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Cognitive screening of older physicians: What’s fair?
Cognitive screening of 141 clinicians 70 years or older at Yale New Haven (Conn.) Hospital identified 18 with cognitive deficits likely to impair their ability to practice medicine. Six retired and 12 agreed to limit their practice to closely proctored environments, according to a report in JAMA.
It was part of a program to screen all practitioners 70 years or older who apply for reappointment to the medical staff, and every 2 years thereafter, due to “concerns about the potentially compromised ability of older clinicians,” said the authors, Yale rheumatologist and geriatrician Leo M. Cooney Jr., MD, and Thomas Balcezak, MD, Yale New Haven’s chief medical officer.
Yale is not alone. Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, Penn Medicine, and the University of California, San Diego, are among the institutions with similar programs.
The move is being driven by the aging of the medical community. About 15% of U.S. physicians are over 65 years old, a tripling from 23,000 in 1980 to 73,000 in 2012-2016, and the number is growing, according to an editorial by Jeffrey L. Saver, MD, professor of neurology and senior associate vice president of neurology at the University of California, Los Angeles.
Given the trend, “it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade,” Katrina Armstrong, MD, chair of the department of medicine at Massachusetts General Hospital, Boston, and Eileen E. Reynolds, MD, associate professor of medicine at Beth Israel Deaconess Medical Center, Boston, noted in a second editorial.
“Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years,” they said.
The data on whether older clinicians pose a risk to patients is limited and somewhat mixed. An analysis of 736,537 Medicare hospitalizations found no association between physician age and 30-day patient mortality among physicians 60 years or older with more than 201 admissions per year, but higher mortality among older physicians with lower volumes.
A meta-analysis of 62 studies showed that “older physicians have less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.”
The new Yale data, meanwhile, suggests that “approximately 13% [18 of 141] of physicians and other clinicians older than 70 years should not be practicing independently,” Dr. Armstrong and Dr. Reynolds said in their editorial.
There is support for screening efforts. “As a profession that deals with human life, medical practitioners must obviously have the cognitive capacity to safely practice medicine. I applaud the approach taken by Yale New Haven Hospital in that cognitive abilities themselves, and not simply funds of knowledge, are assessed,” said Richard J. Caselli, MD, professor of neurology at the Mayo Clinic Arizona, Scottsdale, and a leader of the Alzheimer’s disease program there.
However, it’s not hard to imagine highly competent but older physicians taking umbrage at cognitive screening, and there’s been pushback. Stanford was considering a Yale-like approach but opted instead for peer review after opposition. Objections from the Utah Medical Association led Utah to enact a law banning age-based physician screening. In 2015, the American Medical Association issued a report calling for the development of guidelines and standards for assessing competency in aging physicians, but the AMA House of Delegates shelved it pending further study.
There are concerns about age discrimination, discounting the accumulated wisdom of long-practicing physicians, and misclassifying competent physicians, particularly those who provide quality care in rural and other underserved areas. Indeed, 8 of 14 clinicians who screened positive at Yale and underwent more extensive testing were allowed to recredential, “suggesting that the false-positive screening rate could be as high as 57%,” Dr. Armstrong and Dr. Reynolds noted.
The consensus seems to be that there probably is a need for some sort of screening, but it must be both sound and fair. Rather than a piecemeal institutional approach, perhaps there is “an important opportunity for other groups, including specialty boards and state licensing boards” to standardize the process, they said.
Among other things, assessments could focus less on test scores and more on the practice of medicine. For instance, fine motor skill/motor planning assessments for surgeons, and intermediate results could trigger a more extensive assessment of actual clinical performance, perhaps even direct observation, Dr. Saver said in his editorial.
As far as clinical performance goes, none of the 18 clinicians at Yale had previous performance problems. “Was this a failure of the system to report impaired physicians or were these physicians compensating sufficiently to avoid detection?” In either case, “cognitive testing should be a red flag that triggers other clinical assessments,” said Carl I. Cohen, MD, professor and director of the division of geriatric psychiatry at the State University of New York, Brooklyn.
The original plan at Yale was for neurologic and ophthalmologic examinations beginning at age 70, but ultimately it was decided to go with a battery of 16 tests to assess visual scanning and psychomotor efficiency, processing speed under pressure, concentration, and working memory, among other things. Testing takes about 50-90 minutes, and is graded by single neuropsychologist to ensure consistency. Results were compared with normative scores from both older and younger clinicians.
To prevent clinicians from preparing for it, Yale isn’t releasing its test battery.
Suboptimal performance triggered additional evaluations, including in-depth assessment of intellectual, memory, and executive function. Final reviews and recommendations were made by a committee that included a geriatrician, the clinician’s section or department chair, and current and past chief medical officers.
Among the 18 providers who demonstrated deficits impairing their ability to practice medicine, 5 were 70-74 years old; 4 were 75-79; and 9 were 80 years or older. Minor abnormalities were found in 34 other candidates (24.1%); they were allowed to recredential but were scheduled for rescreening at 1-year intervals, instead of every 2 years.
The mean age among the 141 screened clinicians was 74.3 years and ranged from 69 to 92 years; 86% were men. Applicants included 125 physicians (88.7%) as well as 5 advanced practice registered nurses; 4 dentists; 3 psychologists; 2 podiatrists; 1 physician associate; and 1 midwife.
The authors had no relevant disclosures.
SOURCE: Cooney L et al. JAMA. 2020 Jan 14;323(2):179-80.
Cognitive screening of 141 clinicians 70 years or older at Yale New Haven (Conn.) Hospital identified 18 with cognitive deficits likely to impair their ability to practice medicine. Six retired and 12 agreed to limit their practice to closely proctored environments, according to a report in JAMA.
It was part of a program to screen all practitioners 70 years or older who apply for reappointment to the medical staff, and every 2 years thereafter, due to “concerns about the potentially compromised ability of older clinicians,” said the authors, Yale rheumatologist and geriatrician Leo M. Cooney Jr., MD, and Thomas Balcezak, MD, Yale New Haven’s chief medical officer.
Yale is not alone. Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, Penn Medicine, and the University of California, San Diego, are among the institutions with similar programs.
The move is being driven by the aging of the medical community. About 15% of U.S. physicians are over 65 years old, a tripling from 23,000 in 1980 to 73,000 in 2012-2016, and the number is growing, according to an editorial by Jeffrey L. Saver, MD, professor of neurology and senior associate vice president of neurology at the University of California, Los Angeles.
Given the trend, “it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade,” Katrina Armstrong, MD, chair of the department of medicine at Massachusetts General Hospital, Boston, and Eileen E. Reynolds, MD, associate professor of medicine at Beth Israel Deaconess Medical Center, Boston, noted in a second editorial.
“Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years,” they said.
The data on whether older clinicians pose a risk to patients is limited and somewhat mixed. An analysis of 736,537 Medicare hospitalizations found no association between physician age and 30-day patient mortality among physicians 60 years or older with more than 201 admissions per year, but higher mortality among older physicians with lower volumes.
A meta-analysis of 62 studies showed that “older physicians have less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.”
The new Yale data, meanwhile, suggests that “approximately 13% [18 of 141] of physicians and other clinicians older than 70 years should not be practicing independently,” Dr. Armstrong and Dr. Reynolds said in their editorial.
There is support for screening efforts. “As a profession that deals with human life, medical practitioners must obviously have the cognitive capacity to safely practice medicine. I applaud the approach taken by Yale New Haven Hospital in that cognitive abilities themselves, and not simply funds of knowledge, are assessed,” said Richard J. Caselli, MD, professor of neurology at the Mayo Clinic Arizona, Scottsdale, and a leader of the Alzheimer’s disease program there.
However, it’s not hard to imagine highly competent but older physicians taking umbrage at cognitive screening, and there’s been pushback. Stanford was considering a Yale-like approach but opted instead for peer review after opposition. Objections from the Utah Medical Association led Utah to enact a law banning age-based physician screening. In 2015, the American Medical Association issued a report calling for the development of guidelines and standards for assessing competency in aging physicians, but the AMA House of Delegates shelved it pending further study.
There are concerns about age discrimination, discounting the accumulated wisdom of long-practicing physicians, and misclassifying competent physicians, particularly those who provide quality care in rural and other underserved areas. Indeed, 8 of 14 clinicians who screened positive at Yale and underwent more extensive testing were allowed to recredential, “suggesting that the false-positive screening rate could be as high as 57%,” Dr. Armstrong and Dr. Reynolds noted.
The consensus seems to be that there probably is a need for some sort of screening, but it must be both sound and fair. Rather than a piecemeal institutional approach, perhaps there is “an important opportunity for other groups, including specialty boards and state licensing boards” to standardize the process, they said.
Among other things, assessments could focus less on test scores and more on the practice of medicine. For instance, fine motor skill/motor planning assessments for surgeons, and intermediate results could trigger a more extensive assessment of actual clinical performance, perhaps even direct observation, Dr. Saver said in his editorial.
As far as clinical performance goes, none of the 18 clinicians at Yale had previous performance problems. “Was this a failure of the system to report impaired physicians or were these physicians compensating sufficiently to avoid detection?” In either case, “cognitive testing should be a red flag that triggers other clinical assessments,” said Carl I. Cohen, MD, professor and director of the division of geriatric psychiatry at the State University of New York, Brooklyn.
The original plan at Yale was for neurologic and ophthalmologic examinations beginning at age 70, but ultimately it was decided to go with a battery of 16 tests to assess visual scanning and psychomotor efficiency, processing speed under pressure, concentration, and working memory, among other things. Testing takes about 50-90 minutes, and is graded by single neuropsychologist to ensure consistency. Results were compared with normative scores from both older and younger clinicians.
To prevent clinicians from preparing for it, Yale isn’t releasing its test battery.
Suboptimal performance triggered additional evaluations, including in-depth assessment of intellectual, memory, and executive function. Final reviews and recommendations were made by a committee that included a geriatrician, the clinician’s section or department chair, and current and past chief medical officers.
Among the 18 providers who demonstrated deficits impairing their ability to practice medicine, 5 were 70-74 years old; 4 were 75-79; and 9 were 80 years or older. Minor abnormalities were found in 34 other candidates (24.1%); they were allowed to recredential but were scheduled for rescreening at 1-year intervals, instead of every 2 years.
The mean age among the 141 screened clinicians was 74.3 years and ranged from 69 to 92 years; 86% were men. Applicants included 125 physicians (88.7%) as well as 5 advanced practice registered nurses; 4 dentists; 3 psychologists; 2 podiatrists; 1 physician associate; and 1 midwife.
The authors had no relevant disclosures.
SOURCE: Cooney L et al. JAMA. 2020 Jan 14;323(2):179-80.
Cognitive screening of 141 clinicians 70 years or older at Yale New Haven (Conn.) Hospital identified 18 with cognitive deficits likely to impair their ability to practice medicine. Six retired and 12 agreed to limit their practice to closely proctored environments, according to a report in JAMA.
It was part of a program to screen all practitioners 70 years or older who apply for reappointment to the medical staff, and every 2 years thereafter, due to “concerns about the potentially compromised ability of older clinicians,” said the authors, Yale rheumatologist and geriatrician Leo M. Cooney Jr., MD, and Thomas Balcezak, MD, Yale New Haven’s chief medical officer.
Yale is not alone. Intermountain Healthcare, Stanford Hospitals and Clinics, Scripps Health Care, Penn Medicine, and the University of California, San Diego, are among the institutions with similar programs.
The move is being driven by the aging of the medical community. About 15% of U.S. physicians are over 65 years old, a tripling from 23,000 in 1980 to 73,000 in 2012-2016, and the number is growing, according to an editorial by Jeffrey L. Saver, MD, professor of neurology and senior associate vice president of neurology at the University of California, Los Angeles.
Given the trend, “it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade,” Katrina Armstrong, MD, chair of the department of medicine at Massachusetts General Hospital, Boston, and Eileen E. Reynolds, MD, associate professor of medicine at Beth Israel Deaconess Medical Center, Boston, noted in a second editorial.
“Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years,” they said.
The data on whether older clinicians pose a risk to patients is limited and somewhat mixed. An analysis of 736,537 Medicare hospitalizations found no association between physician age and 30-day patient mortality among physicians 60 years or older with more than 201 admissions per year, but higher mortality among older physicians with lower volumes.
A meta-analysis of 62 studies showed that “older physicians have less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes.”
The new Yale data, meanwhile, suggests that “approximately 13% [18 of 141] of physicians and other clinicians older than 70 years should not be practicing independently,” Dr. Armstrong and Dr. Reynolds said in their editorial.
There is support for screening efforts. “As a profession that deals with human life, medical practitioners must obviously have the cognitive capacity to safely practice medicine. I applaud the approach taken by Yale New Haven Hospital in that cognitive abilities themselves, and not simply funds of knowledge, are assessed,” said Richard J. Caselli, MD, professor of neurology at the Mayo Clinic Arizona, Scottsdale, and a leader of the Alzheimer’s disease program there.
However, it’s not hard to imagine highly competent but older physicians taking umbrage at cognitive screening, and there’s been pushback. Stanford was considering a Yale-like approach but opted instead for peer review after opposition. Objections from the Utah Medical Association led Utah to enact a law banning age-based physician screening. In 2015, the American Medical Association issued a report calling for the development of guidelines and standards for assessing competency in aging physicians, but the AMA House of Delegates shelved it pending further study.
There are concerns about age discrimination, discounting the accumulated wisdom of long-practicing physicians, and misclassifying competent physicians, particularly those who provide quality care in rural and other underserved areas. Indeed, 8 of 14 clinicians who screened positive at Yale and underwent more extensive testing were allowed to recredential, “suggesting that the false-positive screening rate could be as high as 57%,” Dr. Armstrong and Dr. Reynolds noted.
The consensus seems to be that there probably is a need for some sort of screening, but it must be both sound and fair. Rather than a piecemeal institutional approach, perhaps there is “an important opportunity for other groups, including specialty boards and state licensing boards” to standardize the process, they said.
Among other things, assessments could focus less on test scores and more on the practice of medicine. For instance, fine motor skill/motor planning assessments for surgeons, and intermediate results could trigger a more extensive assessment of actual clinical performance, perhaps even direct observation, Dr. Saver said in his editorial.
As far as clinical performance goes, none of the 18 clinicians at Yale had previous performance problems. “Was this a failure of the system to report impaired physicians or were these physicians compensating sufficiently to avoid detection?” In either case, “cognitive testing should be a red flag that triggers other clinical assessments,” said Carl I. Cohen, MD, professor and director of the division of geriatric psychiatry at the State University of New York, Brooklyn.
The original plan at Yale was for neurologic and ophthalmologic examinations beginning at age 70, but ultimately it was decided to go with a battery of 16 tests to assess visual scanning and psychomotor efficiency, processing speed under pressure, concentration, and working memory, among other things. Testing takes about 50-90 minutes, and is graded by single neuropsychologist to ensure consistency. Results were compared with normative scores from both older and younger clinicians.
To prevent clinicians from preparing for it, Yale isn’t releasing its test battery.
Suboptimal performance triggered additional evaluations, including in-depth assessment of intellectual, memory, and executive function. Final reviews and recommendations were made by a committee that included a geriatrician, the clinician’s section or department chair, and current and past chief medical officers.
Among the 18 providers who demonstrated deficits impairing their ability to practice medicine, 5 were 70-74 years old; 4 were 75-79; and 9 were 80 years or older. Minor abnormalities were found in 34 other candidates (24.1%); they were allowed to recredential but were scheduled for rescreening at 1-year intervals, instead of every 2 years.
The mean age among the 141 screened clinicians was 74.3 years and ranged from 69 to 92 years; 86% were men. Applicants included 125 physicians (88.7%) as well as 5 advanced practice registered nurses; 4 dentists; 3 psychologists; 2 podiatrists; 1 physician associate; and 1 midwife.
The authors had no relevant disclosures.
SOURCE: Cooney L et al. JAMA. 2020 Jan 14;323(2):179-80.
FROM JAMA
Administrative burden and burnout
In May 2019, SHM sent a letter to U.S. Senators Tina Smith and Bill Cassidy in support of the Reducing Administrative Costs and Burdens in Health Care Act of 2019. In excerpts from the letter below, the society details the link between administrative burdens and physician burnout.
Providers and hospital systems expend countless resources, both time and dollars, adhering to unnecessary and excessive administrative burdens instead of investing those resources in providing quality patient care. National data suggests that more than 50 percent of the physician workforce is burned out. Excessive administrative burden is a major contributor to physician burnout, which negatively affects quality and safety within the hospital and further increases health care costs. Notably, the Reducing Administrative Costs and Burdens in Health Care Act calls for a 50% reduction of unnecessary administrative costs from the Department of Health and Human Services within the next ten years.
Hospitalists are front-line clinicians in America's acute care hospitals whose professional focus is the general medical care of hospitalized patients. Their unique position in the healthcare system affords hospitalists a distinct perspective and systems-based approach to confronting and solving challenges at the individual provider and overall institutional level of the hospital. In this capacity, hospitalists experience multiple examples of administrative requirements directly detracting from patient care and redirecting finite resources away from care to meet compliance demands.
By way of example, navigating the administrative rules around inpatient admissions and outpatient observation care, for example, requires a significant shift of healthcare resources away from patient care. While patients admitted under observation receive nearly identical care to those admitted as an inpatient, hospitalists report that, in addition to themselves as the direct healthcare provider, status determinations between inpatient admissions and outpatient observation care require the input of a myriad of staff including nursing, coding/compliance teams, utilization review, case managers and external review organizations. A recent study in the Journal of Hospital Medicine indicated that an average of 5.1 full time employees, not including case managers, are required to navigate the audit and appeals process associated with hospital stay status determinations. These are resources that should be directly used for patient care, but are redirected towards regulation compliance, increasing cost of care without increasing quality.
To read the entire letter, visit https://www.hospitalmedicine.org/policy--advocacy/letters/shm-supports-the-reducing-administrative-costs-and-burdens-in-health-care-act-of-2019/.
In May 2019, SHM sent a letter to U.S. Senators Tina Smith and Bill Cassidy in support of the Reducing Administrative Costs and Burdens in Health Care Act of 2019. In excerpts from the letter below, the society details the link between administrative burdens and physician burnout.
Providers and hospital systems expend countless resources, both time and dollars, adhering to unnecessary and excessive administrative burdens instead of investing those resources in providing quality patient care. National data suggests that more than 50 percent of the physician workforce is burned out. Excessive administrative burden is a major contributor to physician burnout, which negatively affects quality and safety within the hospital and further increases health care costs. Notably, the Reducing Administrative Costs and Burdens in Health Care Act calls for a 50% reduction of unnecessary administrative costs from the Department of Health and Human Services within the next ten years.
Hospitalists are front-line clinicians in America's acute care hospitals whose professional focus is the general medical care of hospitalized patients. Their unique position in the healthcare system affords hospitalists a distinct perspective and systems-based approach to confronting and solving challenges at the individual provider and overall institutional level of the hospital. In this capacity, hospitalists experience multiple examples of administrative requirements directly detracting from patient care and redirecting finite resources away from care to meet compliance demands.
By way of example, navigating the administrative rules around inpatient admissions and outpatient observation care, for example, requires a significant shift of healthcare resources away from patient care. While patients admitted under observation receive nearly identical care to those admitted as an inpatient, hospitalists report that, in addition to themselves as the direct healthcare provider, status determinations between inpatient admissions and outpatient observation care require the input of a myriad of staff including nursing, coding/compliance teams, utilization review, case managers and external review organizations. A recent study in the Journal of Hospital Medicine indicated that an average of 5.1 full time employees, not including case managers, are required to navigate the audit and appeals process associated with hospital stay status determinations. These are resources that should be directly used for patient care, but are redirected towards regulation compliance, increasing cost of care without increasing quality.
To read the entire letter, visit https://www.hospitalmedicine.org/policy--advocacy/letters/shm-supports-the-reducing-administrative-costs-and-burdens-in-health-care-act-of-2019/.
In May 2019, SHM sent a letter to U.S. Senators Tina Smith and Bill Cassidy in support of the Reducing Administrative Costs and Burdens in Health Care Act of 2019. In excerpts from the letter below, the society details the link between administrative burdens and physician burnout.
Providers and hospital systems expend countless resources, both time and dollars, adhering to unnecessary and excessive administrative burdens instead of investing those resources in providing quality patient care. National data suggests that more than 50 percent of the physician workforce is burned out. Excessive administrative burden is a major contributor to physician burnout, which negatively affects quality and safety within the hospital and further increases health care costs. Notably, the Reducing Administrative Costs and Burdens in Health Care Act calls for a 50% reduction of unnecessary administrative costs from the Department of Health and Human Services within the next ten years.
Hospitalists are front-line clinicians in America's acute care hospitals whose professional focus is the general medical care of hospitalized patients. Their unique position in the healthcare system affords hospitalists a distinct perspective and systems-based approach to confronting and solving challenges at the individual provider and overall institutional level of the hospital. In this capacity, hospitalists experience multiple examples of administrative requirements directly detracting from patient care and redirecting finite resources away from care to meet compliance demands.
By way of example, navigating the administrative rules around inpatient admissions and outpatient observation care, for example, requires a significant shift of healthcare resources away from patient care. While patients admitted under observation receive nearly identical care to those admitted as an inpatient, hospitalists report that, in addition to themselves as the direct healthcare provider, status determinations between inpatient admissions and outpatient observation care require the input of a myriad of staff including nursing, coding/compliance teams, utilization review, case managers and external review organizations. A recent study in the Journal of Hospital Medicine indicated that an average of 5.1 full time employees, not including case managers, are required to navigate the audit and appeals process associated with hospital stay status determinations. These are resources that should be directly used for patient care, but are redirected towards regulation compliance, increasing cost of care without increasing quality.
To read the entire letter, visit https://www.hospitalmedicine.org/policy--advocacy/letters/shm-supports-the-reducing-administrative-costs-and-burdens-in-health-care-act-of-2019/.
Community pediatric care is diminishing
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
The mantra of community hospital administrators is that pediatric care does not pay. Neonatal intensive care pays. For pediatrics, it is similar to how football programs (Medicare patients) support minor sports (pediatrics and obstetrics) at colleges. However, fewer even mildly sick newborns are cared for at community hospitals, which has led to a centralization of neonatal and pediatric care and a loss of pediatric expertise at the affected hospitals.
Pediatric hospitalists are hired to cover the pediatric floor, the emergency department, and labor and delivery, then fired over empty pediatric beds. The rationale expressed is that pediatricians have done such a good job in preventive care that children rarely need hospitalization, so why have a pediatric inpatient unit? It is true that preventive care has been an integral part of primary care for children. Significantly less that 1% of child office visits result in hospitalization.
Advocate Health Care has closed inpatient pediatric units at Illinois Masonic, on Chicago’s North Side, Good Samaritan in Downers Grove, and Good Shepherd in Barrington. Units also have been closed at Mount Sinai in North Lawndale, Norwegian American on Chicago’s West Side, Little Company of Mary in Evergreen Park, and Alexian Brothers in Elk Grove.
As a Chicago-area pediatrician for more than 30 years, I have learned several things about community-based pediatric care:
1. Pediatrics is a geographic specialty. Parents will travel to shop, but would rather walk or have a short ride to their children’s medical providers. Secondary care should be community based, and hospitalization, if necessary, should be close by as well.
2. Hospitals that ceased delivering pediatric inpatient care lost their child-friendliness and pediatric competence, becoming uncomfortable delivering almost any care for children (e.g., sedated MRIs and EEGs, x-rays and ultrasounds, ECGs and echocardiograms, and emergency care).
3. In almost all hospitals, after pediatrics was gone eventually so passed obstetrics (another less remunerative specialty). Sick newborns need immediate, competent care. Most pediatric hospitalizations are short term, often overnight. Delaying newborn care is a medicolegal nightmare. and exposes the child and his or her family to a potentially dangerous drive or helicopter ride.
4. As pediatric subspecialty care becomes more centralized, parents are asked to travel for hours to see a pediatric specialist. There are times when that is necessary (e.g., cardiovascular surgery). Pediatric subspecialists, such as pediatric otolaryngologists, then leave community hospitals, forcing even minor surgeries (e.g., ear ventilation tubes) to be done at a center. In rural areas, this could mean hours of travel, lost work days, and family disruption.
5. Children’s hospitals get uninsured and publicly insured children sent hundreds of miles, because there were no subspecialists in the community who would care for these children.
What is the solution, in our profit-focused health care system?
1. Hospitals’ Certificates of Need could include a mandate for pediatric care.
2. Children’s hospitals could be made responsible for community-based care within their geographic catchment areas.
3. The state or the federal government could mandate and financially support community-based hospital care.
4. Deciding what level of care might be appropriate for each community could depend upon closeness to a pediatric hospital, health problems in the community, and the availability of pediatric specialists.
5. A condition for medical licensure might be that a community-based pediatric subspecialist is required to care for a proportion of the uninsured or publicly insured children in his or her area.
6. Reimbursements for pediatric care need to rise enough to make caring for children worth it.
The major decision point regarding care for children cannot be financial, but must instead embrace the needs of each affected community. If quality health care is a right, and not a privilege, then it is time to stop closing pediatric inpatient units, and, instead, look for creative ways to better care for our children.
This process has led to pediatric care being available only in designated centers. The centralization of pediatric care has progressed from 30 years ago, when most community hospitals had inpatient pediatric units, to the search for innovative ways to fill pediatric beds in the mid-90s (sick day care, flex- or shared pediatric units), to the wholesale closure of community pediatric inpatient beds, from 2000 to the present. I have, unfortunately, seen this firsthand, watching the rise of pediatric mega-hospitals and the demise of community pediatrics. It is a simple financial argument. Care for children simply does not pay nearly as well as does care for adults, especially Medicaid patients. Pediatricians are the poorest paid practicing doctors (public health doctors are paid less).
It is true that pediatricians always have been at the forefront of preventive medicine, and that pediatric patients almost always get better, in spite of our best-intentioned interventions. So community-based pediatricians admit very few patients.
With the loss of pediatric units, community hospitals lose their comfort caring for children. This includes phlebotomy, x-ray, trauma, surgery, and behavioral health. And eroding community hospital pediatric expertise has catastrophic implications for rural hospitals, where parents may have to drive for hours to find a child-friendly emergency department.
Is there an answer?
1. Hospitals are responsible for the patients they serve, including children. Why should a hospital be able to close pediatric services so easily?
2. Every hospital that sees children, through the emergency department, needs to have a pediatrician available to evaluate a child, 24/7.
3. There needs to be an observation unit for children, with pediatric staffing, for overnight stays.
4. Pediatric hospitalists should be staffing community hospitals.
5. Pediatric behavioral health resources need to be available, e.g., inpatient psychiatry, partial hospitalization programs, intensive outpatient programs.
6. Telehealth communication is not adequate to address acute care problems, because the hospital caring for the child has to have the proper equipment and adequate expertise to carry out the recommendations of the teleconsultant.
If we accept that our children will shape the future, we must allow them to survive and thrive. Is health care a right or a privilege, and is it just for adults or for children, too?
Dr. Ochs is in private practice at Ravenswood Pediatrics in Chicago. He said he had no relevant financial disclosures. Email him at [email protected].
For everything there is a season
2020 SoHM Survey ready to launch
Wow, the last 2 years have just flown by! I can’t believe it’s already time to launch the Society of Hospital Medicine State of Hospital Medicine survey again! Right now is the season for you to roll up your sleeves and get to work helping SHM develop the nation’s definitive resource on the current state of hospital medicine practice.
I’m really excited about this year’s survey. SHM’s Practice Analysis Committee has redesigned it to eliminate some out-of-date or little-used questions and to add a few new, more relevant questions. Even more exciting, we have a new survey platform that should massively improve your experience of submitting data for the survey and also make the back-end data tabulation and analysis much quicker and more accurate. Multisite groups will now have two options for submitting data – a redesigned, more user-friendly Excel tool, or a new pathway to submit data in the reporting platform by replicating responses.
In addition, our new survey platform should help us produce the final report a little more quickly and improve its usability.
New-for-2020 survey topics will include:
- Expanded information on nurse practitioner/physician assistant roles
- Diversity in hospital medicine physician leadership
- Specific questions for hospital medicine groups (HMGs) serving children that will better capture unique attributes of these hospital medicine practices
Why participate?
I can’t emphasize enough that each and every survey submission matters a lot. The State of Hospital Medicine report claims to be the authoritative resource for information about the specialty of hospital medicine. But the report can’t fulfill this claim if the underlying data is skimpy because people were too busy, couldn’t be bothered to participate, or if participation is not broadly representative of the amazing diversity of hospital medicine practices out there.
Your participation will help ensure that you are contributing to a robust hospital medicine database, and that your own group’s information is represented in the survey results. By doing so you will be helping to ensure hospital medicine’s place as perhaps the crucial specialty for U.S. health care in the coming decade.
In addition, participants will receive free access to the survey results, so there’s a direct benefit to you and your HMG as well.
How can you participate?
Here’s what you need to know:
1. The survey opens on Jan.6, 2020, and closes on Feb. 14, 2020.
2. You can find general information about the survey at this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/, and register to participate by using this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/sohm-survey/.
3. To participate, you’ll want to collect the following general types of information for your hospital medicine group:
- Basic group descriptive information (for example, types of patients seen, number of hospitals covered, teaching status, etc.)
- Scope of clinical services
- Nurse practitioners and physician assistants in the HMG
- Full-time equivalent (FTE) information
- Information about the physician leader(s)
- Staffing/scheduling arrangements, including backup plans, paid time off, unfilled positions, predominant scheduling pattern, night coverage arrangements, dedicated admitters, unit-based assignments, etc.
- Compensation model (but not specific amounts)
- Value of employee benefits and CME
- Total work relative value units generated by the HMG, and number of times the following CPT codes were billed: 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239
- Information about financial support provided to the HMG
- Specific questions for academic HMGs, including financial support for nonclinical work, and allocation of FTEs
- Specific questions for HMGs serving children, including the hospital settings served, proportion of part-time staff, FTE definition, and information about board certification in pediatric hospital medicine
I’m hoping that all of you will join me in working to make the 2020 State of Hospital Medicine survey and report the best one yet!
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s biannual State of Hospital Medicine survey.
2020 SoHM Survey ready to launch
2020 SoHM Survey ready to launch
Wow, the last 2 years have just flown by! I can’t believe it’s already time to launch the Society of Hospital Medicine State of Hospital Medicine survey again! Right now is the season for you to roll up your sleeves and get to work helping SHM develop the nation’s definitive resource on the current state of hospital medicine practice.
I’m really excited about this year’s survey. SHM’s Practice Analysis Committee has redesigned it to eliminate some out-of-date or little-used questions and to add a few new, more relevant questions. Even more exciting, we have a new survey platform that should massively improve your experience of submitting data for the survey and also make the back-end data tabulation and analysis much quicker and more accurate. Multisite groups will now have two options for submitting data – a redesigned, more user-friendly Excel tool, or a new pathway to submit data in the reporting platform by replicating responses.
In addition, our new survey platform should help us produce the final report a little more quickly and improve its usability.
New-for-2020 survey topics will include:
- Expanded information on nurse practitioner/physician assistant roles
- Diversity in hospital medicine physician leadership
- Specific questions for hospital medicine groups (HMGs) serving children that will better capture unique attributes of these hospital medicine practices
Why participate?
I can’t emphasize enough that each and every survey submission matters a lot. The State of Hospital Medicine report claims to be the authoritative resource for information about the specialty of hospital medicine. But the report can’t fulfill this claim if the underlying data is skimpy because people were too busy, couldn’t be bothered to participate, or if participation is not broadly representative of the amazing diversity of hospital medicine practices out there.
Your participation will help ensure that you are contributing to a robust hospital medicine database, and that your own group’s information is represented in the survey results. By doing so you will be helping to ensure hospital medicine’s place as perhaps the crucial specialty for U.S. health care in the coming decade.
In addition, participants will receive free access to the survey results, so there’s a direct benefit to you and your HMG as well.
How can you participate?
Here’s what you need to know:
1. The survey opens on Jan.6, 2020, and closes on Feb. 14, 2020.
2. You can find general information about the survey at this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/, and register to participate by using this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/sohm-survey/.
3. To participate, you’ll want to collect the following general types of information for your hospital medicine group:
- Basic group descriptive information (for example, types of patients seen, number of hospitals covered, teaching status, etc.)
- Scope of clinical services
- Nurse practitioners and physician assistants in the HMG
- Full-time equivalent (FTE) information
- Information about the physician leader(s)
- Staffing/scheduling arrangements, including backup plans, paid time off, unfilled positions, predominant scheduling pattern, night coverage arrangements, dedicated admitters, unit-based assignments, etc.
- Compensation model (but not specific amounts)
- Value of employee benefits and CME
- Total work relative value units generated by the HMG, and number of times the following CPT codes were billed: 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239
- Information about financial support provided to the HMG
- Specific questions for academic HMGs, including financial support for nonclinical work, and allocation of FTEs
- Specific questions for HMGs serving children, including the hospital settings served, proportion of part-time staff, FTE definition, and information about board certification in pediatric hospital medicine
I’m hoping that all of you will join me in working to make the 2020 State of Hospital Medicine survey and report the best one yet!
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s biannual State of Hospital Medicine survey.
Wow, the last 2 years have just flown by! I can’t believe it’s already time to launch the Society of Hospital Medicine State of Hospital Medicine survey again! Right now is the season for you to roll up your sleeves and get to work helping SHM develop the nation’s definitive resource on the current state of hospital medicine practice.
I’m really excited about this year’s survey. SHM’s Practice Analysis Committee has redesigned it to eliminate some out-of-date or little-used questions and to add a few new, more relevant questions. Even more exciting, we have a new survey platform that should massively improve your experience of submitting data for the survey and also make the back-end data tabulation and analysis much quicker and more accurate. Multisite groups will now have two options for submitting data – a redesigned, more user-friendly Excel tool, or a new pathway to submit data in the reporting platform by replicating responses.
In addition, our new survey platform should help us produce the final report a little more quickly and improve its usability.
New-for-2020 survey topics will include:
- Expanded information on nurse practitioner/physician assistant roles
- Diversity in hospital medicine physician leadership
- Specific questions for hospital medicine groups (HMGs) serving children that will better capture unique attributes of these hospital medicine practices
Why participate?
I can’t emphasize enough that each and every survey submission matters a lot. The State of Hospital Medicine report claims to be the authoritative resource for information about the specialty of hospital medicine. But the report can’t fulfill this claim if the underlying data is skimpy because people were too busy, couldn’t be bothered to participate, or if participation is not broadly representative of the amazing diversity of hospital medicine practices out there.
Your participation will help ensure that you are contributing to a robust hospital medicine database, and that your own group’s information is represented in the survey results. By doing so you will be helping to ensure hospital medicine’s place as perhaps the crucial specialty for U.S. health care in the coming decade.
In addition, participants will receive free access to the survey results, so there’s a direct benefit to you and your HMG as well.
How can you participate?
Here’s what you need to know:
1. The survey opens on Jan.6, 2020, and closes on Feb. 14, 2020.
2. You can find general information about the survey at this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/, and register to participate by using this link: https://www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/sohm-survey/.
3. To participate, you’ll want to collect the following general types of information for your hospital medicine group:
- Basic group descriptive information (for example, types of patients seen, number of hospitals covered, teaching status, etc.)
- Scope of clinical services
- Nurse practitioners and physician assistants in the HMG
- Full-time equivalent (FTE) information
- Information about the physician leader(s)
- Staffing/scheduling arrangements, including backup plans, paid time off, unfilled positions, predominant scheduling pattern, night coverage arrangements, dedicated admitters, unit-based assignments, etc.
- Compensation model (but not specific amounts)
- Value of employee benefits and CME
- Total work relative value units generated by the HMG, and number of times the following CPT codes were billed: 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239
- Information about financial support provided to the HMG
- Specific questions for academic HMGs, including financial support for nonclinical work, and allocation of FTEs
- Specific questions for HMGs serving children, including the hospital settings served, proportion of part-time staff, FTE definition, and information about board certification in pediatric hospital medicine
I’m hoping that all of you will join me in working to make the 2020 State of Hospital Medicine survey and report the best one yet!
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Meeting Committees, and helps to coordinate SHM’s biannual State of Hospital Medicine survey.
State of Hospital Medicine Survey plays key role in operational decision making
Results help establish hospitalist benchmarks
The Hospitalist recently spoke with Brian Schroeder, MHA, FACHE, FHM, assistant vice president, Hospital & Emergency Medicine, at Atrium Health Medical Group in Charlotte, N.C., to discuss his participation in the State of Hospital Medicine Survey, which is distributed every other year, and how he uses the resulting report to guide important operational decisions.
Please describe your current role.
At Carolinas Hospitalist Group, we have approximately 250 providers at nearly 20 care locations across North Carolina. Along with my specialty medical director, I am responsible for the strategic growth, program development, and financial performance for our practice.
How did you first become involved with the Society of Hospital Medicine?
When I first entered the hospital medicine world in 2008, I was looking for an organization that supported our specialty. My physician leaders at the time pointed me to SHM. Since the beginning of my time as a member, I have attended the Annual Conference each year, the SHM Leadership Academy, served on an SHM committee, and participate in SHM’s multisite Leaders group. Additionally, I have served as faculty at SHM’s annual conference for 3 years – and will be presenting for the third time at HM20.
Why is it important that people participate in the State of Hospital Medicine Survey?
Participation in the survey is key for establishing benchmarks for our specialty. The more people participate (from various arenas like private groups, health system employees, and vendors), the more accurate the data. Over the past 4 years, SHM has improved the submission process of survey data – especially for practices with multiple locations.
How has the data in the report impacted important business decisions for your group?
We rely heavily on the investment/provider benchmark within the survey data. Over the years, as the investment/provider was decreasing nationally, our own investment/provider was increasing. Based on the survey, we were able to closely evaluate our staffing models at each location and determine the appropriate skill mix-to-volume ratio. Through turnover and growth, we have strategically hired advanced practice providers to align our investment more closely with the benchmark. Over the past 2 years, our investment/provider metric has decreased significantly. We were able to accomplish this while continuing to provide appropriate care to our patients. We also utilize the Report to monitor performance incentive metrics, staffing model trends, and encounter/provider ratios.
What would you tell people who are on the fence about participating in the survey – and ultimately, purchasing the finished product?
Do it! Our practice would never skip a submission year. The data produced from the survey helps us improve our clinical operations and maximize our financial affordability. The data also assists in defending staffing decisions and clinical operations change with senior leadership within the organization.
Don’t miss your chance to submit data that will build the latest snapshot of the hospital medicine specialty. The State of Hospital Medicine Survey is open now and runs through February 16, 2020. Learn more and register to participate at hospitalmedicine.org/survey.
Results help establish hospitalist benchmarks
Results help establish hospitalist benchmarks
The Hospitalist recently spoke with Brian Schroeder, MHA, FACHE, FHM, assistant vice president, Hospital & Emergency Medicine, at Atrium Health Medical Group in Charlotte, N.C., to discuss his participation in the State of Hospital Medicine Survey, which is distributed every other year, and how he uses the resulting report to guide important operational decisions.
Please describe your current role.
At Carolinas Hospitalist Group, we have approximately 250 providers at nearly 20 care locations across North Carolina. Along with my specialty medical director, I am responsible for the strategic growth, program development, and financial performance for our practice.
How did you first become involved with the Society of Hospital Medicine?
When I first entered the hospital medicine world in 2008, I was looking for an organization that supported our specialty. My physician leaders at the time pointed me to SHM. Since the beginning of my time as a member, I have attended the Annual Conference each year, the SHM Leadership Academy, served on an SHM committee, and participate in SHM’s multisite Leaders group. Additionally, I have served as faculty at SHM’s annual conference for 3 years – and will be presenting for the third time at HM20.
Why is it important that people participate in the State of Hospital Medicine Survey?
Participation in the survey is key for establishing benchmarks for our specialty. The more people participate (from various arenas like private groups, health system employees, and vendors), the more accurate the data. Over the past 4 years, SHM has improved the submission process of survey data – especially for practices with multiple locations.
How has the data in the report impacted important business decisions for your group?
We rely heavily on the investment/provider benchmark within the survey data. Over the years, as the investment/provider was decreasing nationally, our own investment/provider was increasing. Based on the survey, we were able to closely evaluate our staffing models at each location and determine the appropriate skill mix-to-volume ratio. Through turnover and growth, we have strategically hired advanced practice providers to align our investment more closely with the benchmark. Over the past 2 years, our investment/provider metric has decreased significantly. We were able to accomplish this while continuing to provide appropriate care to our patients. We also utilize the Report to monitor performance incentive metrics, staffing model trends, and encounter/provider ratios.
What would you tell people who are on the fence about participating in the survey – and ultimately, purchasing the finished product?
Do it! Our practice would never skip a submission year. The data produced from the survey helps us improve our clinical operations and maximize our financial affordability. The data also assists in defending staffing decisions and clinical operations change with senior leadership within the organization.
Don’t miss your chance to submit data that will build the latest snapshot of the hospital medicine specialty. The State of Hospital Medicine Survey is open now and runs through February 16, 2020. Learn more and register to participate at hospitalmedicine.org/survey.
The Hospitalist recently spoke with Brian Schroeder, MHA, FACHE, FHM, assistant vice president, Hospital & Emergency Medicine, at Atrium Health Medical Group in Charlotte, N.C., to discuss his participation in the State of Hospital Medicine Survey, which is distributed every other year, and how he uses the resulting report to guide important operational decisions.
Please describe your current role.
At Carolinas Hospitalist Group, we have approximately 250 providers at nearly 20 care locations across North Carolina. Along with my specialty medical director, I am responsible for the strategic growth, program development, and financial performance for our practice.
How did you first become involved with the Society of Hospital Medicine?
When I first entered the hospital medicine world in 2008, I was looking for an organization that supported our specialty. My physician leaders at the time pointed me to SHM. Since the beginning of my time as a member, I have attended the Annual Conference each year, the SHM Leadership Academy, served on an SHM committee, and participate in SHM’s multisite Leaders group. Additionally, I have served as faculty at SHM’s annual conference for 3 years – and will be presenting for the third time at HM20.
Why is it important that people participate in the State of Hospital Medicine Survey?
Participation in the survey is key for establishing benchmarks for our specialty. The more people participate (from various arenas like private groups, health system employees, and vendors), the more accurate the data. Over the past 4 years, SHM has improved the submission process of survey data – especially for practices with multiple locations.
How has the data in the report impacted important business decisions for your group?
We rely heavily on the investment/provider benchmark within the survey data. Over the years, as the investment/provider was decreasing nationally, our own investment/provider was increasing. Based on the survey, we were able to closely evaluate our staffing models at each location and determine the appropriate skill mix-to-volume ratio. Through turnover and growth, we have strategically hired advanced practice providers to align our investment more closely with the benchmark. Over the past 2 years, our investment/provider metric has decreased significantly. We were able to accomplish this while continuing to provide appropriate care to our patients. We also utilize the Report to monitor performance incentive metrics, staffing model trends, and encounter/provider ratios.
What would you tell people who are on the fence about participating in the survey – and ultimately, purchasing the finished product?
Do it! Our practice would never skip a submission year. The data produced from the survey helps us improve our clinical operations and maximize our financial affordability. The data also assists in defending staffing decisions and clinical operations change with senior leadership within the organization.
Don’t miss your chance to submit data that will build the latest snapshot of the hospital medicine specialty. The State of Hospital Medicine Survey is open now and runs through February 16, 2020. Learn more and register to participate at hospitalmedicine.org/survey.
Hospitalists deal with patient discrimination
Encounters with bias are underreported
In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.
The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.
“I was wondering what was going to happen and who would provide care to this patient?” she said.
Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.
The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.
To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
Responding to discrimination
A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.
Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.
“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”
Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.
“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”
Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”
“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.
“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.
Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.
One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.
Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.
“This takes time, and in a busy setting, that might not happen,” she acknowledged.
Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.
An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.
Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”
“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
Taking action
Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.
When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.
Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.
“The feedback we received was massive and detailed,” Dr. Polimera said.
Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.
“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”
As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.
Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.
Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.
“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
Adapting to change
While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.
Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.
Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.
“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”
Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.
“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”
Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.
“I think it is important to set limits,” Dr. Bhagat said. “It’s like with your kids. Your children may behave in certain ways, at certain times, that you don’t like. You can tell them, ‘You know, you may not like behaving the way I want you to behave, but the way you’re behaving now is not acceptable.’ If our goal is to try to completely change their world-view at that moment, I think we’re going to be set up for failure. That’s more of a long-term issue for society to address.”
Encounters with bias are underreported
Encounters with bias are underreported
In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.
The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.
“I was wondering what was going to happen and who would provide care to this patient?” she said.
Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.
The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.
To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
Responding to discrimination
A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.
Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.
“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”
Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.
“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”
Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”
“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.
“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.
Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.
One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.
Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.
“This takes time, and in a busy setting, that might not happen,” she acknowledged.
Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.
An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.
Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”
“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
Taking action
Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.
When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.
Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.
“The feedback we received was massive and detailed,” Dr. Polimera said.
Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.
“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”
As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.
Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.
Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.
“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
Adapting to change
While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.
Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.
Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.
“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”
Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.
“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”
Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.
“I think it is important to set limits,” Dr. Bhagat said. “It’s like with your kids. Your children may behave in certain ways, at certain times, that you don’t like. You can tell them, ‘You know, you may not like behaving the way I want you to behave, but the way you’re behaving now is not acceptable.’ If our goal is to try to completely change their world-view at that moment, I think we’re going to be set up for failure. That’s more of a long-term issue for society to address.”
In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.
The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.
“I was wondering what was going to happen and who would provide care to this patient?” she said.
Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.
The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.
To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
Responding to discrimination
A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.
Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.
“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”
Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.
“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”
Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”
“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.
“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.
Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.
One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.
Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.
“This takes time, and in a busy setting, that might not happen,” she acknowledged.
Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.
An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.
Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”
“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
Taking action
Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.
When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.
Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.
“The feedback we received was massive and detailed,” Dr. Polimera said.
Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.
“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”
As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.
Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.
Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.
“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
Adapting to change
While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.
Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.
Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.
“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”
Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.
“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”
Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.
“I think it is important to set limits,” Dr. Bhagat said. “It’s like with your kids. Your children may behave in certain ways, at certain times, that you don’t like. You can tell them, ‘You know, you may not like behaving the way I want you to behave, but the way you’re behaving now is not acceptable.’ If our goal is to try to completely change their world-view at that moment, I think we’re going to be set up for failure. That’s more of a long-term issue for society to address.”
Aligning scheduling and satisfaction
Research reveals counterintuitive results
Hospitalist work schedules have been the subject of much reporting – and recent research. Studies have shown that control over work hours and schedule flexibility are predictors of clinicians’ career satisfaction and burnout, factors linked to quality of patient care and retention.
Starting in January 2017, an academic hospital medicine group at the University of Colorado at Denver, Aurora, undertook a scheduling redesign using improvement methodology, combined with purchased scheduling software. Tyler Anstett, DO, a hospitalist and assistant professor at the university, and colleagues presented the results in an abstract published during the SHM 2019 annual conference last March.
“We wrote this abstract as a report of the work that we did over several years in our hospital medicine group to improve hospitalist satisfaction with their schedules,” said Dr. Anstett. “We identified that, despite not following the traditional seven-on, seven-off model and 100% fulfillment of individual schedule requests, the majority of clinicians were dissatisfied with the scheduling process and their overall clinical schedules. Further, building these complex, individualized schedules resulted in a heavy administrative burden. We strove to provide better alignment of schedule satisfaction and the administrative burden of incorporating individualized schedule requests.”
Prior to January 2017, service stretches had ranged from 5 to 9 days, and there were few limits on time-off requests.
“Through sequential interventions, we standardized service stretches to 7 days (Tuesday-Monday), introduced a limited number of guaranteed 7-day time-off requests (Tuesday-Monday), and added a limited number of nonguaranteed 3-day flexible time-off requests,” according to the authors. “This simplification improved the automation of the scheduling software, which increased the schedule release lead time to an average of 16 weeks. Further, despite standardizing service stretches to 7 days and limiting time-off requests, physicians surveyed reported improved satisfaction with both their scheduling process (34% of participants ‘satisfied’ in 2017 to 67% in 2018) and their overall clinical schedules (50% of participants ‘satisfied’ in 2017 to 75% in 2018).”So counterintuitively, creating individualized schedules may not result in improved satisfaction and likely results in heavy administrative burden, Dr. Anstett said. “Standardization of schedule creation with allowance of a ‘free-market’ system, allowing clinicians to self-individualize their schedules may also result in less administrative burden and improved satisfaction.”
Reference
1. Anstett T et al. K.I.S.S. (Keep It Simple … Schedules): How Standardization and Simplification Can Improve Scheduling and Physician Satisfaction. SHM 2019, Abstract 112. Accessed June 4, 2019.
Research reveals counterintuitive results
Research reveals counterintuitive results
Hospitalist work schedules have been the subject of much reporting – and recent research. Studies have shown that control over work hours and schedule flexibility are predictors of clinicians’ career satisfaction and burnout, factors linked to quality of patient care and retention.
Starting in January 2017, an academic hospital medicine group at the University of Colorado at Denver, Aurora, undertook a scheduling redesign using improvement methodology, combined with purchased scheduling software. Tyler Anstett, DO, a hospitalist and assistant professor at the university, and colleagues presented the results in an abstract published during the SHM 2019 annual conference last March.
“We wrote this abstract as a report of the work that we did over several years in our hospital medicine group to improve hospitalist satisfaction with their schedules,” said Dr. Anstett. “We identified that, despite not following the traditional seven-on, seven-off model and 100% fulfillment of individual schedule requests, the majority of clinicians were dissatisfied with the scheduling process and their overall clinical schedules. Further, building these complex, individualized schedules resulted in a heavy administrative burden. We strove to provide better alignment of schedule satisfaction and the administrative burden of incorporating individualized schedule requests.”
Prior to January 2017, service stretches had ranged from 5 to 9 days, and there were few limits on time-off requests.
“Through sequential interventions, we standardized service stretches to 7 days (Tuesday-Monday), introduced a limited number of guaranteed 7-day time-off requests (Tuesday-Monday), and added a limited number of nonguaranteed 3-day flexible time-off requests,” according to the authors. “This simplification improved the automation of the scheduling software, which increased the schedule release lead time to an average of 16 weeks. Further, despite standardizing service stretches to 7 days and limiting time-off requests, physicians surveyed reported improved satisfaction with both their scheduling process (34% of participants ‘satisfied’ in 2017 to 67% in 2018) and their overall clinical schedules (50% of participants ‘satisfied’ in 2017 to 75% in 2018).”So counterintuitively, creating individualized schedules may not result in improved satisfaction and likely results in heavy administrative burden, Dr. Anstett said. “Standardization of schedule creation with allowance of a ‘free-market’ system, allowing clinicians to self-individualize their schedules may also result in less administrative burden and improved satisfaction.”
Reference
1. Anstett T et al. K.I.S.S. (Keep It Simple … Schedules): How Standardization and Simplification Can Improve Scheduling and Physician Satisfaction. SHM 2019, Abstract 112. Accessed June 4, 2019.
Hospitalist work schedules have been the subject of much reporting – and recent research. Studies have shown that control over work hours and schedule flexibility are predictors of clinicians’ career satisfaction and burnout, factors linked to quality of patient care and retention.
Starting in January 2017, an academic hospital medicine group at the University of Colorado at Denver, Aurora, undertook a scheduling redesign using improvement methodology, combined with purchased scheduling software. Tyler Anstett, DO, a hospitalist and assistant professor at the university, and colleagues presented the results in an abstract published during the SHM 2019 annual conference last March.
“We wrote this abstract as a report of the work that we did over several years in our hospital medicine group to improve hospitalist satisfaction with their schedules,” said Dr. Anstett. “We identified that, despite not following the traditional seven-on, seven-off model and 100% fulfillment of individual schedule requests, the majority of clinicians were dissatisfied with the scheduling process and their overall clinical schedules. Further, building these complex, individualized schedules resulted in a heavy administrative burden. We strove to provide better alignment of schedule satisfaction and the administrative burden of incorporating individualized schedule requests.”
Prior to January 2017, service stretches had ranged from 5 to 9 days, and there were few limits on time-off requests.
“Through sequential interventions, we standardized service stretches to 7 days (Tuesday-Monday), introduced a limited number of guaranteed 7-day time-off requests (Tuesday-Monday), and added a limited number of nonguaranteed 3-day flexible time-off requests,” according to the authors. “This simplification improved the automation of the scheduling software, which increased the schedule release lead time to an average of 16 weeks. Further, despite standardizing service stretches to 7 days and limiting time-off requests, physicians surveyed reported improved satisfaction with both their scheduling process (34% of participants ‘satisfied’ in 2017 to 67% in 2018) and their overall clinical schedules (50% of participants ‘satisfied’ in 2017 to 75% in 2018).”So counterintuitively, creating individualized schedules may not result in improved satisfaction and likely results in heavy administrative burden, Dr. Anstett said. “Standardization of schedule creation with allowance of a ‘free-market’ system, allowing clinicians to self-individualize their schedules may also result in less administrative burden and improved satisfaction.”
Reference
1. Anstett T et al. K.I.S.S. (Keep It Simple … Schedules): How Standardization and Simplification Can Improve Scheduling and Physician Satisfaction. SHM 2019, Abstract 112. Accessed June 4, 2019.
Envisioning the future of hospital medicine
I have written frequently over the last few years on topics related to the sustainability of the hospital medicine practice model. I continue to be concerned by what I see as a confluence of significant trends that are conspiring to challenge hospital medicine’s status quo.
On one hand, the financial pressures on U.S. hospitals are unrelenting, and their willingness or even ability to continue providing significant funding to support their hospital medicine groups is in question. Combine this with hospitalists’ rapidly evolving clinical scope and the ever-increasing demands of physicians in other specialties for hospitalist support, and the result is hospital medicine groups that will continue to grow in size, complexity, and the demand for ever more financial support.
On the other hand, the hospitalists I interact with in my work all over the country seem more stressed out than ever, and many are questioning whether this is a job that can be satisfying and sustainable for a career. Increasing patient complexity, productivity pressures, a lack of resources to address patients’ social issues, a systole-diastole schedule, the frustration of EHRs and other documentation responsibilities, and feeling “dumped on” by physicians in other specialties all contribute to hospitalist job stress.
A quick look at the literature confirms that in 2019 hospitalist burnout is definitely “a thing.” Interestingly, it’s been a thing for a while; the risk of hospitalist burnout was first identified by Hoff, et al., in 2002 (doi: 10.2307/30902462002). My colleague, John Nelson, MD, MHM, has written a number of times about strategies for preventing or mitigating hospitalist burnout.
As these trends converge, the hospital medicine practice model as we know it may be facing an existential crisis. If that sounds overly dramatic, let me say instead that the hospital medicine practice model will need to evolve significantly over the next decade in order to continue to meet patient and institutional needs while remaining both affordable and sustainable for the clinicians who work in it.
In September 2019, SHM’s Multi-Site Leaders Special Interest Group met in Chicago for their second annual Multi-Site Leaders Summit to explore the theme of sustainability in hospital medicine. The participants held robust discussions about coping with our changing practice environment, issues relating to hospitalist burnout and resiliency, innovative staffing models, the role of technology in HM sustainability, and financial sustainability
At the end of the meeting, the group engaged in a visioning exercise designed to move beyond what we are doing today by envisioning what the future of hospital medicine will look like and what interventions will be necessary for us to get from here to there. I’d like to share this visioning exercise with you and encourage you to “play along” by thinking seriously about the questions it poses.
Visioning exercise
Feel free to jot down some thoughts as we go through this exercise. But otherwise, just close your eyes and come along for the ride. Imagine yourself sitting at your desk looking at a desk calendar showing today’s date. Watch the pages flip from today, to tomorrow, to the next day, then to next month, and the next, and then to the next year and so on, until we arrive at December 2029.
Imagine that you look up from your desk, and suddenly realize that you aren’t in your office at all, but instead in a huge auditorium where someone is speaking about an award that is going to be announced. It’s crowded and a little stuffy in the auditorium, but people around you are whispering to each other with an air of eager anticipation, their eyes glued to the stage. You realize that the person being introduced up on the podium is the President of the United States, and the award is the Presidential Medal of Freedom, which is only awarded to people or groups who have made “an especially meritorious contribution to the security or national interests of the United States, world peace, cultural, or other significant public or private endeavors.”
Today, the Medal is being awarded to the Society of Hospital Medicine on behalf of all hospital medicine leaders nationally, for their collective accomplishments in saving the specialty of hospital medicine and, by doing so, ensuring that sick people are able to continue receiving the care they need in our nation’s hospitals – and that the hospitals themselves have become reliably safe, efficient, and effective in achieving high quality outcomes.
The President says, “At no time in the history of this award until now have we given this, the highest civilian award in the land, to a whole group of physician leaders across an entire specialty. But the achievements of this group of people in preserving and even enhancing the presence of highly energized, dedicated, capable clinicians in our nation’s hospitals against the significant odds they have faced over the last 10 years is nothing short of extraordinary.” There is a standing ovation, as people jump up out of their chairs to cheer and applaud. When the applause finally dies down, the President goes on to list all the accomplishments that made this group of leaders deserving. Listen to what she is saying. Fill it in in your own mind. What is it that this group has accomplished?
[Brief silence]
Up on a huge screen beside the stage, a video starts. In it, there are several hospital and physician executives in a focus group, and one exec says, “The thing that is great about what these leaders have accomplished in the field of hospital medicine is…” Fill it in – what did that executive say? Another leader jumps in: “That’s all fine and wonderful, but the thing that really makes hospital medicine stand out today compared to where they were 10 years ago is…” Listen to what these executives are saying. What accomplishments are they praising?
The video then moves on to show a focus group of recent hospital patients. One patient says, “10 years ago when my mom was in the hospital, the poor hospitalists caring for her seemed completely overwhelmed and burnt out, and the whole care system seemed fragmented and inefficient; but my own recent hospital experience was so different because…” Additional patients chime in, talking about how confident they felt about the care they received in the hospital and the reasons for that. What is it these patients are describing?
SHM’s CEO gets up to accept the award and explains that 10 years ago, a group of multi-site hospital medicine leaders from across the country came together to begin addressing the issue of sustainability; this led to a formal process for developing a vision and a plan for the future of hospital medicine, and the execution of that plan eventually resulted in the outcomes recognized by this award. She acknowledges that over the years many people questioned whether the hospital medicine model should even continue to exist or whether some other model for inpatient care should be adopted. She talks about all the compelling reasons that supported the continued existence of the specialty of hospital medicine. What are some of the reasons she listed? The SHM CEO goes on to describe some of the key things that were done to address the issues associated with sustainability of the hospital medicine practice model. Listen to what she says; what was it that SHM and the hospital leaders it represents did?
As you are leaving the auditorium, you overhear a group of mid-career staff hospitalists talking. They are saying that they didn’t originally believe the specialty would actually change, and they weren’t sure if they could do this job for a career – but that it did change. They begin talking about what it feels like to work as a hospitalist now, and how these changes have improved their lives. Listen to what they are saying. How does it feel to work as a hospitalist?
As you leave the auditorium and go back to your desk, you sit down to record some of the things you heard. What was it the President of the US said as she presented the Presidential Medal of Freedom? Why did SHM and the hospital medicine leaders it represents deserve the award? What was it that the SHM CEO said was done to bring about the successful changes? What did the staff hospitalists say about working in the specialty?
Whenever you are ready, take a minute to jot down the specifics that came to mind as you read through this exercise. If you are willing to share your thoughts about sustainability in hospital medicine, I’d love to hear from you. Feel free to email me directly at [email protected].
Let’s build the foundation for a sustainable future for our specialty.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis Committee, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM’s official blog The Hospital Leader.
I have written frequently over the last few years on topics related to the sustainability of the hospital medicine practice model. I continue to be concerned by what I see as a confluence of significant trends that are conspiring to challenge hospital medicine’s status quo.
On one hand, the financial pressures on U.S. hospitals are unrelenting, and their willingness or even ability to continue providing significant funding to support their hospital medicine groups is in question. Combine this with hospitalists’ rapidly evolving clinical scope and the ever-increasing demands of physicians in other specialties for hospitalist support, and the result is hospital medicine groups that will continue to grow in size, complexity, and the demand for ever more financial support.
On the other hand, the hospitalists I interact with in my work all over the country seem more stressed out than ever, and many are questioning whether this is a job that can be satisfying and sustainable for a career. Increasing patient complexity, productivity pressures, a lack of resources to address patients’ social issues, a systole-diastole schedule, the frustration of EHRs and other documentation responsibilities, and feeling “dumped on” by physicians in other specialties all contribute to hospitalist job stress.
A quick look at the literature confirms that in 2019 hospitalist burnout is definitely “a thing.” Interestingly, it’s been a thing for a while; the risk of hospitalist burnout was first identified by Hoff, et al., in 2002 (doi: 10.2307/30902462002). My colleague, John Nelson, MD, MHM, has written a number of times about strategies for preventing or mitigating hospitalist burnout.
As these trends converge, the hospital medicine practice model as we know it may be facing an existential crisis. If that sounds overly dramatic, let me say instead that the hospital medicine practice model will need to evolve significantly over the next decade in order to continue to meet patient and institutional needs while remaining both affordable and sustainable for the clinicians who work in it.
In September 2019, SHM’s Multi-Site Leaders Special Interest Group met in Chicago for their second annual Multi-Site Leaders Summit to explore the theme of sustainability in hospital medicine. The participants held robust discussions about coping with our changing practice environment, issues relating to hospitalist burnout and resiliency, innovative staffing models, the role of technology in HM sustainability, and financial sustainability
At the end of the meeting, the group engaged in a visioning exercise designed to move beyond what we are doing today by envisioning what the future of hospital medicine will look like and what interventions will be necessary for us to get from here to there. I’d like to share this visioning exercise with you and encourage you to “play along” by thinking seriously about the questions it poses.
Visioning exercise
Feel free to jot down some thoughts as we go through this exercise. But otherwise, just close your eyes and come along for the ride. Imagine yourself sitting at your desk looking at a desk calendar showing today’s date. Watch the pages flip from today, to tomorrow, to the next day, then to next month, and the next, and then to the next year and so on, until we arrive at December 2029.
Imagine that you look up from your desk, and suddenly realize that you aren’t in your office at all, but instead in a huge auditorium where someone is speaking about an award that is going to be announced. It’s crowded and a little stuffy in the auditorium, but people around you are whispering to each other with an air of eager anticipation, their eyes glued to the stage. You realize that the person being introduced up on the podium is the President of the United States, and the award is the Presidential Medal of Freedom, which is only awarded to people or groups who have made “an especially meritorious contribution to the security or national interests of the United States, world peace, cultural, or other significant public or private endeavors.”
Today, the Medal is being awarded to the Society of Hospital Medicine on behalf of all hospital medicine leaders nationally, for their collective accomplishments in saving the specialty of hospital medicine and, by doing so, ensuring that sick people are able to continue receiving the care they need in our nation’s hospitals – and that the hospitals themselves have become reliably safe, efficient, and effective in achieving high quality outcomes.
The President says, “At no time in the history of this award until now have we given this, the highest civilian award in the land, to a whole group of physician leaders across an entire specialty. But the achievements of this group of people in preserving and even enhancing the presence of highly energized, dedicated, capable clinicians in our nation’s hospitals against the significant odds they have faced over the last 10 years is nothing short of extraordinary.” There is a standing ovation, as people jump up out of their chairs to cheer and applaud. When the applause finally dies down, the President goes on to list all the accomplishments that made this group of leaders deserving. Listen to what she is saying. Fill it in in your own mind. What is it that this group has accomplished?
[Brief silence]
Up on a huge screen beside the stage, a video starts. In it, there are several hospital and physician executives in a focus group, and one exec says, “The thing that is great about what these leaders have accomplished in the field of hospital medicine is…” Fill it in – what did that executive say? Another leader jumps in: “That’s all fine and wonderful, but the thing that really makes hospital medicine stand out today compared to where they were 10 years ago is…” Listen to what these executives are saying. What accomplishments are they praising?
The video then moves on to show a focus group of recent hospital patients. One patient says, “10 years ago when my mom was in the hospital, the poor hospitalists caring for her seemed completely overwhelmed and burnt out, and the whole care system seemed fragmented and inefficient; but my own recent hospital experience was so different because…” Additional patients chime in, talking about how confident they felt about the care they received in the hospital and the reasons for that. What is it these patients are describing?
SHM’s CEO gets up to accept the award and explains that 10 years ago, a group of multi-site hospital medicine leaders from across the country came together to begin addressing the issue of sustainability; this led to a formal process for developing a vision and a plan for the future of hospital medicine, and the execution of that plan eventually resulted in the outcomes recognized by this award. She acknowledges that over the years many people questioned whether the hospital medicine model should even continue to exist or whether some other model for inpatient care should be adopted. She talks about all the compelling reasons that supported the continued existence of the specialty of hospital medicine. What are some of the reasons she listed? The SHM CEO goes on to describe some of the key things that were done to address the issues associated with sustainability of the hospital medicine practice model. Listen to what she says; what was it that SHM and the hospital leaders it represents did?
As you are leaving the auditorium, you overhear a group of mid-career staff hospitalists talking. They are saying that they didn’t originally believe the specialty would actually change, and they weren’t sure if they could do this job for a career – but that it did change. They begin talking about what it feels like to work as a hospitalist now, and how these changes have improved their lives. Listen to what they are saying. How does it feel to work as a hospitalist?
As you leave the auditorium and go back to your desk, you sit down to record some of the things you heard. What was it the President of the US said as she presented the Presidential Medal of Freedom? Why did SHM and the hospital medicine leaders it represents deserve the award? What was it that the SHM CEO said was done to bring about the successful changes? What did the staff hospitalists say about working in the specialty?
Whenever you are ready, take a minute to jot down the specifics that came to mind as you read through this exercise. If you are willing to share your thoughts about sustainability in hospital medicine, I’d love to hear from you. Feel free to email me directly at [email protected].
Let’s build the foundation for a sustainable future for our specialty.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis Committee, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM’s official blog The Hospital Leader.
I have written frequently over the last few years on topics related to the sustainability of the hospital medicine practice model. I continue to be concerned by what I see as a confluence of significant trends that are conspiring to challenge hospital medicine’s status quo.
On one hand, the financial pressures on U.S. hospitals are unrelenting, and their willingness or even ability to continue providing significant funding to support their hospital medicine groups is in question. Combine this with hospitalists’ rapidly evolving clinical scope and the ever-increasing demands of physicians in other specialties for hospitalist support, and the result is hospital medicine groups that will continue to grow in size, complexity, and the demand for ever more financial support.
On the other hand, the hospitalists I interact with in my work all over the country seem more stressed out than ever, and many are questioning whether this is a job that can be satisfying and sustainable for a career. Increasing patient complexity, productivity pressures, a lack of resources to address patients’ social issues, a systole-diastole schedule, the frustration of EHRs and other documentation responsibilities, and feeling “dumped on” by physicians in other specialties all contribute to hospitalist job stress.
A quick look at the literature confirms that in 2019 hospitalist burnout is definitely “a thing.” Interestingly, it’s been a thing for a while; the risk of hospitalist burnout was first identified by Hoff, et al., in 2002 (doi: 10.2307/30902462002). My colleague, John Nelson, MD, MHM, has written a number of times about strategies for preventing or mitigating hospitalist burnout.
As these trends converge, the hospital medicine practice model as we know it may be facing an existential crisis. If that sounds overly dramatic, let me say instead that the hospital medicine practice model will need to evolve significantly over the next decade in order to continue to meet patient and institutional needs while remaining both affordable and sustainable for the clinicians who work in it.
In September 2019, SHM’s Multi-Site Leaders Special Interest Group met in Chicago for their second annual Multi-Site Leaders Summit to explore the theme of sustainability in hospital medicine. The participants held robust discussions about coping with our changing practice environment, issues relating to hospitalist burnout and resiliency, innovative staffing models, the role of technology in HM sustainability, and financial sustainability
At the end of the meeting, the group engaged in a visioning exercise designed to move beyond what we are doing today by envisioning what the future of hospital medicine will look like and what interventions will be necessary for us to get from here to there. I’d like to share this visioning exercise with you and encourage you to “play along” by thinking seriously about the questions it poses.
Visioning exercise
Feel free to jot down some thoughts as we go through this exercise. But otherwise, just close your eyes and come along for the ride. Imagine yourself sitting at your desk looking at a desk calendar showing today’s date. Watch the pages flip from today, to tomorrow, to the next day, then to next month, and the next, and then to the next year and so on, until we arrive at December 2029.
Imagine that you look up from your desk, and suddenly realize that you aren’t in your office at all, but instead in a huge auditorium where someone is speaking about an award that is going to be announced. It’s crowded and a little stuffy in the auditorium, but people around you are whispering to each other with an air of eager anticipation, their eyes glued to the stage. You realize that the person being introduced up on the podium is the President of the United States, and the award is the Presidential Medal of Freedom, which is only awarded to people or groups who have made “an especially meritorious contribution to the security or national interests of the United States, world peace, cultural, or other significant public or private endeavors.”
Today, the Medal is being awarded to the Society of Hospital Medicine on behalf of all hospital medicine leaders nationally, for their collective accomplishments in saving the specialty of hospital medicine and, by doing so, ensuring that sick people are able to continue receiving the care they need in our nation’s hospitals – and that the hospitals themselves have become reliably safe, efficient, and effective in achieving high quality outcomes.
The President says, “At no time in the history of this award until now have we given this, the highest civilian award in the land, to a whole group of physician leaders across an entire specialty. But the achievements of this group of people in preserving and even enhancing the presence of highly energized, dedicated, capable clinicians in our nation’s hospitals against the significant odds they have faced over the last 10 years is nothing short of extraordinary.” There is a standing ovation, as people jump up out of their chairs to cheer and applaud. When the applause finally dies down, the President goes on to list all the accomplishments that made this group of leaders deserving. Listen to what she is saying. Fill it in in your own mind. What is it that this group has accomplished?
[Brief silence]
Up on a huge screen beside the stage, a video starts. In it, there are several hospital and physician executives in a focus group, and one exec says, “The thing that is great about what these leaders have accomplished in the field of hospital medicine is…” Fill it in – what did that executive say? Another leader jumps in: “That’s all fine and wonderful, but the thing that really makes hospital medicine stand out today compared to where they were 10 years ago is…” Listen to what these executives are saying. What accomplishments are they praising?
The video then moves on to show a focus group of recent hospital patients. One patient says, “10 years ago when my mom was in the hospital, the poor hospitalists caring for her seemed completely overwhelmed and burnt out, and the whole care system seemed fragmented and inefficient; but my own recent hospital experience was so different because…” Additional patients chime in, talking about how confident they felt about the care they received in the hospital and the reasons for that. What is it these patients are describing?
SHM’s CEO gets up to accept the award and explains that 10 years ago, a group of multi-site hospital medicine leaders from across the country came together to begin addressing the issue of sustainability; this led to a formal process for developing a vision and a plan for the future of hospital medicine, and the execution of that plan eventually resulted in the outcomes recognized by this award. She acknowledges that over the years many people questioned whether the hospital medicine model should even continue to exist or whether some other model for inpatient care should be adopted. She talks about all the compelling reasons that supported the continued existence of the specialty of hospital medicine. What are some of the reasons she listed? The SHM CEO goes on to describe some of the key things that were done to address the issues associated with sustainability of the hospital medicine practice model. Listen to what she says; what was it that SHM and the hospital leaders it represents did?
As you are leaving the auditorium, you overhear a group of mid-career staff hospitalists talking. They are saying that they didn’t originally believe the specialty would actually change, and they weren’t sure if they could do this job for a career – but that it did change. They begin talking about what it feels like to work as a hospitalist now, and how these changes have improved their lives. Listen to what they are saying. How does it feel to work as a hospitalist?
As you leave the auditorium and go back to your desk, you sit down to record some of the things you heard. What was it the President of the US said as she presented the Presidential Medal of Freedom? Why did SHM and the hospital medicine leaders it represents deserve the award? What was it that the SHM CEO said was done to bring about the successful changes? What did the staff hospitalists say about working in the specialty?
Whenever you are ready, take a minute to jot down the specifics that came to mind as you read through this exercise. If you are willing to share your thoughts about sustainability in hospital medicine, I’d love to hear from you. Feel free to email me directly at [email protected].
Let’s build the foundation for a sustainable future for our specialty.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis Committee, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM’s official blog The Hospital Leader.
Unit-based rounding in the real world
Balance and flexibility are essential
Many hospitalists agree that their most productive and also sometimes least productive work can happen in the setting of interdisciplinary rounds. How can this paradox be true?
Most hospitals strive to assemble the health care team every day for a brief discussion of each patient’s needs as well as barriers to a safe/successful discharge. On most floors this requires a well-choreographed “dance” of nurses, case managers, social workers, physicians, and advanced practice providers coming together at agreed-upon times. All team members commit to efficient synchronized swimming through the most high-yield details for each patient in order to benefit the patients and families being served.
Of course, there are always challenges to this process in the unpredictable world of patients with acute needs. One variable that is at least partially controllable and tends to promote a more cohesive interdisciplinary experience is that of hospitalist unit-based rounding.
The 2018 State of Hospital Medicine (SoHM) survey reveals that 68% of hospital medicine groups serving adults with greater than 30 physicians employ some degree of unit-based rounding; this trend decreases with smaller group size. About 54% of academic hospital medicine groups use some amount of unit-based rounding. Not surprisingly, smaller hospitals are less likely to have this routine, likely because of fewer total nursing units.
One of the most obvious benefits to unit-based rounding is that the physician or advanced practice provider is more reliably able to participate in the interdisciplinary discussions that day. When more of the team members are at the table each day, patients and families have the best chance of hearing a consistent message around the treatment and discharge plans.
There are challenges to unit-based rounding as well. If patients transfer to different floors for any variety of reasons, strict unit-based rounding may increase handoffs in care. If a hospital has times when it isn’t completely full and nursing units have a varying percentage of being occupied, strict unit-based rounding can cause significant workload inequities among physicians on different units, depending on numbers of patients on each unit.
If there is no attempt at unit-based rounding in larger hospitals, some physicians may be running among five or more units. They work to find different care managers, nurses, and pharmacists – not to mention the challenges of catching patients in their rooms between their departures for diagnostic studies and procedures.
It is often good to balance the benefit of promoting unit-based rounds with the reality of everyday patient care. Some groups maintain that the physician/patient relationship trumps the idea of perfect unit-based rounding. In other words, if a physician establishes a relationship with a patient while they are in the ED being admitted or boarding from overnight, that physician will continue seeing the patient regardless of the patient being assigned to a different unit. It can help for groups to agree that the pursuit of unit-based rounding may create some inequity in the numbers of patients seen each day because of these issues.
In a larger hospital, certain units are often dedicated to specialty care such as cardiac or stroke care. While most hospitalists want to maintain general medical knowledge, there are some who may enjoy having portions of their practice devoted to perioperative medicine or cardiac care, for instance. This promotes familiarity among hospitalists and groups of consultant physicians and nurse practitioners/physician assistants. Over time this allows for enhanced teamwork among those physicians, the nursing team, and the specialty physicians.
Depending on the group’s schedule, patients can be reassigned coinciding with the primary change of service day. This resets the physicians’ patients in the most ideal unit-based way on the evening prior to the first day of rounding for that week or group of shifts.
No matter how you do it, the goal of unit-based rounding is time efficiency for the care team and care coordination benefits for patients and families. If you have other suggestions or questions, go online to SHM HMX to join the discussion.
Take-home message: Unit-based rounding likely has its benefits. Don’t let the inability to achieve perfection in patient distribution to the physicians each day lead to abandonment of attempting these processes.
Dr. McNeal is the division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.
Balance and flexibility are essential
Balance and flexibility are essential
Many hospitalists agree that their most productive and also sometimes least productive work can happen in the setting of interdisciplinary rounds. How can this paradox be true?
Most hospitals strive to assemble the health care team every day for a brief discussion of each patient’s needs as well as barriers to a safe/successful discharge. On most floors this requires a well-choreographed “dance” of nurses, case managers, social workers, physicians, and advanced practice providers coming together at agreed-upon times. All team members commit to efficient synchronized swimming through the most high-yield details for each patient in order to benefit the patients and families being served.
Of course, there are always challenges to this process in the unpredictable world of patients with acute needs. One variable that is at least partially controllable and tends to promote a more cohesive interdisciplinary experience is that of hospitalist unit-based rounding.
The 2018 State of Hospital Medicine (SoHM) survey reveals that 68% of hospital medicine groups serving adults with greater than 30 physicians employ some degree of unit-based rounding; this trend decreases with smaller group size. About 54% of academic hospital medicine groups use some amount of unit-based rounding. Not surprisingly, smaller hospitals are less likely to have this routine, likely because of fewer total nursing units.
One of the most obvious benefits to unit-based rounding is that the physician or advanced practice provider is more reliably able to participate in the interdisciplinary discussions that day. When more of the team members are at the table each day, patients and families have the best chance of hearing a consistent message around the treatment and discharge plans.
There are challenges to unit-based rounding as well. If patients transfer to different floors for any variety of reasons, strict unit-based rounding may increase handoffs in care. If a hospital has times when it isn’t completely full and nursing units have a varying percentage of being occupied, strict unit-based rounding can cause significant workload inequities among physicians on different units, depending on numbers of patients on each unit.
If there is no attempt at unit-based rounding in larger hospitals, some physicians may be running among five or more units. They work to find different care managers, nurses, and pharmacists – not to mention the challenges of catching patients in their rooms between their departures for diagnostic studies and procedures.
It is often good to balance the benefit of promoting unit-based rounds with the reality of everyday patient care. Some groups maintain that the physician/patient relationship trumps the idea of perfect unit-based rounding. In other words, if a physician establishes a relationship with a patient while they are in the ED being admitted or boarding from overnight, that physician will continue seeing the patient regardless of the patient being assigned to a different unit. It can help for groups to agree that the pursuit of unit-based rounding may create some inequity in the numbers of patients seen each day because of these issues.
In a larger hospital, certain units are often dedicated to specialty care such as cardiac or stroke care. While most hospitalists want to maintain general medical knowledge, there are some who may enjoy having portions of their practice devoted to perioperative medicine or cardiac care, for instance. This promotes familiarity among hospitalists and groups of consultant physicians and nurse practitioners/physician assistants. Over time this allows for enhanced teamwork among those physicians, the nursing team, and the specialty physicians.
Depending on the group’s schedule, patients can be reassigned coinciding with the primary change of service day. This resets the physicians’ patients in the most ideal unit-based way on the evening prior to the first day of rounding for that week or group of shifts.
No matter how you do it, the goal of unit-based rounding is time efficiency for the care team and care coordination benefits for patients and families. If you have other suggestions or questions, go online to SHM HMX to join the discussion.
Take-home message: Unit-based rounding likely has its benefits. Don’t let the inability to achieve perfection in patient distribution to the physicians each day lead to abandonment of attempting these processes.
Dr. McNeal is the division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.
Many hospitalists agree that their most productive and also sometimes least productive work can happen in the setting of interdisciplinary rounds. How can this paradox be true?
Most hospitals strive to assemble the health care team every day for a brief discussion of each patient’s needs as well as barriers to a safe/successful discharge. On most floors this requires a well-choreographed “dance” of nurses, case managers, social workers, physicians, and advanced practice providers coming together at agreed-upon times. All team members commit to efficient synchronized swimming through the most high-yield details for each patient in order to benefit the patients and families being served.
Of course, there are always challenges to this process in the unpredictable world of patients with acute needs. One variable that is at least partially controllable and tends to promote a more cohesive interdisciplinary experience is that of hospitalist unit-based rounding.
The 2018 State of Hospital Medicine (SoHM) survey reveals that 68% of hospital medicine groups serving adults with greater than 30 physicians employ some degree of unit-based rounding; this trend decreases with smaller group size. About 54% of academic hospital medicine groups use some amount of unit-based rounding. Not surprisingly, smaller hospitals are less likely to have this routine, likely because of fewer total nursing units.
One of the most obvious benefits to unit-based rounding is that the physician or advanced practice provider is more reliably able to participate in the interdisciplinary discussions that day. When more of the team members are at the table each day, patients and families have the best chance of hearing a consistent message around the treatment and discharge plans.
There are challenges to unit-based rounding as well. If patients transfer to different floors for any variety of reasons, strict unit-based rounding may increase handoffs in care. If a hospital has times when it isn’t completely full and nursing units have a varying percentage of being occupied, strict unit-based rounding can cause significant workload inequities among physicians on different units, depending on numbers of patients on each unit.
If there is no attempt at unit-based rounding in larger hospitals, some physicians may be running among five or more units. They work to find different care managers, nurses, and pharmacists – not to mention the challenges of catching patients in their rooms between their departures for diagnostic studies and procedures.
It is often good to balance the benefit of promoting unit-based rounds with the reality of everyday patient care. Some groups maintain that the physician/patient relationship trumps the idea of perfect unit-based rounding. In other words, if a physician establishes a relationship with a patient while they are in the ED being admitted or boarding from overnight, that physician will continue seeing the patient regardless of the patient being assigned to a different unit. It can help for groups to agree that the pursuit of unit-based rounding may create some inequity in the numbers of patients seen each day because of these issues.
In a larger hospital, certain units are often dedicated to specialty care such as cardiac or stroke care. While most hospitalists want to maintain general medical knowledge, there are some who may enjoy having portions of their practice devoted to perioperative medicine or cardiac care, for instance. This promotes familiarity among hospitalists and groups of consultant physicians and nurse practitioners/physician assistants. Over time this allows for enhanced teamwork among those physicians, the nursing team, and the specialty physicians.
Depending on the group’s schedule, patients can be reassigned coinciding with the primary change of service day. This resets the physicians’ patients in the most ideal unit-based way on the evening prior to the first day of rounding for that week or group of shifts.
No matter how you do it, the goal of unit-based rounding is time efficiency for the care team and care coordination benefits for patients and families. If you have other suggestions or questions, go online to SHM HMX to join the discussion.
Take-home message: Unit-based rounding likely has its benefits. Don’t let the inability to achieve perfection in patient distribution to the physicians each day lead to abandonment of attempting these processes.
Dr. McNeal is the division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.