results, according to Dr. Wright. To understand your personality characteristics a little better, she adds, you can take basic tests like the Minnesota Multiphasic Personality Inventory (MMPI).
Other useful personality surveys that can give you an accurate sense of leadership readiness include the Myers-Briggs Type Indicator assessment and the DiSC personality assessment (the acronym reflects a four-quadrant personality model: Dominance, Influence, Steadiness, and Conscientiousness), says Kornacki.
A good self-assessment workbook to test whether you have an inclination toward leadership is Edgar H. Schein’s “Career Anchor, 3rd Edition,” Kornacki says. The book presents a taxonomy of eight competencies, which people prioritize differently: Technical/Functional, General Managerial, Autonomy/Independence, Security/ Stability, Entrepreneurial Creativity, Service/Dedication to a Cause, Pure Challenge, and Lifestyle. How you prioritize those themes offers insight into your values and motivations as a leader.
You might also consider having a professional assess your leadership strengths and weaknesses. Companies like Personnel Decisions International (www.personneldecisions.com) offer coaches who interact with you to assess your cognitive and experiential skills and make recommendations on what you need to work on, says Dr. Klocke.
Pursue the Right Training Venues
Once you’ve identified your strengths and weaknesses, as well as the core requirements of your leadership duties, you are ready to pursue the right training path. Leadership can be learned, whether you’re thrust into it and find yourself in “damage control” mode, or you want to pursue new leadership opportunities for career advancement, Dr. Howell says.
Your first step might be to develop your leadership skill set through informal self-help training. The easiest way is by reading books that other hospitalist leaders have found to be valuable when they were starting out (see “Self-Training Resources,” below left).
The next step is to find a mentor. This person should be a good leader whom you trust and respect, and from whom you can seek advice. “A leadership position can be awfully lonely,” Dr. Nelson says. “I suggest that people find a confidant and mentor at their local institution, someone who is very accessible, who they see all the time, who works in the same environment and knows the local politics.” The mentor could be someone you trained with, or under, or perhaps a hospitalist program director at another institution. It could be the chief nursing officer at your institution. “It is reassuring to know that others are facing similar problems elsewhere,” Dr. Nelson adds.
A local mentor can help with technical matters like offering you a “crash course” in financial spreadsheets, says Patience Agborbesong, MD, SFHM, medical director of a 17-hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. She notes that SHM provides networking resources to help you connect with other HM leaders (www.hospitalmedicine.org/leadership).
Large hospitalist groups frequently offer mentorship opportunities throughout their chain of operations, says Ethan B. Dunham, MBA, director of organizational development for Brentwood, Tenn.-based Cogent Healthcare. “If you find you’ve received something akin to a ‘battlefield promotion’ and are in over your head, you can turn to someone who has been there,” Dunham says.
Many larger health systems and academic medical centers—and even some community hospitals—offer in-house leadership training and mentorship programs, says David L. Klocke, MD, chair of the Division of Hospital Internal Medicine at Mayo Clinic in Rochester, Minn. In his institution, physician leaders are paired with partners from administration who fill in any gaps in their management or leadership skills, Dr. Klocke says. “You’re mentoring them as well about medical issues and skills,” he adds.
Another way to hone your skills is to join hospital committees. “Build up time in the saddle,” Dunham says. “Indicate your leadership potential and your interest in taking the next steps.” If you seek out committees, you’ll get on them, Dr. Nelson says. “And once on them, if you can distinguish yourself by helping to lead the committee in a good direction, your career will be off and running,” he explains. There are many kinds of hospital committee work to choose from, including peer review, performance improvement, practice guideline development, utilization review, pharmacy, and therapeutics.
Advanced Training
For hospitalists wanting a deeper dive, more formal business and leadership training is available through a variety of workshops and courses, many of which offer CME credit. “My favorite was the SHM Leadership Academy, which is fairly short and very practical. Every minute was directly relevant to me as a hospitalist,” Dr. Howell says of the four-day program. Covered topics include teamwork collaboration, communication strategies, hospital performance metrics, scheduling and compensation, strategic planning, financial reports, recruitment, negotiation, motivating others, and managing physician performance.
The American College of Physician Executives (ACPE) offers leadership training modules with certification, as well as MBA and MMM (master’s in medical management) programs through partnerships with universities, according to Dr. Agborbesong. There are several other organizations that offer leadership training, she notes, including The Institute for Medical Leadership, the Boot Camp on Leadership Fundamentals for Physicians, the Center for Creative Leadership, and the Carolinas Center for Medical Excellence (CCME) Physician Leadership Institute.
An MBA is an appropriate goal for many hospitalist leadership scenarios, such as entry-level program director, lead hospitalist at a healthcare system with multiple hospital medicine programs, or regional coordinator for a hospital medicine staffing company, says Michael Stahl, PhD, director of the Physician Executive MBA Program and professor of Strategy and Business Planning at the University of Tennessee in Knoxville.
“An MBA program is particularly well-suited to the physician who gets invited, all of a sudden, to be a leader and discovers they don’t have the knowledge, skill sets, tools and techniques, and ways of thinking about the business side of healthcare. It’s not unusual to see people at the start of their leadership careers saying, ‘I’m going to make an investment in my own human capital by earning an accredited MBA,’ ” Stahl says.
A rapidly changing healthcare landscape requires greater attention to business planning, capital and budget, revenue, and cost-containment principles, Stahl notes. “There will be incredible pressure on controlling the cost of healthcare in the future,” he says. “New reimbursement models are probably going to yield lower reimbursement. What we’re most interested in is equipping people with the tools and techniques of finance so that they can learn to model those new reimbursement types, whatever they are, and no matter how their regulations change.”
Although an MBA sounds daunting, many programs are tailored to a new leader’s busy schedule. For example, the Physician Executive MBA program at UT-Knoxville takes only one year to complete, focuses entirely on healthcare contexts, and combines four weeklong residence periods on campus with 40 Web-based classes, typically on Saturday mornings.
Traditional MBA programs typically take two years to complete and require more physical presence on campus. But in return, they offer ongoing face-to-face interaction with faculty and peers from a variety of business backgrounds that immerse you in the culture of business leadership, says Guy David, PhD, assistant professor of Healthcare Management at the Wharton School at the University of Pennsylvania in Philadelphia. Coursework includes finance, marketing, management, entrepreneurship, strategic development, data mining, economics, legal issues, IT, and other areas, David says. The coursework, he adds, gives physicians who have been trained to focus on the individual patient a much broader understanding of the system in which they operate.
Successful career advancement ultimately requires managerial and leadership acumen: proof that you can run the business, manage upstream and downstream communication, and handle administrative and liaison duties within the hospital, Dunham says. “An MBA is a shorthand, a way to signal to people that that skill set exists, maybe rather than having to prove it in the trenches,” he adds.
As the healthcare landscape continues to evolve, there will be a growing demand for physicians—particularly hospitalists—with greater procedural and conceptual understanding of healthcare systems and financials.
“Over time, it may become increasingly important to have received formal education in the business discipline,” Dunham says. “That’s something that time will tell.” TH
Chris Guadagnino is a freelance medical writer based in Philadelphia.
Reference
- Miller JA, Nelson JR, Whitcomb WF. Hospitalists: A Guide to Building and Sustaining a Successful Program. Health Administration Press: Chicago; 2008.
Veteran Advice For Aspiring HM leaders
Think carefully about whether you’re appropriately balancing the interests of your employer (i.e. the hospital) and the physicians in your group. Some hospitalist group leaders tilt toward being “union pit bosses” and beat up management, lobbying aggressively for their groups’ interests, Dr. Nelson explains. Other hospitalist leaders tilt too far the opposite way and try to beat the physicians into submitting to whatever the hospital might want. You’re going to be talking to both parties about all kinds of issues on a long-term basis, and you need to forsake adversarial negotiating tactics to cultivate long-term relationships.
Don’t make promises that are hard to keep. A leader often faces a tricky issue and might be tempted to take the easy way out by granting special deals, caving in, or meeting demands (e.g. promising a desirable scheduling arrangement as a recruiting inducement). That’s a rookie mistake, Dr. Nelson says, and others in the practice might resent it.
Advocating for your physicians doesn’t always mean more pay, bigger offices, or better benefits. “Good leadership goes beyond that,” Dr. Howell says, “by having good situational awareness to notice what’s important to other parties and building their trust.” By turning one of his offices into a part-time lactation room for mothers with newborns (half of his hospitalists were women of childbearing age, and five of them gave birth in the same year), Dr. Howell earned their trust and respect for the price of a door lock and a small refrigerator.
Pediatric HM Literature Review
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the relationship between duration of intravenous (IV) antibiotic therapy and treatment failure in infants <6 months of age hospitalized with urinary tract infections (UTIs)?
Background: There is an inadequate evidence base to drive decisions regarding duration of IV antibiotic therapy in young infants hospitalized with UTIs. Documented variability exists in length of stay (LOS) and resource utilization for these infants, which might be a direct result of practice variation with respect to IV therapy.
Study design: Retrospective cohort study.
Setting: Twenty-four freestanding children’s hospitals.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was used to identify healthy infants <6 months of age admitted with a primary or secondary diagnosis of UTI or pyelonephritis from 1999 to 2004 to participating hospitals. Duration of IV therapy was defined as a dichotomous variable with three days (short course: three days) selected because it was the median length of therapy. Treatment failure was defined as readmission within 30 days.
More than 12,300 records were analyzed. Male gender, neonatal status, black race, Hispanic ethnicity, nonprivate insurance, severity of illness, known bacteremia, known genitourinary tract disorders, and specific hospital were independently associated with increased likelihood of long-course (four days) therapy.
Unadjusted analysis initially revealed that long-course therapy was significantly associated with a higher rate of treatment failure. After multivariate (to include propensity scores) adjustment, a significant association between treatment duration and failure was no longer identified. Treatment failure association with known genitourinary abnormalities and higher severity of illness remained.
A significant limitation of this study is the potential for multivariate analysis to fail to mitigate a bias toward sicker patients receiving longer duration of antibiotic therapy and, thus, having a higher likelihood of treatment failure. In addition, the greater question of when IV antibiotics (and hospital admission) are indicated in this population was not addressed by the study design.
Nonetheless, the data likely support a limited utility to long-course IV antibiotic therapy in this population. The study also adds to the evolving picture of considerable and widespread variation in physician practice.
Bottom line: Short-course IV therapy for infants with UTIs does not increase risk of treatment failure.
Citation: Brady PW, Conway PH, Goudie A. Length of intravenous antibiotic therapy and treatment failure in infants with urinary tract infections. Pediatrics. 2010;126(2):196-203.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Sound Advice
Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.
Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?
Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.
The Legislation
Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.
Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.
The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).
The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.
Controlled Substance “Takeback”
The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.
Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:
- Name and address of the person;
- Name and quantity of each controlled substance to be disposed of;
- Explanation of how the applicant obtained the controlled substance, if known; and
- Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.
Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.
State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.
The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:
- Taking the prescription drugs out of their original containers;
- Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
- Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
- Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
- Placing the sealed container with the mixture, and the empty drug containers, in the trash.
Unused Medication Donation
The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.
Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.
Conclusion
Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.
The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH
Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.
Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.
Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?
Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.
The Legislation
Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.
Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.
The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).
The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.
Controlled Substance “Takeback”
The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.
Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:
- Name and address of the person;
- Name and quantity of each controlled substance to be disposed of;
- Explanation of how the applicant obtained the controlled substance, if known; and
- Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.
Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.
State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.
The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:
- Taking the prescription drugs out of their original containers;
- Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
- Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
- Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
- Placing the sealed container with the mixture, and the empty drug containers, in the trash.
Unused Medication Donation
The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.
Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.
Conclusion
Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.
The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH
Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.
Recent media reports about the dangers surrounding unused prescription medications, including abuse by teens and medications finding their way into the water supply, have prompted an increase in inquiries to healthcare providers about disposing of unused medication. These issues are complicated when controlled substances are involved.
Often, providers are unsure how to respond to patient questions about medication disposal. For example, what would you do if a patient requests an alternative medication because of an unwanted side effect and brings the originally prescribed medication back to you? What if the family of a recently expired patient brings unused medication to you and asks you to donate it to other patients? What if you have a colleague who performs mission work; could you accept and donate unused medication for use in another country?
Unfortunately, the Controlled Substances Act (CSA) does not provide a readily available mechanism to accomplish efficient, secure, and environmentally sound methods to collect and use or dispose of unwanted controlled substances. This article explains the rules physicians must adhere to and guidelines for “taking back” controlled substances.
The Legislation
Enacted in 1970, the CSA combined all existing federal drug laws into a single statute. It created five “schedules” in which certain drugs are classified. These “scheduled” drugs are commonly referred to as controlled substances. A drug’s classification depends on its potential for abuse and its currently accepted medical use in the U.S. Additionally, provisions of international treaties impact classification.
Under the classification system, Schedule I drugs have a high potential for abuse and have no currently accepted medical use in treatment in the U.S. In contrast, Schedule V drugs have a low potential for abuse and do have a currently accepted medical use in treatment in the U.S.
The CSA governs the manufacture, import, export, possession, use, and distribution of controlled substances. In doing so, the CSA established a system to register those authorized to handle controlled substances. Manufacturers, dispensers, distributors, and individual practitioners who prescribe controlled substances must be registered with the Drug Enforcement Administration (DEA).
The CSA requires registrants to keep certain records for at least two years related to their handling of controlled substances. For example, physician registrants must keep records of controlled substances in Schedules II, III, IV, and V that are dispensed via methods other than prescribing or administering (e.g., industry samples). Inventories of controlled substances are required. Most notably, physicians generally are not required to keep records of prescribed medications; however, records must be kept if drugs are dispensed or administered. Moreover, there are heightened recordkeeping responsibilities for providers who prescribe, dispense, or administer for maintenance or detoxification.
Controlled Substance “Takeback”
The system of registration established by the CSA prohibits a DEA registrant from acquiring controlled substances from nonregistered entities and, in turn, bars an end-user from distributing pharmaceutical controlled substances to a DEA registrant. In other words, physicians cannot receive controlled substances from anyone who does not also have a registration. Thus, physicians may not “take back” prescribed medications from patients or their family members. Similarly, except in cases of a drug being recalled or a dispensing error, patients are not allowed to return controlled medications to a pharmacy.
Information on how a patient or family member should properly dispose of medication is commonly misunderstood. DEA regulations provide a process for nonregistrants to dispose of unused medication; however, it is cumbersome and meant to be used only when dealing with large quantities of controlled substances (e.g., large quantities of abandoned drugs). In such cases, the DEA special agent in charge (SAC) may instruct on disposal, which may include transfer of the substance to a DEA registrant, delivery to a DEA agent or office, destruction in the presence of an agent of the administration or other authorized person, or by other means. The person must submit a letter to the local SAC, which includes:
- Name and address of the person;
- Name and quantity of each controlled substance to be disposed of;
- Explanation of how the applicant obtained the controlled substance, if known; and
- Name, address, and registration number, if known, of the person who possessed the controlled substances prior to the applicant.
Federal legislation also provides a way for the DEA to grant approval to law-enforcement agencies to operate “takeback” programs. The regulation states that “any person in possession of a controlled substance and desiring to dispose of such substance may request assistance from the SAC in the area in which the person is located.” The regulation allows the SAC to authorize and specify the means of disposal to assure that the controlled substances do not become available to unauthorized persons.
State and local government agencies and community associations might hold takeback programs only if law enforcement makes the request, takes custody of the controlled substances, and is responsible for the disposal.
The U.S. Office of National Drug Control Policy has published guidelines for medication disposal. These guidelines advise flushing medications only if the prescription label or accompanying patient information specifically states to do so. Instead of flushing, the guidelines recommend that medications be disposed of through a takeback program or by:
- Taking the prescription drugs out of their original containers;
- Mixing the drugs with an undesirable substance, such as cat litter or used coffee grounds;
- Placing the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag;
- Concealing or removing personal information, including Rx number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off; and
- Placing the sealed container with the mixture, and the empty drug containers, in the trash.
Unused Medication Donation
The rising cost of prescription medication leaves many questioning whether there is a need for a safe method to allow unused medication to be donated to others. At least 10 states have passed laws allowing or encouraging the donation of unused pharmaceutical drugs. Many of these programs involve healthcare facilities, nursing homes, or pharmacies. The CSA and current DEA regulations, however, prohibit patients from delivering or distributing controlled substances to a DEA registrant, even if it is for the purpose of a donation. Moreover, the Food and Drug Administration (FDA) does not permit redistribution of medications, except under limited circumstances.
Consequently, state law may be inconsistent with federal law for donation and reuse of controlled substances.
Conclusion
Physicians who fail to comply with CSA handling requirements are subject to criminal charges, discipline against their DEA registration, and discipline against their license to practice medicine. Consequently, physicians should use caution whenever handling unused medication.
The application of various aspects of the CSA and implementing rules is situation-specific. Moreover, the DEA may issue additional regulations. Accordingly, if you have a question about a specific situation, consult an attorney, or contact your local DEA field division office and ask for the diversion duty agent. TH
Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado Denver.
Real Doctoring
Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.1 But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.
Time-Motion Studies
What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.
Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.
90 Minutes of Doctoring?
While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.
A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.
I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.
Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.
I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?
What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.
Max “Doctoring” Time
I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.
I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.2 Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.
Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.
All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.
Coda
I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.
Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
References
- O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
- Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.1 But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.
Time-Motion Studies
What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.
Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.
90 Minutes of Doctoring?
While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.
A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.
I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.
Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.
I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?
What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.
Max “Doctoring” Time
I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.
I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.2 Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.
Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.
All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.
Coda
I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.
Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
References
- O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
- Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
Despite never advancing his musical tastes beyond the arena bands of the 1970s and ’80s (think Def Leppard), Mark Williams, MD, FACP, FHM, editor-in-chief of the Journal of Hospital Medicine, has done a great job in securing informative and meaningful research and opinion for the journal. Did you see read the July/August 2010 issue of JHM? It is a great example of content uniquely relevant to hospitalists: several original research articles documenting how hospitalists spend their time. Anyone thinking about the best way to organize and operate a hospitalist practice should read through these studies, along with one published by Kevin O’Leary, MD, and colleagues in the March/April 2006 issue.1 But as a service, I’ll provide a CliffsNotes version of them, along with some comments here.
Time-Motion Studies
What all the studies demonstrate is that academic hospitalists spend only about 15% to 20% of their time in direct patient care, generally defined as time spent taking a patient’s history and examination, meeting with families, etc. Indirect patient care, such as time spent reviewing records, documenting, and communicating with consultants and other patient care staff, consumes about 60% to 70% of their time. The remainder of time is spent in transit (around 7% of each day) and in personal activities.
Remember, all these studies reported on academic hospitalists in large academic medical centers. As noted in the discussion sections, the results in nonteaching community hospitals might be different. My guess is that community hospitalists spend about the same portion of time in the broad categories above, but the individual activities within each category might differ. So I’m willing to believe that these studies tell us something about the majority of hospitalists who practice outside of academia.
90 Minutes of Doctoring?
While the JHM studies assess hospitalist time in a number of different categories, I think it makes the most sense to divide our time into just two categories: “real doctoring” and other. We’ll probably never see a study that divides hospitalists’ time that way, as there would be endless debate about what is and isn’t real doctoring. But it is worth thinking about your work this way.
A lot of what the studies generally defined as indirect patient care is still “real doctoring.” Things like reviewing old records are critically important and typically can’t be done adequately by a nonclinician. But the 10 minutes you spent to get the CD of outside X-rays to show up on your computer, and rearranging the faxed pages so they’re all oriented the same way and in order, are not a good use of your time; a clerical person could do it.
I periodically have an experience that makes me think I spend too much time on patients’ social issues (e.g. long conversations about why Medicare won’t pay for a patient’s skilled nursing facility stay) and too little on “real doctoring.” One such experience is when I have a patient with an unusual pulmonary infiltrate and the radiologist is able to generate a much more comprehensive differential diagnosis than I can. This is embarrassing. Maybe the radiologist is just smarter than I am, but I think it could be because, compared to me, he spends more of his time every day thinking about “real medicine,” such as pulmonary diseases, and less time dealing with nonclinical issues.
Even though we’re paid for a full day’s work, I suspect many hospitalists might spend only about 90 minutes a day immersed in thought about “real medicine,” while doctors in most other specialties probably spend a lot more. If I’m right, then it shouldn’t be a surprise that after practicing for many years, the radiologist who spends several hours a day exercising his fund of medical knowledge probably has more command of some clinical things than a hospitalist who does so only 90 minutes a day. Actively practicing as a hospitalist might not be as effective a method of maintaining proficiency as it is in other specialties. More than many other specialties, we need to rely on self-study and continuing education courses to prevent erosion of our knowledge base.
I’ve just made up this 90-minute figure. I have no idea how accurate it might be, and, the JHM studies don’t offer a lot of insight either. Clearly, it varies a lot by individual doctor and practice setting. How much of your day do you think you spend on “real doctoring” vs. other activities?
What really matters is whether we’ve ended up with too much work that isn’t “real doctoring.” Sure, all of the work needs to be done, but the system isn’t served best when paying a doctor to do work a less expensive person could do.
Max “Doctoring” Time
I think most hospitalists, including me, are stuck spending too much time on activities that don’t add value. For example, while complete and informative documentation is essential, most of us probably spend too much time on it, in part because we’re trying to immunize against lawsuits and ensure our documentation matches the relevant coding regulations.
I think hospitalists have a communication burden that is higher than that of most other specialties. The JHM article by Tipping and colleagues notes that a time-motion study of ED doctors (Ann Emerg Med. 1998:31(1):87-91) found that they spent 13% of their time communicating with other providers and staff, compared with their finding that hospitalists spent 26% of their time communicating.2 Only a portion of this communication is real doctoring. Discussing patient management with a surgeon is, but spending 20 minutes figuring out which surgeon is on call and how to reach her isn’t.
Tipping’s study also found that when patient census was above average, hospitalists spent less time communicating and documenting in the electronic record, even though the total time spent working on those days increased. Of course, it is possible that when the patient census is below average, we just work more slowly and let work fill the time available, and the reduced time spent documenting and communicating when busy simply reflects working more efficiently. But I suspect that when our patient census climbs above a certain point, or we’re made less efficient by things like implementing a new technology, we compensate in part by relying on consultants more to do the real doctoring we would otherwise be doing and communicating with them less.
All of us should be thinking about ways to make communication as efficient as possible so that we can spend less time doing it. I’m hopeful that we will figure out new ways to communicate (e-mail, text, IM, etc.) that are quicker and just as effective in certain situations.
Coda
I try to write most of my columns in a way that minimizes the editorializing and maximizes the practical advice. This month is an exception; it’s all editorializing. But I do have some advice for Dr. Williams: Investigate music options other than the arena bands of the 1980s. Try something like Alison Krauss’ live album or Puccini’s opera Gianni Schicchi, which has the beautiful aria O mio babbino caro.
Or do what I do: Ask former SHM board member Brad Flansbaum, MD, SFHM, for advice. 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
References
- O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.
- Tipping MD, Forth VE, O’Leary KJ, et al. Where did the day go? A time-motion study of hospitalists. J Hosp Med. 2010;5(6):323-328.
BCBS of North Carolina’s refund to customers due to changes in health reform legislation
Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.
The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.
Lew Borman,
media relations,
Blue Cross Blue Shield of North Carolina
Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.
The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.
Lew Borman,
media relations,
Blue Cross Blue Shield of North Carolina
Bryn Nelson in the October issue of The Hospitalist (see “A Taxing Future for HM?,” p. 16) incorrectly states that Blue Cross Blue Shield of North Carolina’s refund to customers was a result of an overcharge. In point of fact, the refund is a result of a one-time opportunity due to the changes brought about by the health reform law. The new rating and grandfathering rules in the Patient Protection and Affordable Care Act create a one-time circumstance enabling these refunds.
The funds come from active life reserves, which are portions of the premium set aside in the early years of a policy to pay future claims and keep rates stable as customers’ medical expenses rise during the life of the policy. However, policies purchased or substantially modified after March 23, 2010, will end in 2014 under the new healthcare reform law, which is when the new products under health reform will be introduced. Therefore, the reserves held for these products will cover a much shorter period of time, allowing for these funds to be released.
Lew Borman,
media relations,
Blue Cross Blue Shield of North Carolina
Career Challenge
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.
Whether it’s directing a quality-improvement initiative on the hospital floor, training new recruits, or presenting metrics to hospital administrators, demonstrating leadership is a key competency for hospitalists. And, despite how it looks in the movies, most leaders are trained, not born.
That’s the foundation of SHM’s Leadership Academy program, a series of intense, four-day programs designed specifically to help hospitalists develop their leadership skills in a hands-on environment.
The demand for continued leadership training has been so high that SHM has developed a third leadership course for hospitalists who have completed either of the original tracks. CME credits are available for all three Leadership Academy course levels.
The new course, March 11-14 at the Aria Resort & Casino in Las Vegas, will follow the same four-day format as its predecessors. For updates and to register, visit the “Hospitalist Leadership Academies” page of the SHM website, www.hospitalmedicine.org/leadership.
“This is about building skills and growing momentum,” says Tina Budnitz, MPH, senior advisor for quality initiatives at SHM. “Participants walk away from Leadership Academy with newfound tools and the motivation to use them to lead important projects in their hospital.”
For Budnitz, the new academy course is a natural extension of the existing program. “Developing leadership skills is an ongoing process, so it makes sense to provide new material and new insights to hospitalists,” she says.
A Better Way to Communicate
The new course will bring in leadership experts and will help established leaders manage their hospitalist teams, says Leadership Committee chair Patience Agborbesong, MD, SFHM, who plans on attending the Las Vegas academy.
“It came into being because people were asking about other topics,” says Dr. Agborbesong, lead hospitalist at Wake Forest Inpatient Physicians in Winston-Salem, N.C. “We were getting the same questions from attendees asking for more. Hospitalists were saying, ‘Now what? I feel like I still need to develop these skills.’ ”
One of the key sessions in the new course focuses on advanced communications—a critical skill for hospitalists with long-term career aspirations. In the session, scientist-turned-filmmaker and author Randy Olson will offer his unique perspective on how clinicians and scientists can improve their communications with team members, hospital administrators, patients, and the public. After laying the groundwork for better communications, Olson will lead the hospitalists through a highly interactive set of exercises that culminate in participants presenting back to the group.
Published in 2009, Olson’s book Don’t Be Such a Scientist invites scientists to become better communicators and storytellers as a means to getting their points across and influencing audiences.
A full day of the course is devoted to leading and managing teams, including how to build a successful hospitalist program by selecting and investing in the right people. Another portion of the day teaches hospitalists skills they can use to build trust within their teams.
The final day focuses on an often-neglected element of leadership: self-investment. An executive coach will work with hospitalists to understand the importance of investing in their own careers, and help them develop tools to make self-investment easier.
The Originals
Years ago, as it became clear that hospitalists would be on the vanguard of changing healthcare in the hospital, it became equally clear that clinical and diagnostic skills alone would not be sufficient to tackle challenges that were as much about the people involved as they were about the technical requirements of healthcare.
The foundational SHM Leadership Academy course was developed to address the interpersonal dynamics of leadership in the hospital. Since its inception, the principles of hospitalist leadership apply equally to physicians and nonphysicians, including hospital administrators, physician assistants, and other hospital-based caregivers.
The allure for many hospitalists, including Dr. Agborbesong, is its particular relevance to the hospital setting.
“I had been to other leadership trainings, but this one was geared right to me. Everything was focused on the practice of HM and was oriented toward a leader at my level, when I was still new in my leadership position,” she says. “Other courses assumed that I was midway through my career or further.”
The real-world basis of the academy is apparent in the teaching model as well as its subject. Because many of the participants are already active and engaged leaders, the academy’s courses are structured to be interactive, hands-on learning experiences. Participants in the first Leadership Academy program walk away with, among other skill sets, the ability to:
- Evaluate personal leadership strengths and weaknesses and apply them to everyday leadership and management challenges;
- Predict and plan for the near-term challenges affecting the viability of their hospitalist programs;
- Improve patient outcomes through successful planning, allocation of resources, collaboration, teamwork, and execution;
- Understand key hospital drivers and examine how hospital performance metrics are derived, as well as how HM practices can influence and impact these metrics; and
- Implement methods of effective change through leadership, shared vision, and managing the organizational culture.
Participants in the second SHM Leadership Academy course build on those skills and learn to:
- Drive culture change through specific leadership behaviors and actions;
- Use financial reports to drive decision-making in clinical and operational practices;
- Recruit and retain the best physicians for their group;
- Build exceptional physician satisfaction; and
- Engage in effective, professional negotiation activities using proven techniques. TH
Brendon Shank is a freelance writer based in Philadelphia.
Fellow in Hospital Medicine Spotlight
Joseph Charles, MD, FACP, FHM
Dr. Charles, a 12-year SHM member, is an assistant professor of medicine and division education coordinator of the department of internal hospital medicine at Mayo Clinic Hospital in Phoenix.
Since 1998, he has served as a teaching attending for the clinic’s flourishing hospitalist program. He was selected as Educator of the Year in 2000, 2005, and 2006. In 2009, he was honored as Top Doctor in the Phoenix area.
Medical school: Aberdeen University, Aberdeen, Scotland
Internship and residency: The Royal Infirmary in Aberdeen
Chief residency: Maricopa Medical Center in Phoenix
Fellowship and general practice: In pediatrics, obstetrics, and gynecology at Dartford in Kent, England
Notable: He is writing a chapter on acid-based disorders for Medical Knowledge Self-Assessment Program for Students and recently presented “What Every Internist Should Know about Hospitalists” at a CME conference in Sedona, Ariz.
His most recent publications include “60-Year-Old Man with Rash” in the Mayo Clinic Proceedings in 2009, “Inpatient to Outpatient Transfer to Diabetes Care: Planning an Effective Hospital Discharge” in Endocrine Practice in 2009, and “More Patients Pick Acupuncture” in The Hospitalist in 2007.
FYI: What Dr. Charles enjoys most about hospital medicine is that “no two days are the same; there is always action.” Physical and creative activities out of the hospital keep him refreshed for his weeks on service. Once an avid runner, he has completed one marathon and three half-marathons. More recently, he enjoys photography and playing guitar.
—Sarah Gelotte
HM11 Right Around the Corner
Hospital Medicine 2011, or HM11, the premier event for healthcare professionals who specialize in hospital medicine, is just months away, and includes the specialty’s best opportunities for education, networking, and career advancement.
HM11 will present the future of HM in an authentic Lone Star State setting—the Gaylord Texan Hotel and Convention Center in Grapevine, Texas, May 10-13. The official kickoff to HM11 will be Wednesday morning; educational pre-courses will be offered Tuesday.
In addition to dozens of sessions from the best in the specialty on issues like clinical practice, practice management, new academic research, and quality initiatives, SHM again will present pre-courses specifically designed for in-depth education.
New pre-courses in 2011 include:
- Advanced Interactive Critical Care;
- Portable Ultrasound for the Hospitalist;
- Perioperative Medicine for the Hospitalist; and
- Succeeding in Challenging Times: Advances in Hospital Practice Management.
The continued growth of SHM’s annual conference also means new opportunities for exhibitors and sponsors to reach thousands of the most influential individuals in modern healthcare. Materials for both exhibitors and sponsors are available at the HM11 website.
Discounted early registration is available through April 3. For details and updates, visit www.hospitalmedicine2011.org.